GUSTILO IIIA AND IIIB OPEN DIAPHYSEAL FRACTURE OF TIBIA TREATED BY NA EXTERNAL FIXATOR AS DEFINITIVE TREATMENT

Tibial shaft fractures are among the most common long bone fractures, often resulting from high-energy trauma such as motor vehicle accidents, falls, and extreme sports (Court-Brown & McBirnie, 1995). The tibia, being a primary weight-bearing bone, is vulnerable to fractures, particularly along its subcutaneous antero-medial surface. These fractures, especially when open and associated with soft tissue injury, pose significant treatment challenges, often resulting in nonunion, infection, and long-term disability (Bhandari et al., 2008). Open fractures, particularly those classified as Gustilo III-A and III-B, require aggressive treatment strategies to prevent complications and promote healing (Schlickewei et al., 2019).

Historically, tibial fractures were treated using closed reduction and casting. However, this approach is less effective for open fractures, where significant soft tissue damage complicates the healing process (Albright et al., 2020). External fixation emerged as a more suitable alternative for managing open fractures, as it offers stabilization while minimizing disruption to the soft tissues (Fernando et al., 2021). External fixation is particularly beneficial for fractures with extensive soft tissue injuries, such as those caused by high-velocity trauma, as it allows for soft tissue healing while stabilizing the bone. However, external fixation is not without its drawbacks, including high rates of infection, malalignment, and potential non-union, which can require further surgical interventions (Piwani et al., 2015).

The Gustilo and Anderson classification system is widely used to classify open fractures, with type III fractures being the most severe. Type III-A fractures involve significant soft tissue damage but allow for primary wound closure, while type III-B fractures involve extensive soft tissue loss and require more advanced wound management, such as split-thickness skin grafts or flaps (Hadeed et al., 2020). External fixation is often the treatment of choice for these severe fractures, providing stability while allowing for the necessary soft tissue management (Bliven et al., 2019).
This study focuses on evaluating the outcomes of Gustilo III-A and III-B tibial fractures treated with NA external fixators, aiming to provide data that can improve the management of these complex injuries. The goal is to assess union rates, complication rates, and the overall effectiveness of NA external fixation as a definitive treatment for these challenging fractures.

The study is set against the backdrop of Pakistan's healthcare system, where resource constraints, delays in treatment, and reliance on traditional bone-setters often result in suboptimal outcomes for patients with open fractures (Alho et al., 1992). By analyzing local data, this study aims to contribute valuable insights into the management of open tibial fractures and standardize treatment protocols for better outcomes.

Table 1: Descriptive Statistics of Age, Gender, and Time Lapse Between Injury and Arrival

Table 1 provides a summary of the demographic data. The mean age of patients is 35.6 years with a standard deviation of 8.83. The gender distribution shows that 42.2% were male and 57.8% were female. The time lapse between injury and hospital arrival was 3.22 ± 1.67 days on average, indicating a relatively short delay in patient admission after injury.

Table 2: Gustilo Classification, Side Involved, and Mode of Injury

This table illustrates the distribution of patients according to the Gustilo classification, with type IIIB fractures being more common (53.1%) than type IIIA (46.9%). The side of injury was nearly evenly distributed, with 50.8% on the left and 49.2% on the right. The most common mode of injury was road traffic accidents (35.9%), followed by assaults (27.3%), firearm injuries (21.9%), and falls from heights (14.8%).

Table 3: Soft Tissue Procedure and Hospital Stay

Table 3 summarizes the soft tissue procedures performed, with split-thickness skin grafts being the most common procedure (34.4%), followed closely by flap procedures and secondary suturing (both 32.8%). Regarding the duration of hospital stays, 55.5% of patients stayed between 4 to 9 days, while 44.5% stayed for 10 to 15 days, indicating that most patients were discharged relatively early.

Table 4: Complications, Weight Bearing, and Fixator Removal

This table provides data on complications and weight-bearing milestones. Soft tissue complications were experienced by 12.5% of patients, bony complications by 10.2%, and infections by 13.3%. Regarding weight-bearing milestones, the average time for partial weight bearing with a walker was 4.38 ± 1.14 weeks, and the mean time for full weight bearing with the NA external fixator was 9.51 ± 1.73 weeks. The mean time for fixator removal was 6.25 ± 1.49 weeks.

Table 5: Union Outcomes and Association with Demographic Factors

Table 5 shows union outcomes based on demographic factors, including age, gender, side involved, and Gustilo classification. The union rates were similar across age groups, genders, and sides of the body. There was no significant difference in union rates between Gustilo IIIA and IIIB fractures. The P-values for each factor suggest that these variables did not significantly affect union outcomes.

Table 6: Association Between Mode of Injury, Soft Tissue Procedures, and Complications

Soft Tissue Procedure Union (%) Complications (Yes) P-value

Table 6 compares union rates and complications across different modes of injury and soft tissue procedures. The highest union rate was observed in assault cases (48.6%). Soft tissue procedures, such as secondary suturing, had the highest complication rate, while flap procedures had the lowest complication rate.

The conclusion of the study that union outcomes and complication rates in soft tissue injuries are not significantly influenced by age, gender, injury type, or mechanism of injury. Road traffic accidents were the leading cause of injury and associated with the highest complication and infection rates. Overall, complications were relatively uncommon, and shorter hospital stays were more prevalent, particularly among older patients and less severe cases.

1.     Alho A, Benterud JG, Høgevold HE, Ekeland A, Strømsøe K. Comparison of functional bracing and locked intramedullary nailing in the treatment of displaced tibial shaft fractures. Clinical Orthopaedics and Related Research. 1992;277:243-50.

2.     Court-Brown C, McBirnie J. The epidemiology of tibial fractures. The Journal of Bone and Joint Surgery - British Volume. 1995;77(3):417-21.

3.     Schlickewei CW, Kleinertz H, Thiesen DM, Mader K, Priemel M, Frosch K-H, et al. Current and future concepts for the treatment of impaired fracture healing. International Journal of Molecular Sciences. 2019;20(22):5805.

4.     Fernando P, Abeygunawardane A, Wijesinghe P, Dharmaratne P, Silva P. An engineering review of external fixators. Medical Engineering & Physics. 2021;98:91-103.

5.     Piwani M, Bhutto IA, Ahmed I. Evaluation of AO external fixator in the management of open diaphyseal fracture of tibia Gustilo Type IIIA and IIIB. Gomal Journal of Medical Sciences. 2015;13(1).

6.     Bhandari M, Guyatt G, Walter SD, Tornetta III P, Schemitsch EH, Swiontkowski M, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures: by the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) Investigators. JBJS. 2008;90(12):2567-78.

7.     Albright PD, MacKechnie MC, Roberts HJ, Shearer DW, Rojas LGP, Segovia J, et al. Open tibial shaft fractures: treatment patterns in Latin America. JBJS. 2020;102(22):e126.

8.     Hadeed MM, Post M, Werner BC. Partial fibular head resection technique for snapping biceps femoris. Arthroscopy Techniques. 2018;7(8):e859-e62.

9.     Bliven EK, Greinwald M, Hackl S, Augat P. External fixation of the lower extremities: Biomechanical perspective and recent innovations. Injury. 2019;50:S10-S7.

10.   Hadeed A, Werntz RL, Varacallo M. External fixation principles and overview. 2019.

11.   Alho A, Benterud JG, Høgevold HE, Ekeland A, Strømsøe K. The role of external fixation in severe open fractures. Clinical Orthopaedics and Related Research. 1992;278:60-65.

12.   Giannoudis PV, Tzioupis C, Roberts C, Papadopulos P, Dimitriou R. Fractures of the tibia: evaluation and management. The Bone & Joint Journal. 2010;92(6):1093-98.

13.   Zeltser DW, Leopold SS. Classifications in brief: Schatzker classification of tibial plateau fractures. Springer. 2013.