INTRAMEDULLARY NAILING VERSUS EXTERNAL FIXATION FOR THE TREATMENT OF GRADE III OPEN TIBIAL FRACTURES

Abstract

Aim: The open tibial fracture is an increasingly common injury. In those with severe soft tissue damage (i.e., Gustilo type III), it is still controversial how to primarily stabilise the bony structure. This study aims to compare the use of the unreamed interlocking tibial nail (URTN) with external fixation (Ex-Fix) in the treatment of patients with grade III open tibial fractures.

Methods: A Medline literature search identified 21 studies. Only those comparing URTN with Ex-Fix for the treatment of grade III open tibial fractures, in adults, were included. Non-comparative studies were excluded. The quality of each study was assessed and relevant data extracted.

Results: Total number of patients in studies included was 53 in the URTN group and 54 in the Ex-Fix group. Non-union occurred in 10.7% of patients treated with URTN compared to 25.2% in the Ex-Fix group. Mal-union and malrotation were much lower in the URTN group than in the Ex-Fix group, 26.5% vs. 41.7% and 8.7% vs. 21.7%, respectively. Time to union was shorter with URTN (31.9 weeks) compared to Ex-Fix (37 weeks). Time to full weight bearing was significantly shorter with URTN compared to Ex-Fix, 16.6 weeks vs. 28.7 weeks, respectively. Infection rate was higher with Ex-Fix (29.1%) compared to URTN (11.5%), and nerve injury also occurred more with Ex-Fix, 16.7% vs. 9.8%. Re-operation rate was high in both groups (40% URTN, 35.9% Ex-Fix).

Conclusions: The unreamed interlocking tibial nail is superior to external fixation in the treatment of grade III open tibial fractures. It is a safe, effective technique with comparably low complication rates. Management of concomitant soft tissue injuries is consistently easier, and patients have a significantly shorter time to full weight bearing. External fixation, however, still has a role in the immediate stabilisation of these fractures, especially in the critically ill unstable patient.