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The Journal of Bone and Joint Surgery, Vol 70, Issue 6 900-911, Copyright © 1988 by Journal of Bone and Joint Surgery, Inc
Treatment of open tibial-shaft fractures. External fixation and secondary intramedullary nailing
JM McGraw and EV Lim
Department of Orthopaedic Surgery, University of Cincinnati Medical Center, Ohio 45267.
Between 1979 and 1986, sixteen of 369 open fractures of the tibial shaft
were treated by external fixation followed by intramedullary nailing. These
fractures comprised one Type-I, two Type-II, and thirteen Type-III
injuries. This method of treatment was the original treatment plan in nine
patients (56 per cent), for delayed union while the external fixator was
still in place in four patients (25 per cent), for loss of reduction in a
plaster cast in two patients (13 per cent), and for osteomyelitis and a
segmental defect in one patient (6 per cent). The average duration of
external fixation was 8.5 weeks; the average time between removal of the
external fixator and intramedullary nailing, three weeks; and the average
time between injury and nailing, twelve weeks. All sixteen patients were
followed until either the fracture had united (eleven patients) or there
was an established non-union (five patients). At that time, seventeen
additional procedures were performed, including bone-grafting, fibulectomy,
and re-nailing. Only five of the sixteen fractures healed without
additional surgical procedures or major complications. The five fractures
that progressed to a non-union were all Type III, and all were complicated
by a deep infection. Over-all, the complications included seven deep
infections (an intramedullary infection in four patients, osteomyelitis in
two, and a chronic draining sinus associated with a ring sequestrum in
one); five minor infections during external fixation, which developed into
five of the seven deep infections that occurred after the secondary
intramedullary nailing; and eight non-unions, three of which progressed to
union after multiple procedures. The over-all incidence of non-union was 50
per cent and that of deep infection, 44 per cent. On the basis of the high
incidence of complications in both the present series and the few reports
in the literature, we concluded that alternative treatment options should
be carefully considered before electing this sequential method of fixation.
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