Open distal tibia fracture, one of the most severe limb injuries, tends to be accompanied by many problems such as bone and soft tissue loss. Improper treatment might result in many complications, including wound infection and osteomyelitis. Due to these thorny problems, achieving good results is highly challenging [4]. The basic treatment aspects of this injury include infection prevention, soft tissue coverage, fracture fixation, functional improvement, and more. In particular, clinicians are disputed on whether to treat these fractures by one-stage internal or external fixation [5]. When treating open fractures, the surgical purpose is to promote fracture healing, restore joint function, and minimize complications, including infection. Effective antibiotic treatment, meticulous debridement, fracture stability, and wound coverage are essential when treating open distal tibia fractures [6, 7]. We used EFLIF to treat these fractures as it can exert beneficial effects. In our study, no single fixation was suitable for all open distal tibia fractures. The final decision depended on the fracture type and other indications, including the soft tissue condition and surgical expertise, as in the study by Silluzio et al., who treated complex open pilon fractures [8].
Previous studies have shown that the number of complications increases with the complexity of the open fracture [5]. External fixation can fix the ankle in a functional or neutral position to provide it with stability and prevent the increase in shear force during skin flap treatment or skin grafting. External fixation can also prevent the loss of lower limb length. However, some questions related to the external fixation process remain. The long healing time of open fractures causes some inconvenience in the patients’ daily and social life. For example, they need special pants to accommodate the extra space-occupying external fixation. However, external fixation might increase the likelihood of septic arthritis and fixation loosening [9]. Some studies suggested an increased risk of infection after over four weeks of external fixation [10]. In our institution, we ask the patients to cover the nail tracks with alcohol-soaked gauzes daily to reduce the risk of infection and fixation loosening. External fixation provides far less stability to the fracture than internal fixation and might result in loss of fracture reduction. Some scholars believe that if the soft tissue condition is good and there is no sign of infection, external fixation can be replaced by internal fixation within 3 to 4 weeks [11, 12]. Fowler et al. suggested that a temporary internal fixation with a flap can achieve similar effects and even confers additional advantages in long-term deep infection [13]. We think the number of treatment sessions should be reduced as soon as possible. Mishra et al. compared Kirschner wire and screw fixation and suggested that Kirschner wire fixation can achieve satisfactory outcomes when treating distal tibia fractures [14]. Therefore, we used Kirschner wire or limited internal fixation to fix the fracture, ensure stability, and avoid the need for another operation to replace the internal fixation. When the fracture healed, we removed the external fixation or Kirschner wire by a small incision, thereby reducing the surgical injury.
With the development of the internal fixation technology and debridement, internal fixations do not necessarily increase the infection rate. In a series of ten Gustilo-Anderson type III open distal tibial and tibial shaft fractures, He et al. [15] suggested that the minimally invasive plate osteosynthesis technique was a reasonable and safe option; however, they failed to confirm the safety of its clinical application. One-stage internal fixation is acceptable for patients with Gustilo-Anderson types I and II open distal tibia fractures. For Gustilo-Anderson type III open fractures, using bioabsorbable implants was feasible and effective [16, 17]. Franklin et al. [18] believed that early internal fixations did not increase the infection rate of open ankle fractures. Although the proportion of Gustilo-Anderson type III open ankle fractures was very low in these studies, we think these fractures can be treated with limited internal fixation. Some surgeons believe that EFLIF can achieve similar functional outcomes in open distal tibia fractures and shorten the operation and fracture healing times [19–21]. Meena et al. suggested that combined external and internal fixations were a safe and effective management option for intra-articular distal tibial fractures [22]. Therefore, we concluded that using limited internal fixation could provide enough stability, cannot be replaced by internal fixation, and presents a lower infection risk than it. It took two years for the fracture in one patient to heal, possibly due to the severity of the injury and poor patient compliance rather than the surgical technique.