The management of type III open tibial fractures.

In extensive type III open tibial fractures, limb salvage is considered worthwhile when there is good distal circulation and nerve function. The use of the external fixator has revolutionized the management of skin and soft tissues. However, the subsequent morbidity is still high. A retrospective study of 17 cases is analysed: the amputation rate was 6 per cent, delayed union 60 per cent, infected non-union 30 per cent and mal-union 40 per cent. The final functional result was good in 13 per cent of cases, satisfactory in 30 per cent, fair in 30 per cent and poor in 27 per cent. All patients preferred a functional limb to a prosthesis. The technique of using external fixation and the subsequent management are discussed. To improve the result, we recommend perfect alignment, fixation of the fracture with semi-rigid external fixation and early cancellous bone grafting for comminuted fractures and bone loss. Secondary internal fixation using implants is not advisable. A radical approach is necessary in infected ununited fractures. This includes excision of dead and contaminated tissue and the insertion of gentamicin methyl methacrylate bead implants. Although the complication rate is high and the rehabilitation period is prolonged, the main aims of limb salvage, viz. to retain a functional leg, are largely fulfilled.