SLR - June 2019 - Matthew J. Dougherty

A Retrospective Comparative Cohort Study Comparing Temporary Internal Fixation to External Fixation at the First-Stage Debridement in the Treatment of Type IIIB Open Diaphyseal Tibial Fractures

Reference: Fowler, T. A Retrospective Comparative Cohort Study Comparing Temporary Internal Fixation to External Fixation at the First-Stage Debridement in the Treatment of Type IIIB Open Diaphyseal Tibial Fractures. J Orthop Trauma. 2019; 33(3), 125–130.

Scientific Literature Review

Reviewed By: Matthew J. Dougherty, DPM
Residency Program: Temple University Hospital, Philadelphia, PA

Podiatric Relevance: Open fractures of the lower extremity are podiatric surgical emergencies that are both complex and associated with high rates of complications. Due to the severity of these injuries, definitive methods of fixation usually cannot be used initially. Historically, the application of external fixation has been the gold standard for treatment of open fractures of the lower extremity. The aim of this study was to assess the prevalence of deep infection when comparing the use of external fixation to the use of temporary internal fixation with Type IIIB open tibial diaphyseal fractures.

Methods: This is a level III study utilizing a retrospective contemporaneous comparative cohort design. Records of patients with Type IIIB open diaphyseal tibial fractures treated with temporary internal fixation or external fixation between May 2014 and May 2016 were reviewed. Temporary internal fixation consisted of a 3.5 mm small fragment plate, which was applied with bicortical screw fixation. In total, 47 patients were included in the study, with 24 undergoing temporary internal fixation and 23 with external fixation. All patients underwent initial procedures within 72 hours. The mean follow-up period was 2.1 years.    

Results: Of the 47 patients, 31 were male and 16 were female with a median age of 41. Comorbidities in the patient population included 11 patients who abused tobacco and three patients living with diabetes. Overall, there was a total of six patients who experienced complications. There was a total of four cases of deep infection with the rate of deep infection being 13 percent in the external fixation group and 4 percent in the temporary internal fixation group.   

Conclusions: Open fractures of the lower extremity are podiatric surgical emergencies that threaten the viability of the lower limb. While external fixation has been the gold standard for open fracture treatment, this study found temporary internal fixation to be an adequate treatment for Type IIIB open tibial diaphyseal fractures. The limitations of this study include the retrospective nature and nonrandomized allocation leading to potential selection bias. Finally, there was also no blinding at follow-up. In conclusion, both methods are viable options for treating Type IIIB open tibial diaphyseal fractures. 

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