Hybrid fixation combining limited internal and external fixation has been proposed to improve alignment and stability in severe open tibial fractures, but its benefit in Gustilo IIIB and IIIC injuries remains unclear.

(1) Does hybrid fixation combining limited internal and external fixation (HF) improve alignment correction compared to external fixation (EF) alone? (2) Are final alignment outcomes improved with HF? (3) Do union rates, time to union, and complication rates differ between the HF and EF alone? (4) Is there a threshold for initial deformity above which HF is beneficial?

We retrospectively reviewed 57 patients with Gustilo type IIIB or IIIC open tibial shaft fractures treated between 2015 and 2024. The patients underwent either HF (HF group; n = 20) or EF alone (EF group; n = 37) during their first surgery.

The HF group demonstrated significantly better alignment correction than the EF group ( p = 0.036). At each evaluation stage – after the first surgery, after conversion, and at final follow-up – reduction quality was consistently superior in the HF group compared with the EF group ( p = 0.046, 0.01, and 0.019, respectively). No malunions occurred in the HF group, whereas several malunions were observed in the EF group. Union rate, time to union, and infection-related complications were comparable between the groups. Receiver operating characteristic analysis identified an initial deformity angle of 15.2° as the threshold for predicting benefit from HF (area under the curve = 0.74).

Hybrid fixation combining limited internal fixation with external fixation during the first-stage management of Gustilo IIIB and IIIC open tibial fractures provides better alignment control without increasing infection risk or surgical burden. This approach represents a safe and effective option for managing severe open tibial fractures.

III; Retrospective comparative study.