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Original Article
DOI: https://doi.org/10.13107/jcorth.2026.v11.i01.850
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Comparative Analysis of Early Intramedullary Interlocking Nailing (Definitive Fixation) and Damage Control Orthopedics in Gustilo-Anderson Grade IIIA Open Tibial Diaphyseal Fractures

Original Article | Volume 11 | Issue 1 | JCORTH Jan-Jun 2026 | Page 88-95 | Rajendra Butala [1], Parth Dahiwadkar [1], Nishant Kumar [1], Prakash Samant [1], Sachin Kale [1], Kaustav Das [1]. DOI: https://doi.org/10.13107/jcorth.2026.v11.i01.850
Authors: Rajendra Butala [1], Parth Dahiwadkar [1], Nishant Kumar [1], Prakash Samant [1], Sachin Kale [1], Kaustav Das [1]
[1] Department of Orthopaedics, Dr. DY Patil Hospital, Navi Mumbai, Maharashtra, India.
Address of Correspondence:
Dr. Parth Hitendra Dahiwadkar, Department of Orthopaedics, Dr. DY Patil Hospital, Navi Mumbai, Maharashtra, India. E-mail: pdahiwadkar@gmail.com
Article Received : 2025-05-15,
Article Accepted : 2026-01-05

Abstract

Introduction: Gustilo-Anderson grade IIIA open tibial diaphyseal fractures are complex injuries associated with a high risk of infection, nonunion, and functional deficits. A significant controversy exists regarding the optimal management strategy for hemodynamically stable patients: Early intramedullary interlocking (IMIL) nailing for immediate stable fixation, or a staged approach using damage control orthopedics (DCO) with temporary external fixation to permit initial soft tissue recovery. This paper aims to systematically compare the clinical efficacy, complication profiles, and functional outcomes of these two divergent strategies specifically in isolated Grade IIIA injuries.

Materials and Methods: A retrospective cohort study was conducted analyzing 50 consecutive adult patients treated for Gustilo-Anderson grade IIIA open tibial diaphyseal fractures. Inclusion criteria required patients to be adults with isolated Grade IIIA fractures and be hemodynamically stable (excluding injury severity score >16 and Grade IIIC injuries). Patients were allocated into two groups: The Early IMIL Group (n = 28), receiving definitive fixation within 24 h of injury, and the DCO Group (n = 22), receiving temporary external fixation followed by staged definitive internal fixation 7–21 days later. All patients received a standardized protocol of urgent debridement and broad-spectrum triple antibiotics. Primary outcome measures were the rate of deep infection and time to union.

Results: The cohorts were well-matched demographically (mean age 38.3 years). A statistically significant difference was found in the rate of deep infection (P = 0.015). The Early IMIL Group demonstrated a low deep infection rate of 10.7% (3/28), while the DCO Group had a markedly higher rate of 40.9% (9/22). The DCO strategy carried an approximately 5.5 times higher risk of deep infection (odds ratio for early IMIL: 0.18). The surgical burden was also substantially increased in the DCO cohort, with 100% requiring at least one subsequent major surgical event (conversion to definitive internal fixation), compared to only 7.1% in the Early IMIL group (P < 0.001). Furthermore, Early IMIL was associated with faster time to union (14–18 weeks vs. 18–26 weeks) and significantly shorter hospital stays (7–14 days vs. 14–28 days).

Conclusion: This comparative analysis demonstrates that early definitive fixation with IMIL Nailing provides superior clinical and functional outcomes and reduces resource utilization compared to the DCO staged approach for the management of Gustilo-Anderson grade IIIA tibial diaphyseal fractures in stable patients. The significantly lower deep infection rate and reduced surgical morbidity strongly support the integration of early IMIL nailing as the standard of care for suitable, isolated open tibial shaft fractures. DCO should be reserved for cases involving massive contamination or physiological instability.

Keywords: Diaphyseal tibia fracture, negative pressure wound therapy, damage control orthopedics, intra-medullary interlocking nailing, infection.

References

  • 1.
    Adhikari V, et al. Functional Outcome of Solid Interlocking Nail in Open Tibial Fractures Lower than GA III B. Nepal J Orthop 2024;12:72-8. [Google Scholar]
  • 2.
    Walters CL, Simister SK, Tse S, Saade A, Megerian MF, Fitzpatrick EP, et al. Temporary stabilization of tibia fractures: Does external fixation or temporary plate fixation result in better outcomes? Iowa Orthop J 2024;44:179-84. [Google Scholar]
  • 3.
    Borah PJ, Patowary C, Das A, Shirdinayak TS. Outcome of hybrid external fixator in the treatment of open distal tibia fractures. Indian J Orthop Surg 2022;8:171-5. [Google Scholar]
  • 4.
    Healthcare Bulletin Editorial Board. Prospective Study on Outcome of Primary Nailing in Gustilo Type 3A Tibia Fractures. Healthc Bull 2023;13:2019-25. [Google Scholar]
  • 5.
    Aishwarya A, et al. Outcomes of Intramedullary Nailing in Tibial Shaft Fractures. J Clin Community Practice 2025;8:45-52. [Google Scholar]
  • 6.
    Albushtra A, Mohsen AH, Alnozaili KA, Ahmed F, Aljobahi YM, Mohammed F, et al. External fixation as a primary and definitive treatment for complex tibial diaphyseal fractures: An underutilized and efficacious approach. Orthop Res Rev 2024;16:75-84. [Google Scholar]
  • 7.
    Haller JM, Holt D, Rothberg DL, Kubiak EN, Higgins TF. Does early versus delayed spanning external fixation impact complication rates for high-energy tibial plateau and plafond fractures? Clin Orthop Relat Res 2015;474:1436-44. [Google Scholar]
  • 8.
    Flagstad I, et al. Early versus delayed definitive fixation relative to soft-tissue recovery in lower limb fractures. Injury 2024;55:1055-61. [Google Scholar]
  • 9.
    Prakash V, Singh N, Manjhi LB. Outcome of intramedullary interlocked nailing in closed and gustilo anderson grade I tibial fractures. Inter J Sci Study 2023;10:36-43. [Google Scholar]
  • 10.
    Subbaiah Institute, Shimoga. Longitudinal study to assess outcome of open type I and II tibia fractures treated with interlocking nailing. Inter J Med Public Health 2023;14:97-102. [Google Scholar]
  • 11.
    Srinivasa SB, Sharath JS, Vinaykumar SI, Manjunath S. A longitudinal study to assess the clinical outcome of open type 1 and type 2 (Gustilo Anderson) tibial fracture treated with intramedullary interlocking nailing beyond golden period (6 to 48hours) at tertiary care centre. Int J Med Pub Health 2024;14:97-102. [Google Scholar]
  • 12.
    Saxena A, Mahore SK, Gupta A, Sriwastava AK, Gupta M. Comparative evaluation of functional outcomes following surgical and conservative management of distal tibia shaft fractures: A prospective observational study. J Orthop Case Rep 2025;15:275-81. [Google Scholar]
  • 13.
    Flagstad I, Albright P, Pedri T, Kleinsmith RM, Schmidt A, Alley M, et al. Early versus delayed definitive fixation relative to fasciotomy closure in high-energy tibial plateau fractures with compartment syndrome. J Orthop Trauma 2024;38:195-200. [Google Scholar]
  • 14.
    Zied M, Marouene B, Islem C, Wajdi C, Ali H, Bacem Z. Compartment syndrome following intramedullary nailing of the tibia: A case report. J Orthop Case Rep 2024;14:141-6. [Google Scholar]
  • 15.
    Tornetta P 3rd, French BG. Compartment pressures during nonreamed tibial nailing without traction. J Orthop Trauma 1997;11:24-7. [Google Scholar]
  • 16.
    McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br 2000;82:200-3. [Google Scholar]
  • 17.
    Soraganvi PC, Anand-Kumar BS, Rajagopalakrishnan R, Praveen-Kumar BA. Anterior knee pain after tibial intra-medullary nailing: Is it predictable? Malays Orthop J 2016;10:23-8. [Google Scholar]
  • 18.
    Aydın M, Karadama OL, Kaplan BA, Aydilek A, Sabri Ertaş E. Radiological factors causing anterior knee pain after intramedullary nailing of tibial shaft fractures. Gulhane Med J 2025;67:127-32. [Google Scholar]
  • 19.
    Court-Brown CM, Gustilo T, Shaw AD. Knee pain after intramedullary tibial nailing: Its incidence, etiology, and outcome. J Orthop Trauma 1997;11:103-5. [Google Scholar]
  • 20.
    Leliveld MS, Verhofstad MH. Prevalence of rotational malalignment after intramedullary nailing of tibial shaft fractures: Can we reliably use the contralateral uninjured side as the reference standard? Injury 2012;43:1982-6. [Google Scholar]
  • 21.
    Sener N, Karakaplan M, Ökay S, Karaman I, Kasap H, Öztürk A. Functional outcome of rotational malalignment of tibia after healed fracture treated with closed intramedullary nailing. Int J Orthop Sci 2022;8:464-9. [Google Scholar]
  • 22.
    Salawu ON, Opadele T, Giwa SO. Thermal necrosis complicating reamed intramedullary nailing of a closed tibial diaphysis fracture: A case report. J Med Case Rep 2008;2:255. [Google Scholar]
  • 23.
    Ghaffar S, Ghaffar U, Ahmed S, Hussain S. Thermal necrosis after tibial reaming for intramedullary nail: A diagnostic challenge and review of literature. Injury 2010;41:215-20. [Google Scholar]
  • 24.
    Giannoudis PV, Tzioupis C, Pape HC. Fat embolism: The reaming controversy. Injury 2006;37 Suppl 4:S50-8. [Google Scholar]
  • 25.
    Tavakolizadeh S, Neumann C, Keil H, Fuchs T, Citak M, Suero EM, et al. Fat embolism syndrome after nailing an isolated open tibial shaft fracture. J Med Case Rep 2014;8:434. [Google Scholar]
  • 26.
    Soni A, Nema S, Sinha NN. Screw breakage in tibial interlocking nailing. J Med Thesis 2016;24:103-6. [Google Scholar]
  • 27.
    Agrawal A, Srivastava SK, Aggarwal PK. Implant failure in intramedullary nailing of tibia: A review. Med J Armed Forces India 2015;71:287-90. [Google Scholar]
  • 28.
    Yin W, Almubarak S, Ma D, Liao H, Wang H, Wu L, et al. Risk factors for infection after intramedullary nailing of open tibial fractures: A meta-analysis. Injury 2019;50:1467-72. [Google Scholar]
  • 29.
    Senthil Kumar P, Ramprasath A, Krishnamurthy D, Shanmugasundaram S. Blood loss after reaming in intramedullary nailing of fractures of shaft of femur and fractures of shaft of tibia. J Evid Based Med Healthc 2015;2:6267-72. [Google Scholar]
  • 30.
    Sarmiento A, Latta LL. Iatrogenic fracture lines and comminution during intramedullary nailing of the tibia. Orthop Clin North Am 1995;26:397-403. [Google Scholar]
  • 31.
    Papakostidis C, Dijkman BG, Kreder H, Bhandari M, et al. Training in intramedullary nailing of tibial fractures-does the level of experience affect the outcome? Injury 2006;37:769-77. [Google Scholar]
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© 2026 Journal of Clinical Orthopaedics
How to Cite This Article: Butala R, Dahiwadkar P, Kumar N, Samant P, Kale S, Das K. Comparative Analysis of Early Intramedullary Interlocking Nailing (Definitive Fixation) and Damage Control Orthopedics in Gustilo-Anderson Grade IIIA Open Tibial Diaphyseal Fractures. Journal of Clinical Orthopaedics 2026 May, 11(05): 88-95.