Does fixator-assisted tibial nailing outperform conventional tibial nailing? A multicentre comparative study

BACKGROUND: There is no local literature evaluating the outcomes of external fixator-assisted tibial nailing. This study aimed to investigate the peri- and postoperative outcomes of tibial nailing using either an unassisted or an external fixator-assisted nailing method, in patients with tibial fractures. METHODS: A prospective cohort study including skeletally mature (> 18 years) patients with tibial fractures presenting to one of three different hospitals within the Western Cape province of South Africa, and treated with intramedullary nailing, was conducted. Participant demographic, clinical and surgical characteristics were documented perioperatively up until six weeks post-surgery. Differences in operative time, fluoroscopy time, adequacy of reduction, and short-term complications in patients treated with external fixator-assisted versus unassisted tibial nailing were investigated. RESULTS: A total of 154 patients with tibial fractures (n = 74 fixator-assisted tibial nails; n = 80 unassisted nails) enrolled in the study. Fixator-assisted tibial nailing was associated with significantly longer operation (median 80, interquartile range [IQR] 60-95 minutes) and fluoroscopy times (median 140, IQR 96-214 seconds) compared to the unassisted group (60, IQR 50-90 minutes and 82.5, IQR 63-121 seconds, respectively) (p < 0.001 and p < 0.001, respectively). No differences were observed in the adequacy of reduction, or prevalence of complications, between groups. CONCLUSION: Comparing fixator-assisted tibial nailing to unassisted tibial nailing, this prospective cohort study suggests that both techniques are comparable when managing tibia fractures in terms of adequacy of reduction and the prevalence of short-term complications. The benefits of fixator-assisted tibial nailing include being relatively easy to apply by all orthopaedic surgeons regardless of surgical experience, maintaining reduction during all steps of tibial nail insertion, reduced need for open fracture reduction, reduced radiation exposure to the surgeon and assistant, and no added risk to the patient.