Primary locked intramedullary nailing versus ilizarov fixation for gustilo type I–IIIA open tibial shaft fractures: a prospective comparative study

M. Mizanur Rahman; Shankar Kumar Roy; Muhammad Baqi Billah; Syed Abdus Sobhan; A. H. M. Hasanul Haque Prodhan; Jabed Minhaz Siddiquei

doi:10.18203/issn.2455-4510.IntJResOrthop20263895

Authors

M. Mizanur Rahman BscDepartment of Orthopaedic Surgery, Sylhet M. A. G. Osmani Medical College Hospital, Sylhet, Bangladesh
Shankar Kumar Roy Department of Orthopaedic Surgery, Sylhet M. A. G. Osmani Medical College Hospital, Sylhet, Bangladesh
Muhammad Baqi Billah Department of Orthopaedic Surgery, Sylhet M. A. G. Osmani Medical College Hospital, Sylhet, Bangladesh
Syed Abdus Sobhan Department of Orthopaedic Surgery, Sylhet M. A. G. Osmani Medical College Hospital, Sylhet, Bangladesh
A. H. M. Hasanul Haque Prodhan Department of Orthopaedic Surgery, Upazila Health Complex, Gobindaganj, Gaibandha, Bangladesh
Jabed Minhaz Siddiquei Department of Orthopaedic Surgery, Sylhet M. A. G. Osmani Medical College Hospital, Sylhet, Bangladesh

DOI:

https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20263895

Keywords:

Open tibial fracture; Intramedullary nailing; Ilizarov fixation; Fracture union; Gustilo–Anderson classification

Abstract

Background: Open tibial shaft fractures are challenging injuries with substantial risks of infection, delayed union, and functional impairment. Primary locked intramedullary nailing (PLIN) and Ilizarov fixation are commonly used definitive treatment options. The objective of the study is to compare the clinical, radiological, functional outcomes and complications of these two techniques in Gustilo–Anderson type I–IIIA open tibial shaft fractures.

Methods: This prospective comparative observational study was conducted at Sylhet M.A.G. Osmani Medical College Hospital, Bangladesh, from April 2023 to March 2025. Seventy patients aged 18–65 years were included and equally allocated to PLIN (Group A, n=35) and Ilizarov fixation (Group B, n=35). Operative time, postoperative pain, weight-bearing status, fracture union, complications, and functional outcomes were assessed. Functional outcome was evaluated using the Karlström–Olerud score.

Results: The mean operative time was significantly shorter with PLIN than Ilizarov fixation (71.14±10.92 vs. 101.86±20.51 minutes; p=0.001). At one-month, full weight bearing was achieved in 51.4% of PLIN patients versus 100.0% of Ilizarov patients (p=0.001). At six months, union was achieved in 100.0% and 94.3% of patients, respectively (p=0.493), with mean union times of 18.25±2.17 and 19.42±2.82 weeks (p=0.094). Complications were significantly more frequent with Ilizarov fixation (p=0.002). Good functional outcomes were observed in 77.1% of PLIN and 51.4% of Ilizarov patients (p=0.079).

Conclusions: Both techniques achieved satisfactory outcomes; however, PLIN demonstrated shorter operative time and fewer complications, while Ilizarov fixation provided earlier full weight bearing.

References

Lillo M, El Ezzo O, Cauteruccio M, Ziranu A, De Santis V, Maccauro G. Infections in primary intramedullary nailing of open tibial fractures: a review article. Eur Rev Med Pharmacol Sci. 2019;23(2 Suppl):195-200.

Court-Brown CM. The epidemiology of fractures and dislocations. In: Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta P III, editors. Rockwood and Green's Fractures in Adults. 8th ed. Philadelphia: Wolters Kluwer Health; 2015. p.59-108.

Parupalli S, Shafeek M. Study of functional outcome of management by external fixation followed by definitive internal fixation in compound tibial fractures. Natl J Clin Orthop. 2018;2(4):205-11.

Balakrishna B, Vivek VV, Satya Kumar K. Role of various modalities in the management of compound grade 3A and 3B fractures of tibia. Int J Orthop Sci. 2019;5(3):131-7.

O'Toole RV, Gary JL, Reider L, Bosse MJ, Gordon WT, Hutson JJ, et al. A prospective randomized trial to assess fixation strategies for severe open tibia fractures: modern ring external fixators versus internal fixation (FIXIT Study). J Orthop Trauma. 2017;31(Suppl 1):S10-7.

Rudloff MI. Fractures of the lower extremity. In: Azar FM, Beaty JH, editors. Campbell's Operative Orthopaedics. 14th ed. Philadelphia: Elsevier; 2021. Chap 54.

Gueorguiev B, Moriarty TF, Stoddart M, Acklin PY, Richards GR, Whitehouse M. Principles of fractures. In: Blom A, Warwick D, Whitehouse MR, editors. Apley & Solomon's System of Orthopaedics and Trauma. 10th ed. Boca Raton: CRC Press; 2018.

Islam T, Nazibullah M, Ripon AA. Evaluation of Ilizarov technique in the treatment of open fractures of tibia. IOSR J Dent Med Sci. 2020;19(12):1-6.

Patil NVP, Bellad SH, Anand SR. Intramedullary interlocking nailing in type II and type III open fractures of tibia: a clinical study. J Kar Orthop Assoc. 2016;4(1):39-43.

Roussignol X, Sigonney G, Potage D, Etienne M, Duparc F, Dujardin F. Secondary nailing after external fixation for tibial shaft fracture: risk factors for union and infection. A 55 case series. Orthop Traumatol Surg Res. 2015;101(1):89-92.

Seyni SB, Saidou MG. Treatment of open leg fractures by intramedullary nailing. J Trauma Treat. 2016;5(3).

Liu J, Xie L, Liu L, Gao G, Zhou P, Chu D, et al. Comparing external fixators and intramedullary nailing for treating open tibia fractures: a meta-analysis of randomized controlled trials. J Orthop Surg Res. 2023;18:13.

Hany ZS, Wael SM, Kareem SA. Treatment of open comminuted diaphyseal fracture of the tibia by Ilizarov. Egypt J Hosp Med. 2019;77(6):5965-5972.

Ramos T, Eriksson BI, Karlsson J, Nistor L. Ilizarov external fixation or locked intramedullary nailing in diaphyseal tibial fractures: a randomized, prospective study of 58 consecutive patients. Arch Orthop Trauma Surg. 2014;134(6):793-802.

Inan M, Halici M, Ayan I, Tuncel M, Karaoglu S. Treatment of type IIIA open fractures of tibial shaft with Ilizarov external fixator versus unreamed tibial nailing. Arch Orthop Trauma Surg. 2007;127(8):617-23.

Siddiqui EH, Forhad S, Alam MS, Sultana J, Shameem MAA. Treating open fracture of lower one third of tibia by Ilizarov technique: a study in a tertiary care hospital of Bangladesh. Am J Biomed Life Sci. 2021;9(2):128-32.

Jeremic D, Grubor N, Bascarevic Z, Slavkovic N, Krivokapic B, Vukomanovic B, et al. Comparative analysis of complication rates in tibial shaft fractures: intramedullary nail vs. Ilizarov external fixation method. J Clin Med. 2024;13(7):2034.

Kisitu DK, O'Hara NN, Slobogean GP, Howe AL, Blachut PA, O'Brien PJ, et al. Unreamed intramedullary nailing versus external fixation for the treatment of open tibial shaft fractures in Uganda: a randomized clinical trial. J Orthop Trauma. 2022;36(9):349-57.

Rohilla R, Arora S, Kundu A, Singh R, Govil V, Khokhar A. Functional and radiological outcomes of primary ring fixator versus antibiotic nail in open tibial diaphyseal fractures: a prospective study. Injury. 2022;53(10):3464-70.

Cortez A, Urva M, Haonga B, Donnelley CA, von Kaeppler EP, Roberts HJ, et al. Outcomes of intramedullary nailing and external fixation of open tibial fractures: three to five-year follow-up of a randomized clinical trial. J Bone Joint Surg Am. 2022;104(21):1877-85.

Li M, Wang Y, Zhang Y, Yang M, Zhang P, Jiang B. Intramedullary nail versus locking plate for treatment of proximal humeral fractures: a meta-analysis based on 1384 individuals. J Int Med Res. 2018;46(11):4363-76.

Szelerski Ł, Żarek S, Górski R, Mochocki K, Górski R, Morasiewicz P, et al. Surgical treatment outcomes of the Ilizarov and internal osteosynthesis methods in posttraumatic pseudarthrosis of the tibia—a retrospective comparative analysis. J Orthop Surg Res. 2020;15(1):179.

Yang L, Sun Y, Li G. Comparison of suprapatellar and infrapatellar intramedullary nailing for tibial shaft fractures: a systematic review and meta-analysis. J Orthop Surg Res. 2018;13(1):146.

Sakaki MH, Crocci AT, Zumiotti AV. Comparative study of the locked intramedullary nail and Ender pins in the treatment of tibial diaphyseal fractures. Clinics (Sao Paulo). 2007;62(4):455-64.

Sun J, Li Q, Gao F, Xiang Z, Huang Q, Li L. Application of the Ilizarov technique for knee joint arthrodesis as a treatment for end-stage tuberculosis of the knee. BMC Musculoskelet Disord. 2020;21(1):579.

Hussain A, Ahmad S, Iqbal K, Zeb A, Ullah R, Afzal I. Outcomes of open tibia fracture using Ilizarov ring fixator. Pak J Med Health Sci. 2021;15(12):3755-8.

Pancholiya A, Gunaki RB, Patil VS. A study of the functional outcome of ipsilateral fracture of femur and tibia. Int J Orthop Sci. 2018;4(4):829-33.