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External fixation versus intramedullary nailing for the management of open tibial fracture: meta-analysis of randomized controlled trials

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Abstract

Aim

Tibial shaft fractures are the most common type of long-bone fractures. External fixation (EF) and intramedullary nailing (IMN) are widely used surgical techniques for the definitive fixation of open tibial shaft fractures. The aim of this systematic review and meta-analysis was to compare EF to IMN for the definitive fixation of open tibial fractures.

Methods

Medline, Embase, and CENTRAL databases were searched for eligible studies. We included randomized controlled trials (RCTs) that compared EF to IMN for skeletally mature adults with open tibial fracture (Gustilo I, II, and III). We evaluated the following outcomes: superficial infection, pin-track infection, deep infection, malunion, nonunion, delayed union, and implant/hardware failure. The risk ratio (RR) was used to represent the desired outcomes. The statistical analysis was performed using the random-effects model.

Results

A total of 12 RCTs that enrolled 1090 participants were deemed eligible for the analysis. EF showed a significantly higher rate of superficial infection, pin track infection, and malunion compared to IMN (RR = 2.30, 95% confidence interval (CI): 1.34 to 3.95; RR = 13.52, 95% CI: 6.16 to 29.66; RR = 2.29, 95% CI 1.41 to 3.73, respectively). No substantial difference was found between EF and IMN in terms of deep infection, nonunion, delayed union, or implant/hardware failure (RR = 1.15, 95% CI 0.67 to 1.98; RR = 0.92, 95% CI 0.77 to 1.10; RR = 1.50, 95% CI 0.98 to 3.33; RR = 0.96, 95% CI 0.36 to 2.60, respectively).

Discussion

The findings of our meta-analysis are consistent with the previous systematic reviews excepts for the implant/hardware failure which was found to be significant in favour of IMN by one of the previous reviews.

Conclusion

This meta-analysis confirms that IMN is better than EF with respect to clinical outcomes and complication rate for the definitive fixation of open tibial fracture.

Highlights

  • External fixation (EF) and intramedullary nailing (IN) are widely used for the definitive fixation of open tibial fractures.

  • IMN is more preferred as it is associated with lower risk of infection.

  • Recent randomized clinical trials demonstrated similar risk of infection between the two surgical techniques.

  • We aimed to provide an updated meta-analysis comparing EF to IMN for the definitive fixation of open tibial fractures with respect to infection rate and fracture healing problems.

  • Our review revealed that IMN offers lower rates of superficial infection, pin-track infection, and malunion, supporting the use of IMN over EF for the definitive fixation of open tibial fractures.

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Data availability

All relevant data are reported within this manuscript, additional information will be available upon request to the corresponding author.

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Authors and Affiliations

  1. College of Medicine, King Saud Bin Abdelaziz University for Health Sciences, Jeddah, Saudi Arabia

    Jawaher F. Alsharef, Abdullah A. Ghaddaf, Mohammed S. AlQuhaibi, Esraa A. Shaheen, Lamar H. AboAljadiel, Abdullah S. Alharbi & Bashair Y. AlHidri

  2. King Abdullah International Medical Research Center, Jeddah, Saudi Arabia

    Jawaher F. Alsharef, Abdullah A. Ghaddaf, Mohammed S. AlQuhaibi, Esraa A. Shaheen, Lamar H. AboAljadiel, Abdullah S. Alharbi & Bashair Y. AlHidri

  3. Ibn Sina National College for Medical Studies, Jeddah, Saudi Arabia

    Mohammed K. Alamri

  4. College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

    Asim M. Makhdom

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  1. Jawaher F. Alsharef
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Contributions

All authors contributed to the study conception and design, material preparation, and data collection. The analysis was performed by Jawaher F. Alsharef and Abdullah A. Ghaddaf. The first draft of the manuscript was written by Jawaher F. Alsharef and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Asim M. Makhdom.

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Alsharef, J.F., Ghaddaf, A.A., AlQuhaibi, M.S. et al. External fixation versus intramedullary nailing for the management of open tibial fracture: meta-analysis of randomized controlled trials. International Orthopaedics (SICOT) 47, 3077–3097 (2023). https://doi.org/10.1007/s00264-023-05879-7

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