Problems of various fixation methods for open tibia fractures: experience in a Japanese level I trauma center

Two hundred thirty-seven patients with open tibial fractures (245 fractures) were treated as follows: nonoperative stabilization alone (Nonop group, n = 54); immediate open reduction and internal fixation (ORIF group, n = 47); delayed ORIF (D-ORIF group, n = 109); or external fixation (EF group, n = 35). The D-ORIF group was further divided into ORIF after nonoperative treatment (Nonop/ORIF, n = 86), and ORIF after external fixation (EF/ORIF, n = 23). The open tibial fractures were classified as follows: 42 type I (no infections), 107 type II (4 infections), 43 type IIIA (3 infections), 42 type IIIB (12 infections), and 11 type IIIC (2 infections), with significant differences in infection rate between type IIIB and type I, type II, or type IIIA. The deep infection rates in Nonop, ORIF, Nonop/ORIF, EF/ORIF, and EF groups were 3.7%, 12.8%, 5.8%, 30.4%, and 2.9%, respectively. There were significant differences in deep infection rates between the EF/ORIF and Nonop/ORIF, and the EF group. The mean period of fracture healing for type IIIB fractures was delayed. The mean time to union of the EF/ORIF was significantly longer than that of the ORIF, Nonop/ORIF, and EF groups, respectively. Complete and consecutive debridement procedures and early soft-tissue coverage should be done to avoid wound infection, especially in type IIIB fractures. Delayed internal fixation after external fixation had the highest risk of infection, mandating meticulous wound management in such patients.