Treatment of open tibial-shaft fractures. External fixation and secondary intramedullary nailing

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.