Original Research Article http://doi.org/10.18231/j.ijos.2019.010 Indian Journal of Orthopaedics Surgery, January-March, 2019;5(1):52-56 52 Unilateral external fixator as the primary and definitive treatment modality in type IIIB open tibial fractures: A retrospective study Rashid Anjum 1 , Navdeep Singh 2,* , Jatin Aggarwal 3 , Amrit Rai Badgal 4 , Anil Gupta 5 1,2 Orthopaedics Surgeon, 3 Resident, 4 Ragistrar, 5 Professor and Head, 1,2 Dept. of Orthopaedics, 1,2,4 J & K Health Services, Jammu, 3 MMIMSR, Government Medical College, Jammu, India *Corresponding Author: Navdeep Singh Email: raashidanjum@gmail.com Abstract Introduction: Intramedullary (IM) nailing is considered the method of choice for treatment of closed diaphyseal fractures of the tibia. However, there is controversy in the literature regarding the best way of managing open type III B fractures. The aim of this study was to evaluate the effectiveness of unilateral external fixator as primary and definitive treatment for Gustilo and Anderson compound grade III B open tibial fractures. Materials and Methods: This was a retrospective case series of patients with Gustilo and Anderson compound grade III B open tibial fractures treated in our institution from Jan 2010 to May 2014. All the cases that were treated with unilateral tubular external fixators within 24 hours of injury were included. Serial debridement and early coverage if required, was done within seven days. Dynamisation and partial weight bearing was started at 8-10 weeks on observing early signs of fracture healing. Weight bearing with patellar tendon bearing cast was permitted at 12–16 weeks, on visualization of bridging callus and continued till radiological and clinical union. Results: There were 31 males (83.7%) & 6 females (16.2%) with Gustilo IIIB fractures with a mean age of 37.43± 8.92 years and a standard error of 0.55. The commonest mode of trauma was road traffic accidents followed by fall from height & direct trauma to the limb. All the patients were operated in emergency within 24 hours with debridement of wound and primary external fixation. The average time to union was 22.13 ±2.68, superficial pin track infection occurred in 11 cases & deep infection leading to loosening of Schanz screw was seen in two patients. Delayed union was seen in two patients whereas, non-union was seen in three patients requiring secondary procedures. Conclusion: The results show that unilateral external fixators can be used as primary and definitive treatment for compound type IIIB tibial shaft fractures with satisfactory outcomes. These are particularly helpful in resource limited setups, where the operating surgeons may not have a wide range of implants and instrumentation at their disposal owing to low financial profile of patients. Keywords: External fixation, Definitive treatment, Open tibial fractures, Gustilo Anderson type IIIB. Introduction Tibial shaft fractures are the commonest open fractures of long bones owing to the anatomic location & precarious soft tissue coverage. 1,2 Intramedullary interlocked nailing is considered as gold standard for the treatment of close diaphyseal & Gustilo Anderson type I, II & most of IIIA fractures of tibia, however, in compound IIIB fractures, there are conflicting results in literature making it a grey area with no clear defined guidelines. 3-6 The treatment modalities in such fractures are, primary intramedullary nailing (un reamed), external fixation followed by intramedullary nailing & primary external fixation as a definitive treatment. 2,6 The incidence of infection in fractures which were first treated by external fixation and then with IMIL nailing was considerably much higher than those fractures treated with Primary IM nailing. 4,6 A high rate of infection coupled with repeated surgeries adds further to the misery especially in the resource limited countries. 7,9 The overall cost of treatment is a major factor in deciding the modality of treatment in rural areas of developing countries & with almost same effectiveness external fixators are way cost effective. 10 We generally treat compound IIIB fractures with intramedullary nailing either primary or delayed, however, there is a subset of patients who cannot cope with financial implications because of repeat surgical interventions, so we continued the external fixator as a primary & definitive management. This retrospective analysis was done with an aim to evaluate the functional outcome & complications of external fixation as a primary and definitive line of management for Gustilo IIIB open fractures tibia. Materials and Methods This retrospective analysis was done in a tertiary care institute of northern India, which serves as a referral centre for peripheral/rural health centres from almost ten districts. Between Jan 2010 & May 2014 a total of 153 patient of compound IIIB fractures were treated at this institution. We excluded the patients that were treated by primary IMIL, delayed IMIL, Gustilo Anderson I, II, IIIA, IIIC fractures, incomplete data & poly-trauma patients with other severe injuries that can influence the rehabilitation & outcome. A total of 37 patients constituted the study group that were treated by simple tubular external fixation as a primary & definitive mode of treatment & having at least one year of follow up. The data regarding status of union, infection, pin loosening, malunion time of weight bearing and any other associated complication was noted. All the data was recorded from patient history sheets, admission & discharge summaries, follow up OPD consultation slips, however, the quality of images was not good enough as we didn’t had a computerised data record system in our hospital. We allowed the patients to bear partial weight at around 10 weeks followed by conversion to PTB cast and weight bearing as