***TASK*** the task is to summarize an input biomedical literature in six sentences 
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    Input: Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Severe open fractures of the tibia have a high incidence of complications and a poor outcome . The most usual method of stabilisation is by external fixation , but the advent of small diameter locking intramedullary nails has introduced a new option . We report the early results of a r and omised , prospect i ve study comparing external fixation with non-reamed locked nails in  grade -IIIb open tibial fractures . Of 29 patients , 15 were treated by nails and 14 by external fixation .  Both groups had the same initial management , soft-tissue procedures , and early bone grafting . All 29 fractures healed within nine months , but the nailed group had slightly better motion and less final angulation . Complications included one deep infection and two pin-track infections in the external fixator group and one deep infection and one vascular problem in the nailed group . Although the differences in healing and range of motion were not statistically significant , we found that the nailed fractures were consistently easier to manage , especially in terms of soft-tissue procedures and bone grafting . It is the treatment preferred by patients and does not require the same high level of patient compliance as external fixation . The only factors against nailing are the longer operating time and the greater need for fluoroscopy . We consider that locked non-reamed nailing is the treatment of choice for grade -IIIb open tibial fractures OBJECTIVE To compare unreamed intramedullary nailing ( IMN ) with external fixation ( EF ) in patients with Type II , IIIA , and IIIB open fractures of the tibial shaft . DESIGN An inception cohort of consecutive patients with Type II , IIIA , and IIIB tibial fractures incurred between January 1988 and March 1993 were systematic ally allocated into one of two treatment groups . Patients were treated and followed with a prospect ively design ed protocol . PATIENTS AND SETTING All patients were skeletally mature and had incurred a fracture of the tibial diaphysis within twenty-four hours of presentation to the tertiary care hospital , a Level I Trauma Center . One hundred seventy-four fractures in 168 patients were stabilized with either IMN ( 104 ) or half-pin EF ( 70 ) . There were 132 men and thirty-six women , with an average age of thirty-three years ( range , 14 to 77 years ) . INTERVENTION Except for the selection of the fixation device , open fracture care was similar in the two treatment groups . All patients underwent emergent irrigation and debridement with concomitant skeletal stabilization . Cephalosporin antibiotics were administered perioperatively for twenty-four to forty-eight hours . No wounds were closed primarily . Delayed primary closure , skin grafting , and /or myoplasty were performed between three and ten days after injury . MAIN OUTCOME MEASURES The main outcome measures were final fracture alignment , presence of infection or inflammation , hardware failure , time to union , and the number of operative procedures . RESULTS The IMN group had significantly fewer incidences of malalignment than did the EF group [ 8 vs. 31 percent ; p = 0.00005 ; confidence interval ( CI ) = 0.18 , 0.76 ] and had significantly fewer subsequent procedures ( mean of 1.7 vs. mean of 2.7 per fracture ; p = 0.001 ; CI = 0.45 , 1.59 ) . IMN result ed in fewer infections/ inflammatory problems than did EF at the injury site ( 13 vs. 21 percent ; p = 0.73 ; CI = -0.63 , 0.45 ) and significantly fewer at surgical interfaces ( i.e. , pin sites , nail and interlocking screw insertion sites ; 2 vs. 50 percent ; p = 0.000 ; CI = 0.39 , 0.60 ) . No significant difference was found in the healing rates for the two implant groups . The more severe Gustilo injury types had longer healing times regardless of the type of fixation . CONCLUSIONS Results suggest that unreamed interlocking intramedullary nails are more efficacious than half-pin external fixators , in particular with regard to maintenance of limb alignment . However , the severity of soft tissue injury rather than the choice of implant appears to be the predominant factor influencing rapidity of bone healing and rate of injury site infection Although the intramedullary nailing is thought to be the method of choice for treatment of closed tibial shaft , there is ongoing debate on the optimal surgical approach in patients with open types of these fractures . In addition , choosing between the reamed and unreamed intramedullary nailing is still an issue for the orthopedic surgeons . In present study , we aim ed to compare the outcome and consequences of OA tubular external fixation vs. unreamed intramedullary nailing in open grade IIIA-IIIB tibial shaft fractures . In a r and omized clinical trial , 50 patients with open tibial shaft fractures ( grade s IIIA-IIIB ) were recruited in Tabriz Shohada teaching centre in a 2-year period of time . They r and omized in two equal groups underwent either AO tubular external fixation or unreamed intramedullary nailing . These 2 groups were matched for sex , age and fracture- grade . The follow-up time was one year . Union time , surgical outcome , postoperative complications and the ambulation time were compared between the two groups . Twenty five patients , 20 males and 5 females with a mean age of 30.80 + /- 5.24 years were allocated in unreamed intramedullary group and 25 other patients , 22 males and 3 females with a mean age of 28.92 + /- 8.88 years were studied in the external fixation group ( p = 0.70 and 0.37 , respectively ) . The two groups were matched for sex ( p = 0.70 ) and age ( p = 0.37 ) . The time of union was 3 , 4 , 5 and 6 < or = weeks after operation in 28 , 12 , 32 and 28 % of the cases in unreamed intramedullary group vs. 4 , 12 , 48 and 36 % of the cases in external fixation group , respectively ( p = 0.14 ) . Post-operative infection , soft tissue injury , malunion and nonunion were documented in 16 , 8 , 0 and 4 % of the cases in unreamed intramedullary group vs. 32 , 12 , 24 and 8 % of the cases in external fixation group , respectively ( p = 0.19 , 0.50 , 0.02 and 0.50 , respectively ) . The mean ambulation time after operation was 2.92 + /- 2.43 weeks in the unreamed intramedullary nailing group vs. 2.68 + /- 2.14 weeks in the external fixation group ( p = 0.71 ) . Our results are in favor of  unreamed intramedullary nailing against external fixation  in treatment of open tibial shaft fractures In a prospect i ve study , since March 1989 , 55 tibial shaft fractures have been treated with a new , unreamed solid tibial nail ( UTN ) . This nail was initially design ed as a temporary implant . The first 33 cases with second or third degree soft tissue damage were review ed 6 months or more after the operation . Fractures were classified according to Müller : 6 type A ( 18.2 % ) , 15 type B ( 45.5 % ) , and 12 type C ( 36.7 % ) . In 9 cases ( 27.3 % ) , there was GII ( n = 4 ) or GIII ( n = 5 ) closed soft tissue damage according to Tscherne 's classification . The 24 open fractures ( 72.7 % ) comprised 11 OII , 3 OIIIA and 10 OIIIB fractures ( Gustilo classification ) . 24 patients ( 72.7 % ) were polytraumatized , the mean PTS ( Hannover Polytrauma Score ) was 18 points ( range : 8 - 65 points ) . All fractures were stabilized without reaming . The implant diameter was 8 mm ( n = 14 ) or 9 mm ( n = 19 ) . Static locking was performed in 31 cases . Dermatofasciotomy was necessary because of compartment syndrome in 14 cases . In 1 grade IIIB open fracture soft tissue coverage was performed with a latissimus dorsi myocutaneous free flap 4 days after nailing . In 32 of the 33 cases the use of an additional cast or brace was not necessary during the follow-up treatment ; 1 patient had a cast for 8 weeks for the treatment of accompanying injuries . Full weight-bearing was achieved in 5 cases within 3 weeks , in 16 cases within 12 weeks , and in 30 cases within 26 weeks . In 16 cases ( 48.5 % ) the interlocking screws were removed after 5 - 26 weeks ( mean : 10 weeks ) . ( ABSTRACT TRUNCATED AT 250 WORDS Unreamed intramedullary nailing is an alternative to external fixation in the treatment of open tibial fractures . We compared a prospect i ve series of thirty-one patients managed with a solid nail with static interlocking without intramedullary reaming , with a retrospective series of thirty-one patients managed by external fixation .  The protocol for soft tissue treatment was the same throughout the study period . Most fractures were caused by high energy trauma and included Grade I to III B injuries . The fracture wound infection rate was equal in both groups ; there were two deep and three superficial infections in the nail group and three deep and two superficial infections in the external fixation group . In addition , eleven patients in the external fixation group had severe pin track infections . The mean time to union was five months in the nail group and eight months in the external fixation group . The incidence of delayed union was twice as high in the external fixation group as in the nail group . The number of surgical procedures performed to promote union was three times higher in the external fixation group . The malunion rate did not differ between the groups . Although the treatment groups are not fully comparable , the results indicate that intramedullary nailing is superior to external fixation in the treatment of most open tibial fractures We undertook a prospect i ve study comparing the unreamed interlocking nail to Hoffmann external skeletal fixation ( ESF ) in the treatment of 36 consecutive patients with open type IIIA and IIIB tibia fractures . The choice of interlocking nail or Hoffmann ESF was r and omized , ultimately producing four different patient groups : group 1 , type IIIA fractures treated by interlocking nail ; group 2 , type IIIA fractures treated by ESF ; group 3 , type IIIB fractures with interlocking nail ; and group 4 , type IIIB fractures with ESF .  The average length of follow-up was 20.5 months . The infection rate was highest in group 3 ( 3 of 8) . The malrotation , malunion , and nonunion rates were highest in group 4 and lowest in group 1 . These results suggest the unreamed interlocking nail is a good choice for the treatment of open type IIIA tibia fractures , but not recommended for the treatment of open type IIIB tibia fractures because of the high infection rate We performed a prospect i ve , r and omised study on 50 patients with Tscherne C1 tibial diaphyseal fractures comparing treatment with reamed and unreamed intramedullary nails . Our results show that  reamed nailing is associated with a significantly lower time to union and a reduced requirement for a further operation . Unreamed nailing  should not be used in the treatment of the common Tscherne C1 tibial fracture In 673 open fractures of long bones ( tibia and fibula , femur , radius and ulna , and humerus ) treated from 1955 to 1968 at Hennepin County Medical Center , Minneapolis , Minnesota , and analyzed retrospectively , the infection rate was 12 per cent from 1955 to 1960 and 5 per cent from 1961 to 1968 . In a prospect i ve study from 1969 to 1973 , 352 patients were managed as follows : débridement and copious irrigation , primary closure for Type I and II fractures and secondary closure for Type III fractures , no primary internal fixation except in the presence of associated vascular injuries , cultures of all wounds , and oxacillin-ampicillin before surgery and for three days postoperatively . In 158 of the patients in the prospect i ve study the initial wound cultures revealed bacterial growth in 70.3 per cent and the infection rate was 2.5 per cent . Sensitivity studies suggested that cephalosporin is currently the prophylactic antibiotic of choice . For the Type III open fractures ( severe soft-tissue injury , segmental fracture , or traumatic amputation ) , the infection rates were 44 per cent in the retrospective study and 9 per cent in the prospect i ve study Grade III open tibial fractures are known for frequent complications and poor clinical results , yet published series are few and cite conflicting results . To address this dilemma , the authors report a prospect i ve study of 202 consecutive Grade III tibial fractures . All injuries were treated under protocol at the authors ' university with primary external fixation and serial debridement . Equinus deformity was prevented with a new tibiometatarsal frame extension . Severe injuries crossing the ankle or knee were temporarily stabilized 
    Output:
    
Data analysis revealed that UTN  reduced the incidence rates of superficial infection and malunion after fixation compared with EF .
However , EF led to a significant reduction in hardware failure .
For postoperative deep infection , delayed union and nonunion , the treatment effects were similar between these two groups .