

COPYRIGHT © 2003 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

Outcomes After Treatment

of High-Energy
Tibial Plafond Fractures
BY ANDREW N. POLLAK, MD, MELISSA L. MCCARTHY, MS, SCD,
R. SHAY BESS, MD, JULIE AGEL, ATC, AND MARC F. SWIONTKOWSKI, MD
Downloaded from http://journals.lww.com/jbjsjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 12/10/2021

Investigation performed at the University of Maryland School of Medicine and the R Adams Cowley Shock Trauma Center,
Baltimore, Maryland, and the University of Washington School of Medicine and Harborview Medical Center, Seattle, Washington

Background: Although a number of investigators have documented clinical outcomes and complications associated
with tibial plafond, or pilon, fractures, very few have examined functional and general health outcomes associated
with these fractures. Our purpose was to assess midterm health, function, and impairment after pilon fractures and
to examine patient, injury, and treatment characteristics that influence outcome.
Methods: A retrospective cohort analysis of pilon fractures treated at two centers between 1994 and 1995 was con-
ducted. Patient, injury, and treatment characteristics were recorded from patient interviews and medical record ab-
straction. Study participants returned to the initial treatment centers for a comprehensive evaluation of their health
status. The primary outcomes that were measured included general health, walking ability, limitation of range of mo-
tion, pain, and stair-climbing ability. A secondary outcome measure was employment status.
Results: Eighty (78%) of 103 eligible patients were evaluated at a mean of 3.2 years after injury. General health, as
measured with the Short Form-36 (SF-36), was significantly poorer than age and gender-matched norms. Thirty-five
percent of the patients reported substantial ankle stiffness; 29%, persistent swelling; and 33%, ongoing pain. Of
sixty-five participants who had been employed before the injury, twenty-eight (43%) were not employed at the time of
follow-up; nineteen (68%) of the twenty-eight reported that the pilon fracture prevented them from working. Multivari-
ate analyses revealed that presence of two or more comorbidities, being married, having an annual personal income
of less than $25,000, not having attained a high-school diploma, and having been treated with external fixation with
or without limited internal fixation were significantly related to poorer results as reflected by at least two of the five
primary outcome measures.
Conclusions: At more than three years after the injury, pilon fractures can have persistent and devastating conse-
quences on patients’ health and well-being. Certain social, demographic, and treatment variables seem to contribute
to these poor outcomes.
Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete de-
scription of levels of evidence.

I
n 1969, Rüedi and Allgöwer1 reported promising clinical
results after treatment of eighty-four pilon fractures with
open reduction and internal fixation. Since that time,
many investigators have described a wide variety of treatment
options for displaced pilon fractures2-11. Although there is no
consensus regarding the optimal treatment of these injuries,
most clinicians advocate either open reduction and internal
fixation or external fixation with or without limited internal
fixation; nonoperative treatment is reserved for only the least
displaced fractures. Although a number of investigators have
documented the clinical outcomes and complications associ-
ated with pilon fractures12-16, very few have examined func-
tional outcomes, and studies using well-validated outcomes
instruments are especially scarce17. The purpose of the present
study was to document health, function, and lower-extremity
impairment after pilon fracture and to examine the factors
that influence those outcomes.
Materials and Methods
Overview
retrospective cohort design was used to document the
A health status and functional outcomes of adults in whom
a pilon fracture had been treated with either open reduction
and internal fixation or external fixation with or without lim-
ited internal fixation at one of two North American trauma
centers during 1994 and 1995. These two particular centers
 
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 85-A · N U M B E R 10 · O C T O B E R 2003
were selected because, during the years studied, pilon frac-
tures had been treated primarily with open reduction and in-
ternal fixation at one site whereas external fixation with or
without limited internal fixation typically had been used at
the other site. Two to five years after injury, patients were
asked to return to the medical center where they had been
treated to undergo a comprehensive health status evaluation.
The clinical characteristics of the pilon fracture and its treat-
ment were ascertained by abstraction of the medical records.
We examined the variations in health, function, and midterm
impairment status according to patient, injury, and treatment
characteristics.
Participants and Setting
Patients who were between sixteen and sixty-nine years old at
the time of injury and had been admitted to one of two
trauma centers (Sites A and B) between January 1994 and De-
cember 1995 for treatment of an AO/OTA class-43B or 43C
pilon fracture were eligible for the study18. The centers were
urban-based trauma referral centers from distinct geographic
regions of the country. Large numbers of high-energy injuries
are treated at both facilities, and both centers are part of uni-
versity-based academic medical centers.
Patients were excluded if (1) they had undergone pri-
mary amputation or had not been treated with either open re-
duction and internal fixation or external fixation; (2) they had
received primary or operative treatment elsewhere; (3) they
had sustained a bilateral pilon fracture and had been treated
with both methods; (4) they did not speak English; (5) they
were younger than sixteen or older than sixty-nine years at the
time of injury; (6) they had died; (7) they had had a preexist-
ing medical condition that severely limited physical or mental
health before the injury; or (8) they had sustained a concomi-
tant moderate-to-severe traumatic brain injury (i.e., an injury
with an Abbreviated Injury Scale19 score for the head region of
≥4), a spinal cord injury with a motor deficit, or an ipsilateral
fracture of the femur, patella, or tibia or dislocation of the
knee.
Procedures
The institutional review boards at both centers approved the
study. Informed consent was obtained from all study partici-
pants. The trauma registries at the two sites were used to iden-
tify all patients with eligible injuries, and 152 patients met the
inclusion criteria. However, 32% (forty-nine patients) were
ineligible because of one or more of the above exclusion crite-
ria. Of the forty-nine patients who were excluded, twenty-
seven had sustained a concomitant ipsilateral injury, nine were
ineligible because of their age at the time of injury, six had
died, five met multiple exclusion criteria, and two had a bilat-
eral pilon fracture and had received both types of treatment.
Each of the 103 eligible patients was sent an introduc-
tory letter describing the study and a copy of the consent
form. The letter was followed up with a telephone call from
the site coordinator, who answered any questions that the pro-
spective participant had. Patients who agreed to participate
O U T C O M E S A F T E R TR E A T M E N T O F
H I G H -E N E R G Y T I B I A L P L A F O N D F R A C T U RE S
were each given an appointment to return to the medical cen-
ter for an evaluation consisting of a face-to-face interview and
a functional assessment. A small number of patients who were
unable to return to the medical centers were interviewed by
telephone. Each participant who completed the health status
evaluation was paid $50.
Patient Characteristics
As part of the health status evaluation, the site coordinator
conducted a thirty to forty-five-minute interview with each
patient. Participants were queried about sociodemographic
information that was hypothesized to influence health out-
comes. They were asked their age, marital status, highest grade
completed in school, total personal annual income before
taxes, and type of health insurance that they had at the time of
the interview, if any. They were asked whether they presently
smoked cigarettes and, if so, how many. Finally, they were read
a list of major medical conditions and asked whether a doctor
had ever told them they had any of those conditions.
Injury Characteristics
Data regarding the circumstances of the injury and the sever-
ity of all associated injuries were obtained from each center’s
trauma registry. The nature and severity of each injury was
graded according to the Abbreviated Injury Scale19, which clas-
sifies individual injuries by body region on an ordinal scale of
1 (minor) to 6 (unsurvivable). The side (right or left) of all ex-
tremity fractures was also noted. Head injuries were docu-
mented according to both the head region score of the
Abbreviated Injury Scale and the admission Glasgow Coma
Scale score, a measure of impaired consciousness that ranges
from a score of 3 (comatose) to a score of 15 (no impaired
consciousness)20.
Radiographs made at the time of admission and initial
postfixation radiographs of all participants who completed
the follow-up evaluation were reviewed by the principal inves-
tigator at each site. The pilon fracture was categorized accord-
ing to the AO/OTA classification of long-bone fractures and
whether the fracture was open or closed18. To ensure consis-
tency of grading between the two sites, the radiographs of the
patients treated at one center were then sent to the other cen-
ter and were blindly graded by the principal investigator at
that site. Consistency between the two graders, with regard to
fracture type (AO/OTA type B or C) and location (AO/OTA
location 1, 2, or 3), was evaluated. Overall, agreement between
the two site investigators was high for fracture type but not for
both fracture type and location. There was perfect agreement
regarding the type of fracture in 86% of the cases. However,
when the type was combined with the location of the fracture,
perfect agreement dropped to 55%. When the two site investi-
gators disagreed about the type of fracture, they conferred and
reached a consensus regarding the final grade.
Treatment Characteristics
Data regarding treatment related to the pilon fractures that was
rendered at the respective medical centers (i.e., during the initial
 
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 85-A · N U M B E R 10 · O C T O B E R 2003
hospitalization as well as any rehospitalizations and outpatient
follow-up visits) were abstracted by the site coordinators. The
following information was collected: (1) date and method of
definitive fixation; (2) date and method of revisions of the origi-
nal fixation; (3) date, number, and type of soft-tissue-coverage
procedures; (4) total number of débridements during the initial
hospitalization; (5) date of bone-grafting of the tibia; (6) date
and type of arthrodesis; (7) date and level of amputation; (8)
date and type of stabilization of ipsilateral talar and calcaneal
fractures; (9) any other procedures performed on the tibia; and
(10) any documented limb complications.
Definitive fixation of the pilon fracture was defined in
relation to fracture-healing. If an external fixator was placed
and not removed until the fracture had healed, then external
fixation was considered to be the definitive treatment modal-
ity. If external fixation was used temporarily until open reduc-
tion and internal fixation could be safely performed and was
then removed immediately thereafter, the definitive treatment
was considered to be the open reduction and internal fixation.
If the external fixator was left in place after open reduction
and internal fixation and removed after the fracture had
healed, the open reduction and internal fixation procedure
was considered to be limited and the definitive treatment was
considered to be external fixation with or without limited in-
ternal fixation. All external fixation used in the series was
bridging external fixation. No hybrid frames were used.
Outcomes Assessed
The primary outcomes studied included (1) general health
status as measured by the eight scales of physical and psy-
chosocial health of the Short Form-36 (SF-36), (2) lower-
extremity function as reflected by the ambulation scale of
the Sickness Impact Profile, (3) range-of-motion impairment
as measured by the American Medical Association range-of-
motion impairment rating, (4) pain as indicated on a 100-
point visual analog scale, and (5) stair-climbing performance
as measured by the ability to ascend and descend a flight of
stairs reciprocally. In addition, a secondary outcome of em-
ployment status was assessed for those who were employed at
the time of injury.
The Medical Outcomes Study thirty-six-item Short
Form Health Survey21 (SF-36) consists of thirty-six items or
questions representing eight scales: physical function, role dis-
ability due to physical health problems, bodily pain, general
health perceptions, vitality, social function, role disability due
to emotional problems, and mental health. Scale scores range
from 0 (worst) to 100 (best)21. Age and gender-specific popu-
lation norms have been developed for the SF-36 and were used
to interpret our findings21. The SF-36 has been extensively
tested for its reliability and validity and has been used previ-
ously to measure the health status of other populations with
traumatic injuries22-26.
Participants were also questioned about their ability to
perform different lower-extremity activities. They completed
the ambulation subscale of the Sickness Impact Profile, which
consists of twelve statements related to walking and climbing
O U T C O M E S A F T E R TR E A T M E N T O F
H I G H -E N E R G Y T I B I A L P L A F O N D F R A C T U RE S
stairs27,28. The twelve items describe limitations such as walking
more slowly, being able to walk for only short distances, need-
ing the assistance of another person to walk, and not being
able to walk at all. The Sickness Impact Profile ambulation
subscale ranges from 0 to 100; the higher the score, the greater
the degree of ambulatory dysfunction.
Participants were also asked to report whether they had
difficulty with more strenuous or challenging lower-extremity
activities. All participants were asked how frequently the ankle
caused them difficulty when running one block, wearing dif-
ferent types of shoes, climbing a ladder, or participating in
recreational activities. Finally, participants were queried about
any equipment or devices that they usually used to get around
and how frequently they experienced pain, swelling, or stiff-
ness in the ankle.
The lower-extremity impairment and lower-extremity
function of each participant were evaluated by a physical ther-
apist or certified athletic trainer during the functional evalua-
tion. The active and passive ranges of motion were measured
with use of the start and end positions for each motion of the
hip, knee, and ankle recommended by the American Academy
of Orthopaedic Surgeons29. With use of the American Medical
Association’s Guides to the Evaluation of Permanent Impairment,
range-of-motion values can be summarized as an impairment
rating for the injured extremity30. The lower-extremity impair-
ment ratings range from 0% to 100%. The higher the score, the
greater the range-of-motion impairment.
Patients were also asked to mark on a visual analog scale
the degree of pain that they experienced in the injured leg dur-
ing a typical day. Pain scores range from 0 (no pain) to 100
(unbearable pain).
Lower-extremity function was evaluated by asking par-
ticipants to perform several activities, including complete full
toe excursion (rising onto the toes such that the weight of the
body is borne on and balanced between the metatarsal heads
and the phalanges), ascending and descending a flight of
stairs, squatting and picking up a light object (a pencil) and a
heavy object (a 10-lb [4.5-kg] weight), standing on the injured
leg for thirty seconds, rising from a chair without using the
arms five times within fifteen seconds, and running in place
for thirty seconds. The evaluators observed each participant’s
performance and graded each activity according to whether it
was completed and, if appropriate, whether it was completed
within the specified time.
We also asked participants specifically about employ-
ment status. Participants who reported that they had been
employed at the time of injury but were not employed at the
time of the follow-up interview were asked whether the pilon
fracture had prevented them from resuming work.
Analysis
Analysis was conducted in four phases. First, the patients who
did and those who did not complete the follow-up evaluation
were compared on the basis of the available injury and treat-
ment data. Second, the general health status outcomes in our
study sample were compared with age and gender-matched
 
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 85-A · N U M B E R 10 · O C T O B E R 2003
norms from a general United States population sample; 95%
confidence intervals were calculated around the sample mean
for each SF-36 scale. Third, bivariate analysis was conducted
to examine the primary outcomes according to different pa-
tient, injury, and treatment characteristics. A chi-square statis-
tic was used to test for associations between the independent
variables and the dichotomous outcome variable (stair-climbing
ability); a Student t test or analysis of variance was used for the
continuous outcome variables (SF-36 physical function, Sick-
ness Impact Profile ambulation, American Medical Associa-
tion range-of-motion impairment, and visual analog scale
pain scores). Finally, multivariate regression techniques were
used to simultaneously control for the influence of different
patient, injury, and treatment characteristics on outcome. Be-
cause the ambulation scores, range-of-motion impairment
ratings, and pain scores were all positively skewed, log scores
of each were used in the linear regression models. Stair-climbing
was modeled with use of logistic regression. All outcomes
were modeled separately as a function of the type of fracture
wound, AO/OTA fracture classification, treatment method,
presence of a contralateral injury, mechanism of injury, bilat-
erality of the pilon fracture, age, gender, marital status, educa-
tion, presence of comorbidities, personal annual income,
health insurance status, duration to follow-up, and site of ini-
tial treatment. An interaction term was constructed between
treatment method and site to determine whether there were
significant differences in the outcomes of patients who were
treated with the nondominant treatment method at each site.
The final models included all participants who had sus-
tained either a unilateral or a bilateral pilon fracture because the
O U T C O M E S A F T E R TR E A T M E N T O F
H I G H -E N E R G Y T I B I A L P L A F O N D F R A C T U RE S
Fig. 1
Graph comparing SF-36 scores of the study
participants with a pilon fracture with United
States age and gender-matched norms. Points
along the x axis represent the individual sub-
scales of the SF-36: PF = physical function,
RP = role disability due to physical health
problems, BP = bodily pain, GH = general
health perceptions, VT = vitality, SF = social
function, RE = role disability due to emotional
health, and MH = mental health. Upper and
lower 95% confidence limits (CI) for all average
SF-36 scale scores of the study population are
indicated to show significant differences rela-
tive to the United States (US) age and gender-
matched norms.
results were similar regardless of whether the models included
only patients with a unilateral fracture or both those with a uni-
lateral fracture and those with a bilateral fracture. Differences
were considered significant when p was ≤0.05. However, be-
cause of the small sample size and the limited ability to detect
smaller but potentially meaningful differences in outcome, dif-
ferences were also noted when p was ≤0.10.
Results
f the 103 patients who met the study inclusion criteria,
O eighty (78%) completed a follow-up health status evalu-
ation. Of those eighty, the vast majority (88%) completed
both the interview and the functional status assessment. Ten
participants completed a telephone interview but not the
functional assessment. The mean duration of follow-up was
3.2 years (range, two to five years). Of the twenty-three pa-
tients who did not complete the follow-up evaluation, twenty-
two could not be located and one refused to participate. The
twenty-three patients who were not followed were signifi-
cantly more likely than the patients who were followed to have
sustained a closed fracture that was stabilized with open re-
duction and internal fixation (53%; p < 0.05). No other differ-
ences were noted between those who did and those who did
not complete the follow-up evaluation.
The mean age of the participants at the time of the follow-
up evaluation was forty-four years (range, nineteen to seventy-
two years). Participants were more likely to be male (78%), to
be a high-school graduate (64%), and to have health insurance
(79%) at the time of the evaluation. Patient characteristics did
not vary significantly by treatment method (see Appendix).
 
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 85-A · N U M B E R 10 · O C T O B E R 2003
Overall, study participants were more likely than not to
have sustained a closed pilon fracture (61%) and to have sus-
tained an AO/OTA Type-C pilon fracture (74%). Only six (8%)
of the participants sustained a bilateral pilon fracture, and nine
(11%) had a major injury of the contralateral lower extremity.
Participants treated with external fixation with or without lim-
ited internal fixation were significantly more likely to have sus-
tained an open fracture (53%) and an AO Type-C fracture
(90%) than were participants treated with open reduction and
internal fixation (26% and 60%, respectively) (p < 0.05).
None of the participants underwent delayed amputation
(i.e., after initial surgical treatment) during the index hospital-
ization. However, five underwent late amputation (after hos-
pital discharge). One patient underwent an above-the-knee
amputation, and the other four underwent a below-the-knee
amputation. All five patients had sustained an AO Type-C
fracture, and four of the five fractures were open. All of the
late amputations were performed in patients in whom the
fracture had been treated with external fixation with or with-
out limited internal fixation. None of the patients had major
complications during the initial hospital stay; however, four of
the five patients had a severe wound infection that required
operative treatment before the late amputation.
As reflected by the SF-36 scales, the poorest domain of the
participants’ health was role disability due to physical health
problems (Fig. 1)21. The greatest differences in health between
the study sample and the United States age and gender-specific
norms were in role disability due to physical health problems
(mean difference = 35.6) and physical function (mean differ-
ence = 21.9). Moreover, for all except three of the SF-36 scales
(vitality, role disability due to emotional health, and mental
health), the scores for the study sample were significantly worse
than the general population norms (p < 0.05). Figure 2 shows a
comparison of the average SF-36 physical function score of the
Fig. 2
Bar graph comparing aver-
age SF-36 physical function
scores for the study sample
(Pilon) with published values
for other patient samples
with various chronic medical
conditions and with a general
population sample. CHF =
congestive heart failure, OA +
HTN = osteoarthritis and hy-
pertension, MI = myocardial
infarction, AIDS = acquired
immune deficiency syndrome,
and HTN = hypertension.
O U T C O M E S A F T E R TR E A T M E N T O F
H I G H -E N E R G Y T I B I A L P L A F O N D F R A C T U RE S
study sample with those of other clinical samples21,31-36.
Of the sixty-five participants who were employed at the
time of injury, twenty-eight (43%) were not working at the
time of follow-up. More than two-thirds (68%) of those not
working stated that the pilon fracture prevented them from
being able to work. Approximately one-third of the partici-
pants reported notable difficulty with ankle stiffness (35%),
swelling (29%), or pain (33%). Twenty-five percent of the par-
ticipants reported that they usually wore an orthotic device,
and 13% reported that they usually used a walking aid (e.g., a
cane, crutches, or a walker). Participants also demonstrated
moderate-to-severe difficulty with the performance of many
activities that depend on lower-extremity function. Difficul-
ties included not being able to complete full toe excursion
(52%) and not being able to stand with the weight borne by
the injured leg for thirty seconds (71%) (see Appendix).
Overall, the results of the bivariate and multivariate
analyses were fairly consistent, with two exceptions. First,
marital status was not found to have a strong relationship with
any of the outcomes in the bivariate analyses. However, in the
multivariate analyses, marital status was significantly related
to the physical function, Sickness Impact Profile ambulation,
range-of-motion impairment, and pain scores. Second, a bi-
lateral pilon fracture was associated with poorer physical func-
tion, a worse ambulation score, and greater range-of-motion
impairment in the bivariate analyses but was not found to be a
significant factor in the multivariate models.
In the multivariate analyses, several patient characteris-
tics demonstrated strong relationships with two or more of
the selected outcomes (see Appendix). Married patients re-
ported worse health and demonstrated more range-of-motion
impairment than did patients who were not married at the
time of the interview. Patients with a lower income level or a
lower level of education were significantly more likely to re-
 
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 85-A · N U M B E R 10 · O C T O B E R 2003
port and/or demonstrate poorer health and function than
were patients who had more financial resources and educa-
tion. All of the primary outcomes that were studied, except for
range-of-motion impairment, were significantly poorer in the
presence of two or more comorbidities.
The only injury or treatment characteristic that was sig-
nificantly related to several of the selected outcomes was treat-
ment method. After controlling for other patient and injury
characteristics, participants treated with external fixation with
or without limited internal fixation had more overall range-of-
motion impairment and reported more pain and ambulatory
dysfunction than did participants treated with open reduction
and internal fixation (p < 0.05). The average range-of-motion
impairment rating of patients treated with external fixation
with or without limited internal fixation (27%) was more than
twice as high as that of patients treated with open reduction and
internal fixation (12%). The average pain score of patients
treated with external fixation with or without limited internal
fixation was 25.1 points higher (worse) than that of patients
treated with open reduction and internal fixation. Although the
general physical health of the two treatment groups was not sig-
nificantly different, the average Sickness Impact Profile ambula-
tion subscale score was 19.8 points higher (poorer) for patients
treated with external fixation with or without limited internal
fixation. We found no significant interaction effect between
treatment method and enrollment site, so it was not included in
the final models (Table E-6 in Appendix).
Discussion
his study demonstrated that overall midterm outcomes
T after pilon fractures are not good. In general, study partic-
ipants reported relatively poor physical and psychosocial
health outcomes as measured by the SF-36. The Sickness Im-
pact Profile ambulation scores reflected substantial dysfunc-
tion in basic walking ability at two to five years after injury.
When asked to perform various lower-extremity activities,
such as ascending and descending stairs reciprocally or run-
ning in place for thirty seconds, one-third to one-half of the
participants were unable to do so. Moreover, only 57% of the
patients who had been employed at the time of injury were
working at the time of follow-up.
Previous studies have documented conflicting results re-
garding clinical and functional outcomes after pilon fracture.
Rüedi and Allgöwer1 reported that 71% of their patients
treated with open reduction and internal fixation had a good-
to-excellent result four years after injury. Ninety-two percent
of their study participants had returned to work at the time of
follow-up. However, only 6% of their patients had sustained
an open fracture compared with 39% in our sample. Ovadia
and Beals37 documented a 65% rate of good-to-excellent re-
sults after the treatment of 145 pilon fractures. Only 20% of
the fractures were open. Many other authors have reported
poorer overall results. For example, Teeny and Wiss38 reported
that 50% of their fifty-eight patients had a poor clinical result
after treatment of a pilon fracture with open reduction and in-
ternal fixation. Sands et al.17 reported results that were remark-
O U T C O M E S A F T E R TR E A T M E N T O F
H I G H -E N E R G Y T I B I A L P L A F O N D F R A C T U RE S
ably similar to ours, in a sample of patients evaluated with the
SF-36 at the time of follow-up after open reduction and inter-
nal fixation of a pilon fracture.
In addition to the overall results, the influence of patient,
injury, and treatment characteristics on midterm outcomes was
examined in our study. We chose outcomes that represented a
wide spectrum, including global health, specific lower-extremity
functional activities, limitation of motion, and pain. In addi-
tion, the selected outcomes were determined by a combination
of clinician-rated and patient-reported measures.
Regarding patient characteristics, the presence of two or
more comorbidities resulted in significantly poorer scores for
all selected outcomes except range-of-motion impairment.
This finding is in agreement with those of a previous study of
the effects of comorbidities on long-term health outcomes of
injured patients23. Patients with a lower income level or lower
level of education were significantly more likely to report and/
or demonstrate poorer health and function than were pa-
tients who had more financial resources and education. The
relationship of health with socioeconomic status and educa-
tion has been well documented in the literature and may re-
flect differences in access to appropriate medical and social
services39-41. In the present study, patients who were married at
the time of the follow-up interview reported worse health
than did those who were not married. This finding was unex-
pected and contrary to findings reported in the literature42-44.
Patients treated with external fixation with or without
limited internal fixation reported and demonstrated signifi-
cantly poorer results for three of the five primary out-
comeswalking ability, range-of-motion impairment, and
painthan did patients treated with open reduction and in-
ternal fixation. These findings are somewhat contrary to the
results reported by Wyrsch et al.45, who used a randomized-
surgeon design to compare open reduction and internal fixa-
tion with external fixation with or without limited internal
fixation. Although the differences were not significant, Wyrsch
et al. found that patients treated with open reduction and in-
ternal fixation tended to have worse clinical scores. However,
it is difficult to directly compare their study with ours because
of the difference in the severity of the pilon fractures between
the two treatment groups in their study and because we as-
sessed outcomes differently.
Other studies have demonstrated significant differences
in outcomes based on the clinical characteristics of the frac-
ture or its treatment, such as the degree to which anatomic re-
duction was achieved37,38. For example, Teeny and Wiss38
reported a 37% rate of good-to-excellent results after the
treatment of Rüedi Type-I and II fractures compared with a
rate of only 13% after the treatment of Type-III fractures.
Ovadia and Beals37 reported that 89% of their patients in
whom the reduction was rated as good had a good-to-excellent
clinical result. Conversely, all of their patients with poor frac-
ture reduction had a poor clinical result. In the present study,
both the fracture wound and the fracture type were found to
be significantly associated with two or more of the selected
outcomes in the bivariate analyses. However, in the multivari-
 
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 85-A · N U M B E R 10 · O C T O B E R 2003
ate analyses, neither was significantly associated with at least
two outcomes. This may be the result of the small sample size
or our inclusion of only severe injuries. These findings em-
phasize the importance of controlling for other factors when
judging differences in outcomes associated with different
treatment techniques.
The following limitations must be kept in mind when in-
terpreting the results of this study. First, the study was based on
a relatively small number of patients. Although a host of pa-
tient, injury, and treatment factors may influence health out-
comes, especially more global ones, this study had limited
statistical power to detect those factors. For example, the bivari-
ate analyses clearly demonstrated that patients with a bilateral
pilon fracture fared significantly worse than did patients with a
unilateral pilon fracture. However, this difference did not re-
main significant in the multivariate analyses. We attribute this
to a lack of statistical power.
Second, this was an observational, not a randomized,
study. Not all patients received the same treatment at each study
site, and we were unable to ascertain the specific criteria for
treatment selection for each patient. Although we tried to ac-
count for variations in injury severity and patient characteristics
when we compared outcomes according to the treatment
method in our multivariate regression analyses, the small sam-
ple size limited our ability to adequately address potential treat-
ment bias that may have been present in our cohort. Therefore,
the differences in range-of-motion impairment, walking abil-
ity, and pain that we found between the treatment methods
must be interpreted with caution and examined more rigor-
ously in future studies.
A third limitation of the present study is that it did not
address postdischarge complications (except for late amputa-
tion). Because a large proportion of our patients received care
at other facilities during a relatively long follow-up period, we
chose not to rely solely on the complications noted in the
medical records of the initial treating centers and the partici-
pants’ recall at the time of the follow-up interview. We judged
those sources to be incomplete and inaccurate. It should be
noted, however, that previous investigators have reported fre-
quent and serious limb and systemic complications associated
with pilon fractures38,46-48.
Fourth, we did not evaluate the degree of restoration of
articular congruity after operative treatment because it is our
opinion that the methodology of reviewing postoperative ra-
diographs after treatment of pilon fractures is inherently
flawed because hardware often obscures the details of articular
alignment.
Finally, the generalizability of the findings of the present
study is limited to intra-articular fractures managed at trauma
centers that routinely treat patients who have sustained a
high-energy fracture. All surgery was closely supervised or di-
rectly performed by an experienced attending orthopaedic
References
1. Rüedi TP, Allgöwer M. Fractures of the lower end of the tibia into the ankle-
joint. Injury. 1969;1:92-9.
O U T C O M E S A F T E R TR E A T M E N T O F
H I G H -E N E R G Y T I B I A L P L A F O N D F R A C T U RE S
traumatologist. The results of this study may therefore under-
estimate the disability following the treatment of these frac-
tures in other settings.
In summary, we used well-validated outcomes instru-
ments and other parameters to conduct a comprehensive eval-
uation of midterm outcomes after treatment of pilon fractures
at two trauma centers. We found that patients who sustain a
pilon fracture continue to experience major physical and psy-
chosocial health problems long after the initial injury. Al-
though certain patient characteristics can mitigate these poor
outcomes, individuals who sustain such injuries do not enjoy
the same physical or psychosocial health as do adults in the
general population. Additional, prospective study is war-
ranted to find better ways to treat these severe injuries so that
functional outcomes can be improved.
Appendix
Tables showing patient and injury characteristics, accord-
ing to the treatment method, of the eighty patients who
completed the follow-up evaluation; symptoms and functional
activities at the time of follow-up; outcomes scores according to
patient, injury, and treatment characteristics; and parameter es-
timates for selected outcomes are available with the electronic
versions of this article, on our web site at www.jbjs.org (go to
the article citation and click on “Supplementary Material”) and
on our quarterly CD-ROM (call our subscription department,
at 781-449-9780, to order the CD-ROM).

Andrew N. Pollak, MD
Department of Orthopaedics, University of Maryland School of Medi-
cine, 22 South Greene Street, Suite T3R54, Baltimore, MD 21201. E-mail
address: apollak@umoa.umm.edu
Melissa L. McCarthy, MS, ScD
Department of Emergency Medicine, Johns Hopkins University School
of Medicine, 1830 East Monument Street, Suite 6-111, Baltimore,
MD 21205
R. Shay Bess, MD
Department of Orthopaedics, University of Cleveland School of
Medicine, 11100 Euclid Avenue, Cleveland, OH 44106
Julie Agel, ATC
Marc F. Swiontkowski, MD
Department of Orthopaedics, University of Minneapolis School of
Medicine, 2450 Riverside Avenue, South, Minneapolis, MN 55455
In support of their research or preparation of this manuscript, one or
more of the authors received grants or outside funding from AO Inter-
national Foundation. None of the authors received payments or other
benefits or a commitment or agreement to provide such benefits from a
commercial entity. No commercial entity paid or directed, or agreed to
pay or direct, any benefits to any research fund, foundation, educational
institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.
2. Anglen JO. Early outcome of hybrid external fixation for fracture of the distal
tibia. J Orthop Trauma. 1999;13:92-7.
 
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 85-A · N U M B E R 10 · O C T O B E R 2003
3. Ayeni JP. Pilon fractures of the tibia: a study based on 19 cases. Injury.
1988;19:109-14.
4. Bone L, Stegemann P, McNamara K, Seibel R. External fixation of severely
comminuted and open tibial pilon fractures. Clin Orthop. 1993;292:101-7.
5. Brumback RJ, McGarvey WC. Fractures of the tibial plafond. Evolving treat-
ment concepts for the pilon fracture. Orthop Clin North Am. 1995;26:273-85.
6. Kellam JF, Waddell JP. Fractures of the distal tibial metaphysis with intra-
articular extensionthe distal tibial explosion fracture. J Trauma. 1979;
19:593-601.
7. Martin JS, Marsh JL, Bonar SK, DeCoster TA, Found EM, Brandser EA. As-
sessment of the AO/ASIF fracture classification for the distal tibia. J Orthop
Trauma. 1997;11:477-83.
8. Mast JW, Spiegel PG, Pappas JN. Fractures of the tibial pilon. Clin Orthop.
1988;230:68-82.
9. Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixa-
tion of severe pilon fractures. J Orthop Trauma. 1999;13:85-91.
10. Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for
soft tissue management in the treatment of complex pilon fractures. J
Orthop Trauma. 1999;13:78-84.
11. Tornetta P 3rd, Weiner L, Bergman M, Watnik N, Steuer J, Kelley M, Yang
E. Pilon fractures: treatment with combined internal and external fixation.
J Orthop Trauma. 1993;7:489-96.
12. Borrelli J Jr, Torzilli PA, Grigiene R, Helfet DL. Effect of impact load on
articular cartilage: development of an intra-articular fracture model. J Orthop
Trauma. 1997;11:319-26.
13. Helfet DL, Koval K, Pappas J, Sanders RW, DiPasquale T. Intraarticular
“pilon” fracture of the tibia. Clin Orthop. 1994;298:221-8.
14. McKinley TO, Bay BK. Trabecular bone strain changes associated with carti-
lage defects in the proximal and distal tibia. J Orthop Res. 2001;19:906-13.
15. Ruedi T. Fractures of the lower end of the tibia into the ankle joint: results 9
years after open reduction and internal fixation. Injury. 1973;5:130-4.
16. Torzilli PA, Grigiene R, Borrelli J Jr, Helfet DL. Effect of impact load on
articular cartilage: cell metabolism and viability, and matrix water content.
J Biomech Eng. 1999;121:433-41.
17. Sands A, Grujic L, Byck DC, Agel J, Benirschke S, Swiontkowski MF. Clini-
cal and functional outcomes of internal fixation of displaced pilon fractures.
Clin Orthop. 1998;347:131-7.
18. Muller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classifica-
tion of fractures of long bones. New York: Springer; 1990.
19. Assocation for the Advancement of Automotive Medicine. The abbreviated
injury scale. 1990 revision. Des Plaines, IL: Association for the Advancement
of Automotive Medicine; 1990.
20. Jennett B, Snoek J, Bond MR, Brooks N. Disability after severe head injury:
observations on the use of the Glasgow Outcome Scale. J Neurol Neurosurg
Psychiatry. 1981;44:285-93.
21. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 health survey: manual and
interpretation guide. Boston: The Health Institute; 1993.
22. MacKenzie EJ, McCarthy ML, Ditunno JF, Forrester-Staz C, Gruen GS, Mar-
ion DW, Schwab WC, Pennsylvania Study Group on Functional Outcomes
Following Trauma. Using the SF-36 for characterizing outcome after multiple
trauma involving head injury. J Trauma. 2002;52:527-34.
23. McCarthy ML, MacKenzie EJ, Bosse MJ, Copeland CE, Hash CS, Burgess
AR. Functional status following orthopedic trauma in young women. J Trauma.
1995;39:828-37.
24. McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-Form Health
Survey (SF-36): II. Psychometric and clinical tests of validity in measuring
physical and mental health constructs. Med Care. 1993;31:247-63.
25. McHorney CA, Ware JE Jr, Lu JF, Sherbourne CD. The MOS 36-Item Short-
Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions,
and reliability across diverse patient groups. Med Care. 1994;32:40-66.
O U T C O M E S A F T E R TR E A T M E N T O F
H I G H -E N E R G Y T I B I A L P L A F O N D F R A C T U RE S
26. Michaels AJ, Michaels CE, Moon CH, Smith JS, Zimmerman MA, Taheri PA,
Peterson C. Posttraumatic stress disorder after injury: impact on general
health outcome and early risk assessment. J Trauma. 1999;47:460-7.
27. Bergner M, Bobbitt RA, Carter WB, Gilson BS. The Sickness Impact Profile:
development and final revision of a health status measure. Med Care. 1981;
19:787-805.
28. Damiano AM. The Sickness Impact Profile user’s manual and interpretation
guide. Baltimore: Johns Hopkins University; 1996.
29. American Academy of Orthopaedic Surgeons. Joint motion: method of
measuring and recording. Chicago: The Academy; 1965.
30. Doege TC, editor. Guides to the evaluation of permanent impairment. 4th ed.
Chicago: American Medical Association; 1993.
31. Andresen EM, Gravitt GW, Aydelotte ME, Podgorski CA. Limitations of the
SF-36 in a sample of nursing home residents. Age Ageing. 1999;28:562-6.
32. Bousquet J, Knani J, Dhivert H, Richard A, Chicoye A, Ware JE Jr, Michel
FB. Quality of life in asthma. I. Internal consistency and validity of the SF-36
questionnaire. Am J Respir Crit Care Med. 1994;149:371-5.
33. Kurtin PS, Davies AR, Meyer KB, DeGiacomo JM, Kantz ME. Patient-based
health status measures in outpatient dialysis. Early experiences in developing
an outcomes assessment program. Med Care. 1992;30 (5 Suppl):MS136-49.
34. Osterhaus JT, Townsend RJ, Gandek B, Ware JE Jr. Measuring the functional
status and well-being of patients with migraine headache. Headache. 1994;
34:337-43.
35. Tsevat J, Solzan JG, Kuntz KM, Ragland J, Currier JS, Sell RL, Weinstein
MC. Health values of patients infected with human immunodeficiency virus.
Relationship to mental health and physical functioning. Med Care. 1996;
34:44-57.
36. Wagner AK, Keller SD, Kosinski M, Baker GA, Jacoby A, Hsu MA, Chadwick
DW, Ware JE Jr. Advances in methods for assessing the impact of epilepsy
and antiepileptic drug therapy on patients’ health-related quality of life. Qual
Life Res. 1995;4:115-34.
37. Ovadia DN, Beals RK. Fractures of the tibial plafond. J Bone Joint Surg Am.
1986;68:543-51.
38. Teeny SM, Wiss DA. Open reduction and internal fixation of tibial plafond frac-
tures. Variables contributing to poor results and complications. Clin Orthop.
1993;292:108-17.
39. Adler NE, Ostrove JM. Socioeconomic status and health: what we know and
what we don’t. Ann NY Acad Sci. 1999;896:3-15.
40. Backlund E, Sorlie PD, Johnson NJ. A comparison of the relationships of
education and income with mortality: the National Longitudinal Mortality
Study. Soc Sci Med. 1999;49:1373-84.
41. Feinstein JS. The relationship between socioeconomic status and health: a
review of the literature. Milbank Q. 1993;71:279-322.
42. Hu YR, Goldman N. Mortality differentials by marital status: an international
comparison. Demography. 1990;27:233-50.
43. Kravdal O. The impact of marital status on cancer survival. Soc Sci Med.
2001;52:357-68.
44. O’Dea I, Hunter MS, Anjos S. Life satisfaction and health-related quality of
life (SF-36) of middle-aged men and women. Climacteric. 1999;2:131-40.
45. Wyrsch B, McFerran MA, McAndrew M, Limbird TJ, Harper MC, Johnson
KD, Schwartz HS. Operative treatment of fractures of the tibial plafond. A
randomized, prospective study. J Bone Joint Surg Am. 1996;78:1646-57.
46. Bourne RB, Rorabeck CH, Macnab J. Intra-articular fractures of the distal
tibia: the pilon fracture. J Trauma. 1983;23:591-6.
47. Dillin L, Slabaugh P. Delayed wound healing, infection, and nonunion following
open reduction and internal fixation of tibial plafond fractures. J Trauma.
1986;26:1116-9.
48. Saleh M, Shanahan MD, Fern ED. Intra-articular fractures of the distal tibia:
surgical management by limited internal fixation and articulated distraction.
Injury. 199;24:37-40.