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External Fixation Vs Intramedullary Nailing For Open Tibial Fractures: A Meta-Analysis
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August 2024
External Fixation Vs Intramedullary Nailing For Open Tibial Fractures: A Meta-Analysis
Study Type:Therapy
OE Level Evidence:1
Journal Level of Evidence:1
External fixation versus intramedullary nailing for the management of open tibial fracture: meta-analysis of randomized controlled trials.
Int Orthop . 2023 Dec;47(12):3077-3097.Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
Six randomized controlled trials including 407 patients with open tibial fractures were included in this systematic review and meta-analysis comparing external fixation (EF) versus unreamed tibial intramedullary nailing (UTN). Pooled outcomes of interest included postoperative superficial and deep infections, malunion, delayed union, nonunion, and hardware failure. UTN significantly reduced the rates of superficial infection and malunion compared to EF, while both treatments showed similar effectiveness for deep infections, delayed union, and nonunion. EF, however, resulted in fewer hardware failures. This analysis suggests that UTN might be preferred for managing open tibial fractures, with careful monitoring of postoperative weight-bearing to prevent hardware failure.
Publication Funding Details
Funding
Not Reported
Funding Details
N/A
Disclosures
None disclosed
Why was this study needed now?
Open tibial fractures are common and complex injuries often resulting from high-energy trauma, posing significant challenges in management due to poor soft tissue coverage and blood supply issues leading to complications such as infection and poor bone healing. Both EF and UTN are widely used, but debate continues over the optimal treatment approach. This study is essential now to address gaps in the existing literature by rigorously comparing EF and UTN through a meta-analysis of high-quality randomized controlled trials, aiming to refine treatment recommendations based on up-to-date evidence.
What was the principal research question?
In patients with open tibial fractures, is unreamed tibial intramedullary nailing compared to external fixation more effective in reducing the incidence of complications?
What were the important study characteristics?
Population
407
Total Sample Size
Patients with open tibial fractures.
Intervention
188
External Fixation
Patients in this group underwent external fixation.
Comparison
219
Unreamed Intramedullary Nail
Patients in this group underwent unreamed tibial intramedullary nailing.
Outcomes
Incidence of superficial infection
Adverse events
Incidence of deep infection
Adverse events
Incidence of malunion
Adverse events
Incidence of delayed union
Adverse events
Incidence of nonunion
Adverse events
Incidence of hardware problems
Adverse events
Methods
Meta-analysis
Time
Final follow-up
Outcomes: Adverse events
Risk of Bias
Confidence in the results: Critically Low
Risk of Bias
Yes
Partial Yes
No
Protocol registered before commencement of the review
Adequacy of the literature search
Justification for excluding individual studies
Risk of bias from individual studies being included in the review
Appropriateness of meta-analytical methods
Consideration of risk of bias when interpreting the results of the review
Assessment of presence and likely impact of publication bias
Confidence in the results: Critically Low
What were the important findings?
Significantly Better
No Difference
Significantly Better
External Fixation
Unreamed Intramedullary Nail (Unreamed
Tibial Intramedullary Nailing)
MD: Mean Difference; SMD: Standardized Mean Difference; OR: Odds Ratio, RR: Risk Ratio; CI: Confidence Interval
What should I remember most and how will this affect the care of my patients?
Overall, unreamed tibial intramedullary nailing (UTN) generally offers better outcomes in terms of reduced superficial infections and malunion rates compared to external fixation (EF) in the treatment of open tibial fractures. These results suggest a potential preference for UTN in clinical practice. However, careful postoperative management is essential to prevent hardware failure. The main limitation of this paper is the potential variability in the surgical expertise and methods applied across different studies, which might influence the results.
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