Skeletal fixation of grade IIIB tibial fractures. The potential of metaanalysis.

Contemporary management of Grade IIIB open tibial fractures has evolved to include intravenous antibiotics, thorough interval surgical debridement, rigid skeletal fixation, early local or free tissue myoplasty, and liberal use of autogenous bone graft beneath a clean, stable wound. External fixation has been the skeletal stabilization of choice with the lowest reported deep sepsis rates. Pin tract infection, malunion, and nonunion have complicated its use. Static unreamed locked nailing is an alternative treatment that has been successfully used in lower grade open tibial fractures. A metaanalysis of the literature was undertaken to determine whether there was evidence favoring 1 method of skeletal fixation. Inclusion criteria were restricted to studies that were randomized to either external fixation or unreamed intramedullary nail methods and that used a strict definition of Grade IIIB to include muscle transfer for soft tissue coverage. Two studies were identified and combined to show no difference in deep sepsis rate. Intramedullary nailing significantly shortened union time whereas external fixation showed a trend toward a higher incidence of malunion and superficial sepsis. More well designed randomized studies would add to this initial effort and yield more compelling evidence for either form of fixation.