Intramedullary nailing versus external fixation in Gustilo type III open tibial shaft fractures: a meta-analysis of randomised controlled trials

Abstract

Open tibial shaft fractures are the most common of long-bone open fractures. Management of the fracture is either by intramedullary nailing (IMN) or by external fixation (EF). Since the literature does not indicate clearly which is more effective, a meta-analysis was conducted to establish which approach is more suitable to treat Gustilo type III fractures. MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE and CINAHL databases were searched for randomised controlled trials (RCT) describing IMN and EF treatment of Gustilo type III fractures. As of 15 November 2012, five RCT involving 239 patients had been published; the outcomes examined in this study are their surgical complications. Data analysis led complications to be grouped into infection, fracture healing problems (non-union, malunion) and “other complications” (vascular injury, revision surgery, soft tissue damage, mechanical failure and tibial malalignment). IMN was associated with lower rates of infection and fracture healing problems; the differences between the two approaches for “other complications” were not significant. The data indicate that IMN is the treatment of choice for Gustilo type III fractures.

Open fractures of the lower extremity

“…Recent meta-analyses have shown the incidence of infection to be significantly reduced in Gustilo type III injuries managed with IM nailing when compared with external fixation. 65 , 66 However, another meta-analysis showed insignificant differences in the rate of infection with both internal and external fixation. 64 …”

“…Other factors affecting union include the type of management: external fixation carries higher risk of adverse outcomes than IM nailing, 65 including nonunion and infection rates. The two noted outcomes have a known relationship: infection contributes to development of necrotic bone and fixation failure, making bony union more difficult.…”

Management of the High Energy Traumatism of the Limbs

“…There are some exceptions. It has been observed that some selected cases of III A shaft fractures can be managed like GA type I, II -intramedullary nailing being performed during the first surgery [23]. Some papers have assessed that in tibial shaft fracture it is better to do osteosynthesis as soon as possible, recommended during the first surgical intervention.…”

“…Promptly using the intramedullary nailing has some advantages such as lowering the necessity of second intervention, lowering the risk of infection and faster rehabilitation [25], [39]. This outcome has been noted also in GA III traumatisms of the tibial shaft [23].…”

Current concepts in the management of open tibia fractures

“…Intramedullary nailing (IMN) and external fixation currently represent the most widely used methods of fixation after open fractures, with the use of plate fixation declining since the 1970s. 111 Giovannini et al performed a meta-analysis of five randomised controlled trials comparing intramedullary nailing with external fixation in the management of open tibia fractures. 111 The authors concluded that IMN was more effective due to the lower rate of infection; however, the results of this analysis should be treated with caution as only five studies that included less than 250 patients were reviewed, monolateral and circular fixators were grouped together, and the description of fracture subtypes and complications was not uniform.…”