# Intramedullary nail prior to flap coverage may not increase complications in Gustilo–Anderson Grade IIIB and IIIC open tibial fractures: A retrospective study

## TL;DR

This study found that placing an intramedullary nail early in severe tibial fractures does not increase complications compared to the standard treatment approach.

## Contribution

The study challenges the standard care protocol by showing early intramedullary nailing is safe in resource-limited settings.

## Key findings

- Early intramedullary nailing did not increase deep infection rates compared to external fixation followed by nailing.
- No significant differences were found in nonunion, flap failure, or revision surgery rates between the two groups.
- Logistic regression confirmed no increased risk of infection with early nailing after controlling for confounders.

## Abstract

This study aimed to assess whether immediate intramedullary nailing and delayed flap coverage increases complications of severe open tibial fractures. Current standards for care indicate temporary external fixation, followed by definitive stabilisation at the time of flap coverage within 7 days of injury. However, this approach can be difficult to coordinate for resource‐constrained centres. Earlier intramedullary nailing and allowing for delayed flap coverage may lead to easier coordination of care.

Patients were recruited from a trauma database between 2015 and 2024. Those included were over 18 years old with a Gustilo–Anderson IIIB or IIIC open tibia fracture and at least 6 months follow‐up. Patients were grouped by those who had an intramedullary nail within 24 h with delayed soft tissue coverage (Group 1) and those who received initial external fixation and an intramedullary nail at the time of flap (Group 2). Collected complications were deep infection, aseptic nonunion, flap failure and revision surgery. This study equates to level III evidence.

Group A (n = 34) and Group B (n = 115) were analysed. Gender, smoking status, age and injury severity score were not significantly different. No significant difference was found in outcomes of deep infection rate χ
2(1, N = 149) = 0.08, p = 0.78, nonunion χ
2(1, N = 149) = 0.43, p = 0.51, flap failure χ
2(1, N = 149) = 0.35, p = 0.56 or revision surgery χ
2(1, N = 149) = 1.7, p = 0.19. A binary logistic regression showed no difference in infection rates when controlling for confounders (odds ratio [OR] = 1.14, 95% confidence interval [CI]: 0.46–2.85, p = 0.780).

Intramedullary nailing within 24 h, without simultaneous flap coverage, does not appear to lead to increased complications in Gustilo–Anderson Type IIIB/C open tibia fractures. However, prospective studies with larger sample sizes are required to confirm these findings.

Level III.