Treatment of open tibial diaphyseal fractures by external fixation combined with limited internal fixation versus simple external fixation: a retrospective cohort study

Abstract

Background: The treatment of open tibial shaft fractures is challenging. External fixation (EF) is comparatively safe in treating these open injuries, meanwhile it has the advantages of easy application, minimal additional disruption, and convenient subsequent soft tissue repair. Nevertheless, its application is accompanied by a series of problems in alignment and bone healing. Therefore, limited internal fixation (LIF), such as cortical screws, has been used based on the external fixator for better therapeutic effect. The aim of this study is to compare the outcomes of EF combined with LIF and simple EF in the management of open tibial shaft fractures, evaluating the efficacy and safety of using the combined technique in treating such fractures.

Methods: From January 2012 to December 2016, patients with open tibial shaft fractures treated with EF with or without LIF augmentation were identified. A total of 152 patients were included in the analysis, and there were 85 patients in the simple external fixation group and 67 patients in the EF-LIF group. General assessment indicators included the direct cost of hospitalization and the times of first surgery, full weight bearing, and complete union. Infections and complications in union or limb alignment were compared as primary outcomes. Additionally, the number of patients who changed the fixation system for various reasons were analysed.

Results: Effective follow-up of all participants for statistical analysis was obtained. The follow-up time averaged 17.15 months (range: 12.00 to 24.00 months) in the EF group and 16.20 months (range: 12.00 to 19.00 months) in the EF-LIF group. Combined fixation provided shortened time to bear full weight and achieve complete bone union, while requiring additional first surgery time. No significant difference was found in infection rates or direct cost of hospitalization. Delayed union and non-union in the EF-LIF group were significantly decreased (20.9% versus 40.0, 1.5% versus 14.1%, p < 0.05). In limb alignment, patients with combined fixation exhibited reduced malreduction, loss of reduction, and malunion. In terms of secondary fixation, the EF-LIF group showed a markedly lower incidence (5.8% versus 34.1%, p < 0.001).

Conclusion: Compared with simple EF, combined fixation is an effective and safe alternative for management of open tibial diaphyseal fractures. It provides superior initial reduction, better stability and decreases the risk of inferior alignment and delayed union without increasing the risk of infection.

Keywords: Combined fixation; External fixation; Limited internal fixation; Open tibial diaphyseal fractures.

Fig. 1

Brief intraoperative procedures for a 44-year-old male with grade II open tibial shaft fracture who accepted external fixation combined with limited internal fixation. a The initial injured limb. b Surgical fixation with an external fixator and limited internal apparatus of a Ni-Ti arched shape-memory connector (ASC). c Sufficient soft tissue coverage after placing the internal implants. d Different models of the ASCs

Fig. 2

An illustrative case treated with external fixation combined with cortical screws. a Preoperative radiographs of the injured limb. b The initial postoperative radiographs following application of an external fixator and cortical screws. c Radiographs at final follow-up (12 months after the initial operation)

Fig. 3

An illustrative case treated with external fixation combined with ASCs. a Preoperative radiographs of the injured limb. b The initial postoperative radiographs following application of an external fixator and ASCs. c Radiographs 6 months after from the initial operation. d Radiographs at final follow-up (17 months after the initial operation)