Treatment of complex tibial shaft fractures. Arguments for early secondary intramedullary nailing.

In 135 cases of mainly open tibial shaft fractures treated primarily with external fixation, 73 patients (54%) were treated exclusively with external fixation; osteomyelitis occurred in 8.2%, nonunion in 8.2%, and malunion in 32.8%. Later sequential plating was performed in 38 patients (28%), and in 24 patients (18%) secondary intramedullary nailing. Patients with delayed nailing after primary external fixation had the lowest incidence of osseous infection (4.1%) and nonunion (4.1%), the lowest malunion rates under strict criteria (24%), and a significantly shorter healing time (21.5 weeks versus 33.4 weeks after secondary plating and 30.2 weeks after treatment with external fixation alone). Patients treated with secondary plating had osseous infection in 10.2%, nonunion in 7.8%, and malunion in 29.3%. Changing to an intramedullary nail after primary treatment of open tibial shaft fractures with external fixation was a more effective way to treat these fractures than definitive treatment with external fixation alone or delayed secondary treatment by plating. Sequential nailing can be performed as early as one to three weeks after trauma without the necessity of a safety interval between the removal of external fixation and intramedullary nailing to prevent infection.