SLR - September 2020 - Michael D. Paula

Post-Operative Outcomes of Open Reduction and Internal Fixation Versus Circular External Fixation in Treatment Of Tibial Plafond Fractures: A Systematic Review and Meta-Analysis 

Reference: Malik-Tabassum K, Pillai K, Hussain Y, et al. Post-Operative Outcomes of Open Reduction and Internal Fixation Versus Circular External Fixation in Treatment Of Tibial Plafond Fractures: A Systematic Review and Meta-Analysis. Injury. July 2020;51(7):1448-1456. doi:10.1016/j.injury.2020.04.056

Scientific Literature Review

Reviewed By: Michael D. Paula, DPM
Residency Program: Jackson South Medical Center – Miami, FL

Podiatric Relevance: Pilon fractures account for 1 percent of all lower extremity fractures. The literature is inconclusive regarding the best surgical treatment. The purpose of this study was to conduct a systematic review and meta-analysis to compare both post-operative complications, and functional outcomes of open reduction and internal fixation (ORIF) versus circular external fixation (CEF) for treatment of tibial plafond fractures (TPF). 

Methods: A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Using a list of keywords, two reviewers conducted the search using various search engines. Inclusion criteria was as follows: randomized controlled trials, non-randomized studies, prospective studies, retrospective studies and studies that compared clinical and/or functional outcomes in ORIF versus CEF for operative treatment. Additionally, they had to be in English, and required a minimum follow up of at least 6 months. Outcome measures included bone healing complications, infective complications, postoperative functional outcomes, post-traumatic arthritis and secondary procedures.  

Results: In total five studies met the inclusion criteria: three retrospective, one prospective cohort and one prospective randomised study. The included studies reported a total of 281 tibial plafond fractures with 85 of them being open fractures. One hundred sixty-four of them were treated with ORIF, whereas 117 were treated with CEF. The study found that there were no significant differences between the two groups with regard to bone healing complications, non-unions, malunions, infective complications, superficial infection, deep infection, secondary procedures and arthrodesis. Important to note, neither group reported amputations following treatment. 

The study did however, find some significant differences with regards to functional outcomes, post traumatic arthritis, and metal framework removal. Only one of the included studies showed that postoperative functional outcomes were found to be significantly higher in the ORIF group, however, this finding is treated with caution due to the significant loss of follow up in this particular study. The remaining studies found no significant difference in the functional outcomes. The meta-analysis additionally found lower rates of post-traumatic arthritis and higher rates of metalwork removal in the ORIF group. 

Conclusions: This study was the first ever reported systematic review and meta-analysis comparing clinical and functional outcomes of ORIF versus CEF for management of TPF. They demonstrated that ORIF and CEF are both appropriate surgical treatment options for TPF.  It is important to note that CEF was preferred over ORIF for the treatment of more severe injuries such as open fractures. The number of non-union, malunion, infective complications, and secondary arthrodesis were indistinguishable between ORIF and CEF. Conversely, increased rates of metalwork removal and decreased rates of post-traumatic arthritis were observed in the ORIF group. Most importantly, the post-operative functional outcomes were found to be similar overall between the two treatment groups. The treatment of pilon fractures remains a controversial subject amongst podiatric surgeons, and this study highlights the lack of evidence to support one particular treatment over the other. 

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