This document summarizes evidence from extensive research on the treatment of open tibial fractures comparing external fixation to nailing. It finds that for type 3B open fractures with bone loss, contamination, and delayed presentation, external fixation may have lower deep infection rates than nailing. However, existing studies have had a low number of type 3B cases. A high-quality randomized controlled trial is still needed directly comparing nailing to external fixation for severe 3B open tibial fractures. External fixation can allow for repeat debridement but risks loss of alignment, while infection after nailing requires multiple surgeries. The best treatment choice depends on the specific fracture characteristics and surgeon experience.

1. EXTERNAL FIXATION IN OPEN
TIBIAL FRACTURES-BEST
EVIDENCE
Hitesh Gopalan U
Clinical Asst Professor
www.orthoevidence.com
www.orthopaedicprinciples.com

2. Extensive Research
 Reamed Vs Unreamed
 External Fixation Vs Nailing
 Ex Fix followed by Delayed Nailing
 SPRINT trial, Tornetta et al.,, Bhandari et al.,
Petrisor et al., Schemitsch et al.,
Swiontkowski et al..Giannoudis et al..

4. External Fixation
 3B
 Bone loss
 Extensive periosteal stripping
 Contamination
 Delayed Presentation

5. Meta analysis
 5 Randomised control trials comparing Ex Fix Vs Nailing
 Ex Fix Vs Nailing: no difference in deep infection rates
 The no of patients with type 3B injuries was low(eg.,
SPRINT Trial)
Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch EH: Treatment of open
fractures of the shaft of the tibia. J Bone Joint Surg Br 2001;83:62-68 LEVEL 2.

6. High Quality RCT
 Need for a high quality RCT that compares
nailing Vs external fixation in 3B fractures

7. Infection after IM nailing
 Catastrophe
 Multiple Surgeries
 Prolonged treatment
 Circular Fixator

8. Grading of Complications
Reoperation
 Dynamisation
 Bone Grafting
 Pin tract infections
 Treatment for an infected IM nail

9. Ciery and Mader

10. External Fixation
 Deep infection rates: 4-6%
 Loss of alignment
 Pin Tract Infections
 Union rates are similar with Nailing Vs Ex Fix
Giannoudis PV, Papakostidis C, Roberts C: A review of the management
of open fractures of the tibia and femur. J Bone Joint Surg Br
2006;88:281-289. LEVEL -3

11. Surgeon Choice
 Surgeons across North America
 Surgeons across India

12. Delayed Conversion
 Loss of alignment
 Shorter Duration of Ex fix
 Safe Interval(10-14 days)
Bhandari M, Zlowodzki M, Tornetta P III, Schmidt A, Templeman DC:
Intramedullary nailing following external fixation in femoral and
tibial shaft fractures. J OrthopTrauma 2005;19:140-144.
LEVEL- 2

13. Reamed nailing Vs Ex Fix
 Experimental data on thermal necrosis(Schemitsch et al..)
 Inflammatory mediator release(Il-6 and HLA DR release)-
correlates well with sepsis
Schemitsch EH, Kowalski MJ, Swiontkowski MF, Senft D: Cortical bone
blood flow in reamed and unreamed locked intramedullary nailing: A
fractured tibia model in sheep.
J OrthopTrauma 1994;8:373-382

14. Bone Loss

15. Delayed Presentation
 Delays in Debridement
 Delays in Antibiotic administration
 External fixation: repeat debridements

16. Infection
 External fixator
 Antibiotic loaded cement
 Conversion to a Ring fixator

18. Infection after IM nail
 Removal of IM Nail
 ALBC
 Ring fixator: Excision and Bone transport

19. Evidence Cycle
Ask
Act
Acquire
Apply
Appraise
“EBM Begins and Ends with the Patient”

21. Thank You