Despite better management options available today, the treatment of open tibial fractures presenting late still remains controversial; delays ranging from 6–24 hours before presentation are quite common in developing countries such as India. This study evaluated the comparative outcomes of operative treatment in such patients.
One hundred and forty-two open (type 2 and type 3a) fractures of the tibial shaft in the 16–40 year age group, presenting with significant delays were alternatively treated with external fixation or unreamed tibial nailing. One hundred and fourteen patients were assessed at a mean follow-up of 64.5 weeks; evaluation was based on time to union, evidence of nonunion, presence of malunion or malalignment, presence of deep infection or osteomyelitis.
Union time and infection rates were less in the external fixation group, while malunion and nonunion were less in the unreamed tibial nail group. After repeated surgeries, the nonunions in the external fixation group ultimately united, but four patients in the unreamed tibial nail group were left with a persistent discharging sinus.
From our results, we concluded that an unreamed tibial nail may not be the implant of choice for patients presenting after 6 hours of injury. External fixation is a better alternative in developing countries when patients arrive late to the hospital. Although initial union rates may be lower with external fixation as compared with unreamed tibial nailing, these fractures ultimately unite if a second-staged reamed nailing is carried out.