Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail

Ibrahim Natalwala; Cher Bing Chuo; Isla Shariatmadari; Gavin Barlow; Elizabeth Moulder; Joanna Bates; Hemant Sharma

doi:10.5005/jp-journals-10080-1536

Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail

Strategies Trauma Limb Reconstr. 2021 Sep-Dec;16(3):161-167. doi: 10.5005/jp-journals-10080-1536.

Authors

Ibrahim Natalwala¹, Cher Bing Chuo¹, Isla Shariatmadari², Gavin Barlow³, Elizabeth Moulder⁴, Joanna Bates⁵, Hemant Sharma⁴

Affiliations

¹ Department of Plastic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom.
² Department of General Surgery, Bristol Hospitals NHS Trust, Bristol, United Kingdom.
³ Department of Infectious Diseases, Hull University Teaching Hospitals, Hull, United Kingdom.
⁴ Department of Trauma and Orthopaedic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom.
⁵ Department of Radiology, Hull University Teaching Hospitals, Hull, United Kingdom.

Abstract

Introduction: High-energy grade III open fractures of tibia are associated with significant complications and generate debate over the ideal fixation method. This study compares the clinical outcomes for circular frame fixation (CFF) vs intramedullary nail fixation (IMF) in grade III open tibial fractures.

Materials and methods: Single-centre retrospective study of patients admitted from January 2008 to December 2016. All patients with grade III open diaphyseal tibial fractures (AO 42 A, B, C), treated with either CFF or IMF, were included. The primary outcome was deep bone infection (DBI). Secondary outcomes were delayed or non-union, secondary intervention, and amputation.

Results: A total of 48 limbs in 47 patients had CFF, and 25 limbs in 23 patients had IMF. Median time to definitive fixation was significantly longer for CFF at 9 days (IQR 3-13) compared to IMF at 1 day (IQR 0-3.5) (p <0.001). The DBI rate was significantly lower (2 vs 16%) in the CFF group (p = 0.04). There were 14 limbs (29%) with delayed or non-union in the CFF group vs 5 limbs (20%) in the IMF group. In the CFF group, significantly more limbs required bone grafting for delayed or non-union (p = 0.03). However, there was a greater proportion of limbs in the CFF group with segmental fractures or bone loss (46 vs 4%) and these high-energy fracture patterns were associated with secondary bone grafting (p = 0.005), and with delayed or non-union (p = 0.03). A subgroup analysis of patients without segmental fractures or bone loss treated with either CFF or IMF showed no significant difference in secondary bone grafting (p >0.99) and delayed or non-union rates (p = 0.72). Overall, one patient in each group went on to have an amputation.

Conclusion: Our study found that CFF had a lower rate of DBI compared to IMF. Injuries with high-energy fracture patterns (segmental fractures or bone loss) were more likely to have delayed or non-union and require secondary bone grafting. These factors should be considered when selecting the appropriate method of definitive fixation.

How to cite this article: Natalwala I, Chuo CB, Shariatmadari I, et al. Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail. Strategies Trauma Limb Reconstr 2021;16(3):161-167.

Keywords: Circular frame; Intramedullary nail; Open fracture; Tibia.