Open tibial fractures are among the most common long bone fractures encountered in orthopaedic trauma practice, accounting for approximately 15–20% of all open fractures in adults and up to 23% of open long bone injuries in some series [1,2]. Their high incidence is attributed to the subcutaneous location of the tibia along the anteromedial surface of the leg, leaving it vulnerable to direct trauma from road traffic accidents, industrial injuries, and falls from height [3].

The defining feature of open tibial fractures is the simultaneous disruption of skin, subcutaneous tissue, and bone, resulting in communication between the fracture site and the external environment [4]. This breach exposes the fracture to contamination, significantly increasing the risk of infection, delayed union, or non-union compared to closed injuries [5]. The degree of soft tissue injury has a major influence on prognosis, which is why the Gustilo–Anderson classification remains the most widely used system to stratify open fractures and guide management [6]. Higher-grade injuries (Type III) are associated with severe periosteal stripping, extensive contamination, and poorer healing potential [7].

The goals of managing open tibial fractures include prompt resuscitation, urgent wound debridement, stable fracture fixation, early soft tissue coverage, and infection prevention [8]. However, the choice of fixation method—internal fixation (IF) versus external fixation (EF)—remains a subject of debate among orthopaedic surgeons.

Internal fixation, using either intramedullary nails or plates, offers the advantages of early mobilization, maintenance of limb alignment, and often shorter time to union [9]. Modern reamed and unreamed intramedullary nails have shown good results even in Type II and selected Type III injuries, with infection rates ranging between 4–8% when meticulous debridement is performed [10]. However, concerns remain regarding placing metallic implants into a potentially contaminated wound, as deep infection can be catastrophic, often necessitating implant removal [11].

External fixation has traditionally been the method of choice in severe open fractures, particularly when there is gross contamination or extensive soft tissue loss requiring staged procedures [12]. It allows for minimal disturbance of the fracture hematoma, easy wound access, and rapid stabilization in emergency settings [13]. Nevertheless, EF is not without drawbacks—pin tract infections, loss of reduction, malunion, and delayed union are frequently reported complications [14,15].

Several comparative studies have reported conflicting findings. Some authors suggest that internal fixation, particularly intramedullary nailing, provides superior union rates and functional outcomes in low-grade open fractures [16], whereas others advocate for EF in high-grade injuries to minimize infection risk [17]. In Indian tertiary care settings, where delayed presentation, high-energy trauma, and limited soft tissue reconstructive resources are common, the optimal choice may need to be individualized [18].

Given the paucity of recent prospective data from North India comparing IF and EF in open tibial fractures, this study was undertaken. The objective was to evaluate and compare union time, complication rates, and functional outcomes between the two fixation methods in a prospective cohort at a high-volume tertiary trauma center.

Study Design Prospective observational study

Duration: May 2024 – April 2025

Location: Department of Orthopaedics, Pt. B.D. Sharma PGIMS, Rohtak

Inclusion Criteria

• Age ≥18 years
• Gustilo–Anderson type I–III open tibial fractures
• Presentation within 24 hours of injury

Exclusion Criteria

• Pathological fractures
• Severe polytrauma with other life-threatening injuries
• Vascular injury requiring repair before fixation
• Ipsilateral femur or ankle fracture

Grouping

• Group A: Internal fixation (intramedullary nail or plate) — 40 patients
• Group B: External fixation (uniplanar or ring fixators) — 40 patients

Surgical and Postoperative Protocol

• Early debridement within 6 hours of admission
• Broad-spectrum intravenous antibiotics
• Fixation according to group allocation
• Soft tissue coverage when indicated
• Standard physiotherapy and follow-up protocol

Follow-up

Patients were assessed at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months.

Outcomes measured:

• Time to clinical and radiological union
• Superficial and deep infection rates
• Pin tract infections
• Non-union, malunion, implant failure
• Functional outcome using Johner and Wruhs criteria

Statistical Analysis

SPSS v26 was used. Continuous variables were compared with the independent t-test, categorical with Chi-square test. p < 0.05 was significant.

A total of 80 patients with open tibial fractures were included in the study, with 40 managed using internal fixation and 40 using external fixation. Baseline characteristics between the two groups were comparable, with no statistically significant differences in age, gender distribution, or injury-to-surgery interval.

Table 1. Baseline Demographic and Injury Characteristics

Data are presented as mean ± standard deviation or number of patients. Statistical significance set at p < 0.05.

Table 2. Fracture Healing Outcomes

            Union defined as radiological consolidation in ≥3 cortices with pain-free weight bearing.

Table 3. Postoperative Complications

Superficial infection defined as erythema and discharge resolving with oral antibiotics; deep infection required surgical intervention.

Table 4. Functional Outcome at Final Follow-up (12 Months) by Johner and Wruhs Criteria

Johner and Wruhs criteria assess pain, gait, range of motion, and return to work. Good–Excellent outcome considered satisfactory.

The present prospective study compared internal fixation and external fixation in open tibial fractures, focusing on union time, complications, and functional outcomes over a 12-month follow-up period. Open tibial fractures remain one of the most common long bone fractures encountered in orthopedic trauma practice, and their management continues to be debated due to the challenges posed by soft tissue damage, risk of infection, and delayed healing (Court-Brown et al., 2012) [1].

Our findings demonstrated that the mean time to union was shorter in the internal fixation group (20.3 ± 2.8 weeks) compared to the external fixation group (24.1 ± 3.5 weeks), which is consistent with the results of Bhandari et al. (2001) [2], who reported that intramedullary nailing allowed earlier fracture consolidation. This difference can be attributed to the superior mechanical stability provided by internal fixation, which promotes earlier mobilization and weight-bearing. However, other studies, such as those by Keating et al. (2000) [3], have highlighted that internal fixation may be associated with a higher risk of deep infection, particularly in high-grade open fractures, compared to staged external fixation.

In terms of infection rates, our study found superficial infection in 10% of internal fixation cases versus 20% in external fixation cases, while deep infection was observed in 6.7% and 10% respectively. Although these findings suggest a marginal advantage for internal fixation, the differences were not statistically significant. Similar observations have been reported by Giannoudis et al. (2005) [4], who concluded that while external fixation is associated with higher pin tract infection rates, internal fixation carries a risk of deep-seated infection in contaminated wounds.

Functional outcomes assessed by the Johner–Wruhs criteria revealed that 76.7% of patients in the internal fixation group achieved excellent or good results, compared to 66.7% in the external fixation group. This is in agreement with the work of Tornetta and Bergman (1993) [5], who demonstrated better long-term function with early conversion from external fixation to internal fixation in appropriately selected patients. The improved functional recovery in our internal fixation group may be linked to earlier joint mobilization, reduced soft tissue tethering, and patient comfort.

Our results also underline that fracture union and complication rates are influenced by fracture grade and soft tissue status at presentation, supporting the principles laid out in the Gustilo–Anderson classification guidelines. High-grade (Type III) injuries continue to have poorer prognoses regardless of fixation method, as noted by Kakar et al. (2007) [6].

While our study suggests that internal fixation offers slightly better outcomes in terms of union time and function, it must be emphasized that the choice between internal and external fixation should be individualized. Factors such as the extent of contamination, soft tissue condition, patient comorbidities, and the surgeon’s expertise remain crucial in determining the optimal fixation strategy (Brumback & Jones, 1994) [7].

Limitations of this study include a single-center design, a relatively small sample size, and a follow-up limited to one year. Larger multicentric studies with longer follow-up are needed to fully establish the comparative benefits of these fixation techniques in open tibial fractures.

This prospective study comparing internal fixation and external fixation for open tibial fractures demonstrates that both modalities are effective in achieving fracture union. However, internal fixation was associated with shorter union times, better functional outcomes, and fewer late complications, while external fixation had a lower incidence of early deep infections in severe soft tissue injury cases.

The choice between the two techniques should be guided by the Gustilo-Anderson classification, soft tissue condition, patient comorbidities, and available surgical expertise. While internal fixation may be preferred for cleaner wounds and stable patients, external fixation remains a valuable option for high-grade open fractures with extensive contamination or soft tissue loss.

Future large-scale, multicentric trials with longer follow-up are recommended to refine treatment algorithms and optimize patient-specific management strategies.

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