Short-term outcomes of Gustilo grade 3A open tibia diaphyseal fractures: intramedullary nail versus external fixation

Abstract

Background: Open tibial fractures pose a major therapeutic challenge due to the high incidence of postoperative complications. Although Locked Intramedullary (IM) nail and uniplanar External Fixation (EF) are the most common treatment modalities, the superior mode of management remains controversial.
Objective: The purpose of this study was to prospectively compare short-term outcomes of patients with Gustilo 3A open tibia shaft fractures treated with IM nail compared to uniplanar EF.
Methodology: In this prospective cohort study, adult patients (≥18 years-old) with Gustilo 3A open tibia shaft fractures treated by either intramedullary nail or EF were included. This study was conducted at Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania for a period of twelve months from March 2013 to February 2014. After enrollment, patients were followed-up at 2, 6, 10, 14, and 18 weeks postoperatively. At these visits, rate of callus formation at fracture site and surgical complications (e.g. infection, limb length discrepancy, malalignment) were assessed.
Results: Out of 50 patients enrolled in the study, 26 were treated by IM nail and 24 by external fixation. Twenty-four patients (92.3%) in the IM nail group and 6 (25%) in the external fixation group had callus formation by the 10th week. The mean times to callus formation in the IM nail group and external fixation group were 8.2±2.6 weeks and 14.7±3.3 weeks, respectively (p=0.000). Two (7.7%) patients in the IM nail group and 3 (12.5%) in the external fixation group developed infection (p=0.661). No IM nail patients developed limb length discrepancy. In contrast, to 2 (8.3%) external fixation patients developed limb shortening between 2-3cm. No patients had limb length shortening of >3cm. No malalignment was observed in IM nail patients, but 3 (12.5%) external fixation patients developed malalignment and required reoperation.
Conclusion: Interlocking intramedullary nail appears to be a better option for the treatment of Gustilo 3A open tibia shaft fractures as compared to uniplanar external fixation. Advantages of the IM nail include faster rate of callus formation and lower rates of limb length discrepancy and malalignment.

Key words: Open tibia fractures, Orthopaedic surgery, Tanzania, Intramedullary nail, External fixation