Early unreamed intramedullary nailing without a safety interval and simultaneous flap coverage following external fixation in type IIIB open tibial fractures: A report of four successful cases

The conversion method from external fixation (EF) to intramedullary nailing (IMN) for open tibia fractures, especially to Gustilo type IIIB open tibia fractures, have potentially high risk of infections. We document a report of a more progressive approach in four consecutive cases of type IIIB open tibial fractures successfully managed with early unreamed IMN without a safety interval and simultaneous flap coverage following EF. The mean patients age at the time of injury was 43.8 years (range 23-64 years), and three patients were male. The timing from EF to IMN without safety interval combined with well-vascularised flap (free latissimus dorsi flaps in two patients and pedicled soleus flaps in two patients) ranged 48 to 72 hours. Average time to union was 14 months (range 9-21 months). There was one nonunion patient whose fracture healing was gained by reamed IMN without bone grafting. However, there were no infections. The functions in all patients were satisfactory. This early unreamed IMN without a safety interval and with simultaneous flap coverage following EF is a useful and effective option for treating type IIIB open tibial fractures.