Contributing factors influencing type III open tibial fractures.

Ninety-five patients with severe open tibial fractures (96 fractures) were treated with nonoperative treatment alone (NO group, n = 16), immediate internal fixation (I group, n = 22), delayed internal fixation (D group, n = 34), or external fixation (EF group, n = 24). The D group was divided into a delayed internal fixation group following nonoperative treatment (D1 group, n = 14), and a delayed internal fixation group following external fixation (D2 group, n = 20). Using the classification system of Gustilo, there were 43 type IIIA, 42 type IIIB, and 11 type IIIC open tibial fractures. There were 17 deep infections (type IIIA, n = 3; IIIB, n = 12; IIIC, n = 2). The difference in the deep infection rate (DIR) between the type IIIA and type IIIB fractures was statistically significant (7.0% vs. 28.0%, p < 0.05). The DIRs in groups NO, I, D1, D2, and EF were 12.5, 27.3, 7.1, 35, and 4%, respectively. There was a significant difference in DIR between the D2 group and the EF group. The DIR in the D (D1 + D2) group and group I showed no significant difference. There was no relationship between the DIR and either Injury Severity Score or skin closure time. The authors of this study, therefore, do not feel there is an advantage to immediate internal fixation over delayed procedures for Gustilo type III open fractures of the tibia. However, careful attention must be given to the application of delayed internal fixation, especially intramedullary nailing, after external fixation.