OTA 1999 Posters

The Treatment of Open Tibial Shaft Fractures: A Systematic Overview and Meta-Analysis

Mohit Bhandari, MD; Gordon H. Guyatt, MD; Marc F. Swiontkowski, MD; Emil H. Schemitsch, MD, Department of Clinical Epidemiology and Biostatistics, Hamilton, Ontario, University of Minnesota, Minneapolis, and St. Michael's Hospital, Toronto, Ontario, CANADA

Objective: To determine the effect of different stabilization approaches to open tibial shaft fractures on rates of re-operation, and on secondary outcomes of nonunion, deep and superficial infection, implant failure and malunion.

Design: Quantitative systematic review of randomized and quasi-randomized trials.

Data Identification: We searched computerized databases (MEDLINE, COCHRANE and SCISEARCH) for published clinical studies from 1969-1998 and identified additional studies through hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts and personal files.

Study Selection and Data Extraction: Of 799 citations initially identified, 68 proved potentially eligible, and 8 met all eligibility criteria. Three investigators independently graded study quality and abstracted relevant data.

Results: One study (N = 56) suggests external fixators significantly decrease the relative risk of re-operation relative to plates (relative risk 0.13, 95% confidence interval 0.03-0.54, p value<0.01) Given the similar methodologies and non-significant tests of heterogeneity (p>0.1), statistical pooling of the 5 studies that reported outcomes on non-reamed nails was conducted. Non-reamed nails, in comparison to external fixators (5 studies, n=396 patients), reduced the risk of re-operation (RR 0.51, 95% confidence interval 0.37-0.69, p value<0.0001). Non-reamed nails also offered advantages in decreasing the relative risk of malunion (RR 0.42, 95%confidence interval 0.25-0.71, p value<0.01) and superficial infection (RR 0.24,95% confidence interval, 0.08-0.73, p value<0.01).

Reamed nails, when compared to non-reamed nails, did not significantly decrease the risk of re-operation (2 studies, n=132)(RR 0.75, 95% confidence interval 0.43-1.32, p value=0.32). The indirect comparison between reamed nails and external fixators suggested that reamed nails offered significant advantages in decreasing re-operation risk (RR 0.43, 95% confidence interval 0.19-0.95, p<0.05).

Conclusions: There is compelling evidence that non-reamed nails reduce re-operations, superficial infections and malunions when compared to external fixators. The relative effect of reamed versus unreamed nails in the treatment of open tibial fractures remains uncertain. The issue requires a large, randomized trial comparing reamed versus non-reamed nails for resolution.