Timing of open reduction and internal fixation for acute pilon fractures in adults: Early versus delayed — A systematic review and meta-analysis

Abstract

Objective To compare the safety, clinical outcomes, and healthcare resource utilization associated with early versus delayed definitive fixation for acute pilon fractures through a systematic review and meta-analysis. Method Systematic review and meta-analysis. PubMed, Cochrane Library, Embase, Web of Science, CNKI, SinoMed, VIP Database, and Wanfang Data were searched. Eligibility criteria for study selection: Randomized controlled trials and comparative observational studies reporting early versus delayed definitive fixation in adult patients with pilon fractures were included. Data synthesis: The primary outcome was major soft-tissue complications. Secondary outcomes included minor soft-tissue complications, fracture union time, fracture healing complications, quality of reduction, ankle function, and length of hospital stay. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated. Heterogeneity was assessed using the I2, chi-square, and τ2 statistics. Results A total of 21 studies involving 2,600 fractures were included. No significant difference was observed in major soft-tissue complications between early and delayed definitive fixation (OR,1.01 [95%CI, 0.57 to 1.79]). Early fixation was associated with a significantly shorter hospital stay (MD, -7.91 [95%CI,-10.71 to -5.10]). No significant differences were identified in minor soft-tissue complications, fracture healing complications, reduction quality, or ankle function. Conclusions Early definitive fixation for pilon fractures does not appear to increase the risk of soft-tissue complications when patients are carefully selected based on soft-tissue condition. Early intervention may reduce hospital stay and improve healthcare efficiency. These findings support an individualized, soft-tissue–driven approach to surgical timing rather than arbitrary time thresholds in pilon fractures, although standardization of soft-tissue assessment criteria based on high-quality randomized trials remains necessary.