Based on our data, it appears that the historically high rates of infection associated with open reduction and internal fixation of pilon fractures may be due to attempts at immediate fixation through swollen, compromised soft tissues. When a staged procedure is performed with initial restoration of fibula length and tibial external fixation, soft tissue stabilization is possible. Once soft tissue swelling has significantly diminished, anatomic reduction and internal fixation can then be performed semi-electively with only minimal wound problems. This is evidenced by the lack of skin grafts, rotation flaps, or free tissue transfers in our series. This technique appears to be effective in closed and open fractures alike.

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Smoking places the patient at risk for increased time to union and complications. Previous smoking history also appears to increase the risk of osteomyelitis and increased time to union. The results highlight the need for orthopaedic surgeons to encourage their patients to enter a smoking cessation programs.

Based on our data, it appears that the historically high rates of infection associated with open reduction and internal fixation of pilon fractures may be due to attempts at immediate fixation through swollen, compromised soft tissues. When a staged procedure is performed with initial restoration of fibula length and tibial external fixation, soft tissue stabilization is possible. Once soft tissue swelling has significantly diminished, anatomic reduction and internal fixation can then be performed semi-electively with only minimal wound problems. This is evidenced by the lack of skin grafts, rotation flaps, or free tissue transfers in our series. This technique appears to be effective in closed and open fractures alike.

Using the Mayo Elbow Performance score, the outcomes of the 12 patients treated with ORIF were as follows: 4 excellent, 4 good, 1 fair, and 3 poor (cases that required conversion to TEA). Outcomes of the 12 patients treated with TEA were as follows: 11 excellent and 1 good. There were no fair or poor outcomes in the TEA group. No patients treated with TEA required revision surgery. We believe TEA to be a viable treatment option for distal intraarticular humerus fractures in women older than age 65. This is particularly true for women with associated comorbidities, such as rheumatoid arthritis, osteoporosis, and conditions requiring the use of systemic steroids.