Modern External Ring Fixation Versus Internal Fixation for Treatment of Severe Open Tibial Fractures

Abstract

Major Extremity Trauma Research Consortium (METRC)*Background: Modern external ring fixation has been hypothesized to reduce complications requiring hospital readmission compared with internal fixation when treating patients with high-energy open tibial shaft fractures. In this study, the 1-year probability of a major limb complication was compared between external and internal fixation of severe open tibial fractures.Methods: This multicenter randomized clinical trial included patients 18 to 64 years of age with severe open tibial shaft fractures randomly assigned to either modern external ring fixation (n = 127) or internal fixation (n = 133). The primary outcome was a major limb complication within 365 days after randomization; these complications included amputation, infection, a soft-tissue problem, nonunion, malunion, and a loss of reduction/implant failure.Results: Of 260 randomized patients, 254 were included in the final analysis. Their mean age (standard deviation) was 39 (13) years; 214 (84%) were men. The probability of at least 1 major limb complication was higher for external fixation (62.1% [95% confidence interval (CI): 53.4% to 70.8%]) than internal fixation (43.7% [95% CI: 35.5% to 52.9%]), with a risk difference of 18.4% (95% CI: 5.8% to 30.4%); p = 0.005). The most notable difference was in loss of reduction/implant failure, the rate of which was higher for external fixation (risk difference: 14.4% [95% CI: 7.0% to 21.6%]; p = 0.002). There was no appreciable difference in the probability of deep infection between external fixation (26.1%) and internal fixation (29.7%) (risk difference: 23.5% [95% CI: 214.8% to 7.8%]; p = 0.54). There were also no appreciable differences in the probabilities of amputation, nonunion, soft-tissue problems, malunion, or fracture healing between the groups.Conclusions: These results argue against routine use of modern external ring fixation for the treatment of these severe open tibial fractures.Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. Open tibial shaft fractures are common injuries associated with poor outcomes and high rates of complications [1][2][3][4][5][6][7][8][9][10][11][12] . Traditional treatment protocols utilize intramedullary nails or plates for fracture fixation, which involve placing metal at the open fracture site. Studies indicate that infection rates increase when an implant is placed within a wound, likely due to the difficulty that the immune system has in clearing bacteria from biofilm that can develop on metallic surfaces [13][14][15] . Treatment with modern external ring fixation, which does not place any implant at the fracture site, is therefore thought to reduce rates of deep infection and potentially also reduce overall complication rates.Although there is a theoretical basis to support an advantage of modern external ring fixation 4,6,16 , it is unknown if this treatment performs better than the more commonly used internal fixation in terms of major complicati...

Is fracture management merely a physical process? Exploring the psychological effects of internal and external fixation

“…The results of a randomized controlled trial led by the Major Extremity Trauma Research Consortium (METRC) suggest that even in the case of severe open tibial fractures, the routine use of modern external ring fixation for treatment should be avoided. Patients with poor psychological baselines may require timely psychological intervention if negative emotions worsen within the first week following external fixation treatment [ 57 ]. Notably, internal fixation surgery may be a better choice when both internal and external fixation can be performed on a patient with a fragile psychological health status.…”

Functional outcomes and quality of life at 1-year follow-up after an open tibia fracture in Malawi: a multicentre, prospective cohort study

“…A randomised controlled trial among adults with Gustilo type IIIA or type IIIB open tibia fractures in 20 trauma centres in the USA showed that external ring fixation had a higher complication rate than did internal fixation (62% vs 44%, respectively). 27 If open tibia fractures were prioritised over other orthopaedic injuries in tertiary hospitals, this decision might cause delayed and non-operative management for other orthopaedic injuries. A detailed cost and implementation feasibility analysis of intramedullary nailing is required to determine whether it is feasible to offer intramedullary nailing for all open tibia fractures in Malawi and in other LMICs.…”

Plate-assisted bone-segment transport in the femur with 2 internal lengthening nails: a technical note and a case report

“…This risk can be lowered by adding local antibiotics [ 7 ]. The recent “Fixit” study [ 8 ] has shown that internal fixation is equivalent, if not superior, to external fixation in open fracture cases, and has comparable complication rates. Furthermore, the internal device maintains full mechanical support of the bone, should recurrence, reinfection, or metastatic disease incur.…”