Open versus closed pilon fractures: Comparison of management, outcomes, and complications

•Compared to FWF groups, ORIF groups for AO/OTA type 43C open fractures showed higher AOFAS scores 3, 6, and 12 months post-injury.•Compared to FWF groups, ORIF groups for type 43B closed fractures needed a shorter time to PWB and FWB.•Smokers had a higher AOFAS score 6 months post-injury compared to non-smokers.•Use of two-staged approach involving temporary ex-fix, followed with ORIF or FWF achieved low complication rates and good functional recovery.•We propose 60 weeks as the time when further reconstructive surgery should be undertaken. Despite the low incidence of pilon fractures amongst lower limb injuries, their high impact nature presents difficulties in surgical management and recovery. The high complication rate and long recovery times presents a challenge for surgeons and patients. Current literature is varied, with no universal treatment algorithm. We aim to highlight differences in outcomes and complications between open and closed pilon fractures, and between patients treated by open reduction internal fixation (ORIF) or fine wire fixator (FWF) for open and closed fracture subgroups. This retrospective study was conducted at a major trauma centre including 135 patients over a 6-year period. Primary outcome was AOFAS score at 3, 6, and 12-months post-injury. Secondary outcomes included time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time, and complications during the follow-up time. AO/OTA classification was used (43A: n = 23, 43B: n = 30, 43C: n = 82). Interobserver agreement was high for bone union time (kappa=0.882) and AO/OTA class (kappa=0.807). Higher AOFAS scores were seen in ORIF groups of both open and closed fractures, compared to FWF groups. The difference was not statistically significant apart from 12-month AOFAS score of 43C open fractures (p = 0.003) and in 43B closed fractures 3 and 6 months post-injury (p