Pain, the so-called “fifth vital sign,” is an important and challenging part of trauma care. Understanding what opportunities exist to help to modify the pain experience through non-pharmacological means is an area of ongoing exploration. Despite this, in severe lower-extremity trauma, persistent pain remains a major treatment challenge. The prevalence of long-term pain has been reported to be as high as 77% years after traumatic injury and is considered a substantial contributor to disability and psychosocial burden1. In the current article, Shu et al. have evaluated the potential impact of the treatment method on the patient pain experience following severe open tibial fracture by analyzing data from a previous multicenter randomized controlled trial. The original study, the FIXIT trial from the METRC (Major Extremity Trauma Research Consortium) group, compared major complications between modern external ring fixation and internal fixation for severe open tibial fractures2. Shu et al. performed the current secondary analysis to evaluate pain outcomes at 6 and 12 months as measured using validated instruments such as the Brief Pain Inventory. Leveraging data from the large, multicenter, randomized cohort in the FIXIT trial (n = 254), Shu et al. report no difference in pain intensity between fixation types at either 6 or 12 months; however, pain interference at 6 months was greater in the external fixation group. The difference in pain interference reached the minimum clinically important difference for Brief Pain Inventory scores, suggesting clinical relevance. Importantly, regardless of fixation type, approximately one-third of patients experienced moderate to severe pain at both time points during the study. This finding reflects that complex biopsychosocial sequelae, not merely the surgical technique, underpin the persistence of pain after high-energy trauma3. Unsurprisingly, and perhaps further highlighting the biopsychosocial elements of trauma care, patients with retention of external fixation at the 12-month mark experienced greater pain intensity and interference, a potential clinically actionable insight. Intramedullary fixation has become the standard of care for open tibial shaft fractures; however, high-grade evidence has historically been scarce. Ongoing questions remain regarding the ideal management strategy in these complex cases. In recent years, randomized controlled trials have examined the optimal treatment paradigm for open tibial fractures by comparing definitive external fixation and intramedullary nailing2,4,5. However, the trials have largely focused on union rates and infection, with pain outcomes rarely addressed4,5. Conceptually, the use of external fixation offers reduced overall metal implant load, potentially reducing infection risk, while offering flexibility in the fixation strategy and treatment technique. Early comparative trials suggested differing burdens from internal and external fixation techniques, with increased anterior knee pain with intramedullary nailing, particularly with infrapatellar approaches, and psychological and functional burdens with external fixation. The current work and the FIXIT trial refine the narrative: suprapatellar nailing, now widely adopted, may mitigate knee pain concerns, whereas external fixation’s impact on pain may be transient and linked to frame duration rather than the inherent technique. The persistence of moderate to severe pain in one-third of patients regardless of treatment technique reiterates findings from longitudinal studies highlighting the challenges of these injuries and that early pain intensity predicts chronic pain after musculoskeletal trauma3. Several important limitations in this article temper interpretation. Pain protocols were not standardized, introducing confounding from variable opioid-prescribing and rehabilitation practices, whereas data on psychosocial factors, established moderators of chronic pain, were not captured. Additionally, the site-specific pain scoring system, the adapted Numeric Pain Rating Scale method, lacks validation in populations with trauma, whereas missing data may bias pain prevalence estimates. Despite these caveats, the study’s pragmatic design mirrors real-world practice, enhancing external validity. The nuanced observation that external fixation removal is associated with decreased pain interference at 12 months suggests that minimizing frame duration, when feasible, may improve patient-reported outcomes. For surgeons, the takeaway is clear: fixation choice should prioritize soft-tissue management, union rates, infection risk, and patient preference, not anticipated pain differences. This work challenges assumptions that the fixation method alone drives long-term pain after a severe open tibial fracture. Meanwhile, the high burden of persistent pain calls for multidisciplinary strategies targeting both biological and psychosocial domains. In the broader context of severe open tibial fractures, this work expands on recent literature suggesting a narrower role for definitive external fixation in these challenging fractures and validates the established standard of intramedullary fixation for these injuries.
Jason Strelzow (Thu,) studied this question.