External fixation to intramedullary nailing for femoral and tibial fractures : an eleven-year cohort study at a level I trauma center

Purpose: To identify factors that contribute to the incidence of postoperative complications following staged treatment of femoral and tibial fractures with external fixation (EF) and intramedullary nailing (IMN). Methods: This retrospective cohort study involved patients with tibial and/or femoral fractures temporarily immobilized using EF, followed by IMN. Patient characteristics, types of injury, treatments, and outcomes were recorded. Primary outcomes were pin tract infection (PTI) and fracture-related infection (FRI). Results: The study had 103 patients involving 119 fractures: 73 tibial (61.3%) and 46 femoral (38.7%). Of these, 44.5% were open. 31.1% of the EFs were implanted by an orthopedic trauma (OT) specialist. In femoral fractures, OT specialists placed the pins a mean 78.2 mm from the fracture site, versus just 37.3 mm by non-OT surgeons (p < 0.01). This difference was not observed in the tibia. The average time of EF was 12.6 ± 7.8 days. PTI occurred in seven cases (5.9%), on average 14.9 ± 10.9 days after EF placement. FRI occurred in nine patients (7.6%): two in the femur (4.5%) and seven in the tibia (10.6%). All FRIs occurred in cases where the EF had been implanted by a surgeon without specialization in OT (p = 0.03). FRI was more frequent in patients with prior PTI than in those without (57.1% vs. 4.5%, respectively; p < 0.01). Conclusion: PTI was a risk factor for FRI after IMN of tibial and femoral fractures. Surgeon specialization in OT was a protective factor against FRI, probably related to pin placement further from the fracture site.