Clinical outcomes and safety of surgical strategies for Pilon fractures: A network meta-analysis

Background: To evaluate the clinical outcomes and safety of different surgical techniques for Pilon fractures using a network meta-analysis. Methods: Studies were retrieved from China National Knowledge Infrastructure, Chinese Biomedical Literature Database, PubMed, Web of Science, the Cochrane Library, and EMBASE up to August 2025. Randomized controlled trials (RCTs) and retrospective studies involving patients with Pilon fractures treated surgically were included. Primary outcomes were operative time, intraoperative blood loss, fracture healing time, postoperative functional recovery, and complication rate. Study quality was assessed using the Cochrane risk-of-bias tool and Methodological Index for Non-Randomized Studies scale, with evidence graded by Grading of Recommendations Assessment, Development, and Evaluation. A random-effects network meta-analysis was performed with effect sizes reported as odds ratios or mean differences and 95% confidence intervals. Surface under the cumulative ranking curve values were used for ranking, and publication bias was assessed by funnel plots. Results: Seventeen studies (7 RCTs and 10 retrospective studies) with 1054 patients were included. The posteromedial (PM) approach significantly improved functional recovery compared with the anterolateral (AL) approach (odds ratios = 2.09, 95% confidence intervals: 0.49–3.68, P = .011). Modified posteromedial (mPM) and posterolateral (PL) approaches also ranked highly for functional outcomes. No significant differences in complications were found, although combined approaches (anterolateral plus anteromedial, AM + PL) ranked better. Anterolateral plus modified posteromedial significantly reduced operative time (–20.20 minutes, P = .019), while AM + PL prolonged it (+11.65 minutes, P = .037). Anterolateral plus anteromedial (+23.26 mL, P = .002) and AM + PL (+17.28 mL, P = .015) caused greater blood loss. PM, mPM, and PL shortened fracture healing by 2 to 3 weeks ( P < .001). Conclusions: PM, mPM, and PL approaches show advantages in functional recovery and fracture healing, while combined approaches may reduce complications. Anterolateral plus modified posteromedial improves surgical efficiency. Surgical choice should consider fracture type, soft tissue condition, and operative goals. Further high-quality multicenter RCTs are needed to confirm these findings.