Unreamed Intramedullary Nailing Versus External Fixation for Type IIIA and IIIB Open Fractures of Tibial Shaft: A Subgroup Analysis of Randomized Trials

Objects: The aim of this article is to provide a comprehensive and concise review of the literature and subsequent meta-analysis of data regarding the effect of unreamed intramedullary nailing versus external fixation for type IIIA and IIIB open tibial fractures. Methods: We selected PubMed; Cochrane Library; EMBASE; BIOSIS; Ovid and the relevant English orthopedic journals and pooled data from eligible trials including six eligible prospective randomized trials comparing unreamed intramedullary nailing and external fixation for type IIIA or IIIB open tibial fractures to conduct a subgroup analysis, aiming to summarize the best available evidence. Results: The results showed compared with external fixation, unreamed intramedullary nailing led to fewer superficial infection rate in patients with type IIIA (95% confidence interval (CI) 0.04–0.39, P=0.0003) and type IIIB open tibial fractures (95% CI 0.22–0.86, P=0.02). And there was the trend of obtaining better clinical effect towards less deep infection rate in unreamed intramedullary nailing group for patients with type IIIA and IIIB open tibial fractures, respectively (95% CI 0.29–1.77, P=0.47) and (95% CI 0.12–1.17, P=0.09), although no significant differences were viewed. Meanwhile, unreamed intramedullary nailing reduced the incidence of reoperation (95% CI 0.25–0.85, P=0.01) and malunion (95% CI 0.14–0.50, P<0.0001) and shortened the radiographic time to union (95% CI (-5.54, -1.86), P<0.0001) while no significant difference was viewed towards nonunion rate (95% CI 0.50–2.77, P=0.71) in patients with type III open tibial fractures. Conclusions: We suggest that the final results are significant and there are some evidences supporting the use of unreamed intramedullary nailing for type IIIA and IIIB open tibial shaft fractures. Limitations remain, operative duration, blood loss and some functional evaluation indicators such as range of motion in ankle and knee should be more carefully considered and reported in a reliable, consistent and standardized manner.