Assessment of Fixation Strategies for Severe Open Tibia Fractures
Condition: Severe Open Fractures of the Tibia (Shin) Bone
MeSH terms: Fractures, Bone; Tibial Fractures; Fractures, Open
Study type: Interventional
Phase: Phase 3

Summary: 
      The purpose of this study is to compare the use of modern ring external fixation versus
      internal fixation for fracture stabilization of severe open tibia fractures.
    

Detailed description: 
      Severe open fractures of the tibia (shin) bone are difficult to treat and are associated with
      high rates of infection and other complications. There is controversy regarding the best
      treatment, particularly in fractures with large wounds from trauma. The two current standard
      treatment options are to place an internal fixation device (a nail or plates with screws) or
      to use a device with pins that stick out of the skin and attach to rings outside the body
      (modern ring external fixator). It is unknown which of these standard of care treatment
      options will result in lower complication rates and better function of the leg.

      Our goal is to perform a multi-center randomized controlled trial of the use of modern ring
      external fixation versus internal fixation for fracture stabilization of severe open tibia
      fractures. Patients who refuse randomization have the option of participating in a
      prospective observational study and the treatment is decided by the surgeon and patient.

      Primary Aim: To compare the outcomes associated with modern ring external fixators versus
      standard internal fixation techniques in treating "severe" open tibia shaft or metaphyseal
      fractures with or without a bone defect of any size.

      Primary Hypothesis: Among patients with open tibia shaft or metaphyseal fractures (with or
      without a bone defect of any size), the rate of re-hospitalization for major limb
      complications will be lower for patients treated with ring fixators than those treated with
      standard internal fixation.

      Secondary Hypotheses: Among patients with open tibia shaft or metaphyseal fractures (with or
      without a bone defect of any size), the overall rate of infections will be lower for patients
      treated with ring fixators than those treated with standard internal fixation. Measures of
      fracture healing, limb function, and patient reported outcomes (including pain) will be as
      good or better among patients treated with ring fixators than those treated with standard
      internal fixation.

      Secondary Aim #1: To determine the percentage of Gustilo IIIB open tibia shaft fractures that
      can be treated successfully (i.e. without amputation) without a soft tissue flap secondary to
      the use of ring external fixators.

      Secondary Aim #2: To determine the two-year treatment costs associated with fixation of
      "severe" open tibia shaft or metaphyseal fractures (with or without a bone defect of any
      size) using modern ring external fixators versus standard internal fixation techniques.

      Secondary Aim #3: To determine patient reported levels of satisfaction with the fixation
      method and overall treatment and to compare satisfaction between the two treatment groups.
    

Intervention name(s): Surgery with an external ring fixator; Definitive fixation with a locked IM nail or plate
Intervention type(s): Procedure; Procedure
Intervention description(s): Modern ring external fixator is defined as any fixator that has at least 1 ring proximal and 1 ring distal to the fracture site. The rings may be connected to the tibia using any combination of external fixation pins or wires at the surgeon's discretion. There must be at least two pins or wires connected to each ring, and typically there will be at least three pins or wires. Any FDA approved ring fixator meeting this definition from any manufacturer is allowed.; Eligible patients with tibial diaphyseal fractures will typically receive a standard locked IM Nail. The nail must use at least one static interlock proximal to and one static interlock distal to the fracture site. The nail may be placed with either a reamed or unreamed technique.
Methaphyseal fractures, especially those with fracture lines extending into the joint may be more commonly treated with plate fixation. The plate may be applied in an open or percutaneous fashion. Any combination of locked and/or non-locked screws may be used.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: External ring fixation; internal fixation; traumatic tibia fracture