Surgeons' preferences for the operative treatment of fractures of the tibial shaft. An international survey

Current management of tibial shaft fractures: a survey of 450 Canadian orthopedic trauma surgeons

BACKGROUND AND PURPOSE

Strategies to manage tibial fractures include nonoperative and operative approaches. Strategies to enhance healing include a variety of bone stimulators. It is not known what forms of management for tibial fractures predominate among Canadian orthopedic surgeons. We therefore asked a representative sample of orthopedic trauma surgeons about their management of tibial fracture patients.

METHODS

This was a cross-sectional survey of 450 Canadian orthopedic trauma surgeons. We inquired about demographic variables and current tibial shaft fracture management strategies.

RESULTS

268 surgeons completed the survey, a response rate of 60%. Most respondents (80%) managed closed tibial shaft fracture operatively; 47% preferred reamed intramedullary nailing and 40% preferred unreamed. For open tibial shaft fractures, 59% of surgeons preferred reamed intramedullary nailing. Some surgeons (16%) reported use of bone stimulators for management of uncomplicated open and closed tibial shaft fractures, and almost half (45%) made use of this adjunctive modality for complicated tibial shaft fractures. Low-intensity pulsed ultrasound and electrical stimulation proved equally popular (21% each) and 80% of respondents felt that a reduction in healing time of 6 weeks or more, attributed to a bone stimulator, would be clinically important.

INTERPRETATION

Current practice regarding orthopedic management of tibial shaft fractures in Canada strongly favors operative treatment with intramedullary nailing, although respondents were divided in their preference for reamed and unreamed nailing. Use of bone stimulators is common as an adjunctive modality in this injury population. Large randomized trials are needed to provide better evidence to guide clinical decision making regarding the choice of reamed or unreamed nailing for tibial shaft fractures, and to inform surgeons about the actual effect of bone stimulators.

Decreasing incidence of tibial shaft fractures between 1998 and 2004: information based on 10,627 Swedish inpatients

BACKGROUND AND PURPOSE

There is a lack of national epidemiological data on the characteristics of patients with tibial shaft fractures. We therefore analyzed data on Swedish patients with tibial shaft fractures in this nationwide population study based on data from 1998 through 2004.

METHODS

Data on all patients with tibial shaft fractures were extracted from the Swedish National Hospital Discharge Register.

RESULTS

We identified 10,627 hospital admissions for tibial shaft fractures, corresponding to an annual incidence rate of 17 per 100,000 person-years (pyr). The number of hospital admissions decreased by 12% during the period 1998-2004, mostly from a reduction in male incidence. The median (SD) age at admission was 28 (22) years for men and 51 (26) years for women. The two major mechanisms of injury were falls on the same level (48%) and transport accidents (21%). Surgical procedures were dominated by osteosynthesis with nail (48%), followed by closed reduction and plaster cast (27%), and external fixation (12%). 12% of all tibial shaft fractures were classified as open, corresponding to an incidence rate of 2.3 per 100,000 pyr, which declined during 1998-2004.

INTERPRETATION

This nationwide study of tibial shaft fractures shows a falling off of fracture incidence, a finding that can be used to advantage by healthcare providers.

Surgeons' beliefs and perceptions about removal of orthopaedic implants

Background

The routine removal of orthopaedic fixation devices after fracture healing remains an issue of debate. There are no evidence-based guidelines on this matter, and little is known on surgeons' practice and perceived effectiveness of implant removal in different clinical settings.

Methods

A 41-item questionnaire was distributed to 730 attendees of the AO Principles and Masters Courses of Operative Fracture Treatment in Davos, Switzerland, to assess their attitudes towards removal of different types of implants, and perceived benefits and risks with this common procedure.

Results

The response rate was 655/730 (89.7%), representing 54.6% of all 1199 course attendees. Surgeons from 65 countries (571 males and 84 females, mean age 39 ± SD 9 years) took part in the survey. Fifty-eight percent of the participants did not agree that routine implant removal is necessary, and 49% and 58% did not agree that indwelling implants pose an excess risk for fractures or general adverse effects. Forty-eight percent felt that removal is riskier than leaving the implant in situ. Implant removal in symptomatic patients was rated to be moderately effective (mean rating on a 10-point-scale, 5.8, 95% confidence interval 5.7–6.0). Eighty-five percent of all participants agreed that implant removal poses a burden to hospital resources. Surgeons were undetermined whether implant removal is adequately reimbursed by payers of health care services (44% "I-don't-know"-answers).

Conclusion

Many surgeons refuse a routine implant removal policy, and do not believe in clinically significant adverse effects of retained metal implants. Given the frequency of the procedure in orthopaedic departments worldwide, there is an urgent need for a large randomized trial to determine the efficacy and effectiveness of implant removal with regard to patient-centred outcomes.

The orthopaedic trauma literature: an evaluation of statistically significant findings in orthopaedic trauma randomized trials

Background

Evidence-based medicine posits that health care research is founded upon clinically important differences in patient centered outcomes. Statistically significant differences between two treatments may not necessarily reflect a clinically important difference. We aimed to quantify the sample sizes and magnitude of treatment effects in a review of orthopaedic randomized trials with statistically significant findings.

Methods

We conducted a comprehensive search (PubMed, Cochrane) for all randomized controlled trials between 1/1/95 to 12/31/04. Eligible studies include those that focused upon orthopaedic trauma. Baseline characteristics and treatment effects were abstracted by two reviewers. Briefly, for continuous outcome measures (ie functional scores), we calculated effect sizes (mean difference/standard deviation). Dichotomous variables (ie infection, nonunion) were summarized as absolute risk differences and relative risk reductions (RRR). Effect sizes >0.80 and RRRs>50% were defined as large effects.

Using regression analysis we examined the association between the total number of outcome events and treatment effect (dichotomous outcomes).

Results

Our search yielded 433 randomized controlled trials (RCTs), of which 76 RCTs with statistically significant findings on 184 outcomes (122 continuous/62 dichotomous outcomes) met study eligibility criteria. The mean effect size across studies with continuous outcome variables was 1.7 (95% confidence interval: 1.43–1.97). For dichotomous outcomes, the mean risk difference was 30% (95%confidence interval:24%–36%) and the mean relative risk reduction was 61% (95% confidence interval: 55%–66%; range: 0%–97%). Fewer numbers of total outcome events in studies was strongly correlated with increasing magnitude of the treatment effect (Pearson's R = -0.70, p < 0.01). When adjusted for sample size, the number of outcome events revealed an independent association with the size of the treatment effect (Odds ratio = 50, 95% confidence interval: 3.0–1000, p = 0.006).

Conclusion

Our review suggests that statistically significant results in orthopaedic trials have the following implications-1) On average large risk reductions are reported 2) Large treatment effects (>50% relative risk reduction) are correlated with few number of total outcome events. Readers should interpret the results of such small trials with these issues in mind.

A knowledge-based computer-aided system for closed diaphyseal fracture reduction

BACKGROUND

We recently developed an algorithm to perform closed fracture reduction using unilateral external fixator. Although its validity has been verified experimentally, the whole reduction process was not evaluated owing to the lack of a device that could facilitate its implementation in clinical practice. The objective of this study is to develop a prototype of such a system, and quantify its reduction accuracy.

METHODS

The system consists of a custom-made unilateral external device and a self-contained software package. The device features 7 one degree of freedom joints, each allows for continuous adjustments and is equipped with measurement components to facilitate accurate positioning. A CT-based method was developed, which facilitates virtual reduction and calculates the adjustment requirements that reduce a fracture deformity. The device was adjusted off-the-site and reattached back in place to guide the reduction of the fracture fragments. Reduction accuracy was evaluated using eight phantoms of different types, sides and fracture patterns by calculating the rotation about a screw axis and the displacement between the origins of the distal and proximal local coordinate systems after the reduction.

FINDINGS

The mean (SD) of the translational and rotational reduction errors were 1.73 (0.97)mm and 2.57 degrees (1.36 degrees), respectively, which demonstrated the accuracy and reliability of the system.

INTERPRETATION

The system allows surgeons to perform fracture reduction in an objective, efficient, and accurate manner yet minimize the radiation exposure and lessens the extent of tissue disruption around the fracture site during the reduction process.

Peroneal nerve damage by oblique proximal locking screw in tibial fracture nailing: a new emerging complication?

Interlocking intramedullary nailing currently is the preferred treatment for most tibial fractures requiring operative treatment. Good results with a relative low complication rate have been reported in large clinical series, as well as in comparative series. The reported incidence of neurological complications after tibial nailing varies, involving mainly the peroneal nerve. The mechanism of peroneal nerve damage in tibial fracture nailing is usually indirect, caused by leg traction or compartment syndrome. Direct peroneal nerve damage related to the proximal locking screw seems to be very rare since we were able to identify only one report in the English literature. We report a case of partial peroneal nerve damage caused by a long oblique proximal locking screw. Removal of the proximal locking screw leaded to a gradual improvement of the nerve function and a complete resolution at one year. This seems to be a new emerging iatrogenic complication related to nails designed with oblique proximal locking screws. We feel that the placement of the oblique proximal screw from medial to lateral side needs an extra care. Even fluoroscopy, does not give enough safety due to the spatial geometry of the proximal tibia and the known problems of viewing oblique interlocking screws with a two-dimensional image-intensifier.

Extending the Indication of Intramedullary Nailing of Tibial Fractures

Intramedullary nailing is an effective and well-established method for the treatment of a wide spectrum of tibial fractures. Nevertheless, the handling of metaphyseal and open fracture remains challenging. Surgical and technical advancements have opened up new possibilities to broaden the indication of intramedullary nailing in these areas.

Treatment of open tibial shaft fractures using tightly fitted interlocking nailing

Between 2000 and 2003 we treated 23 patients who sustained open tibial shaft fractures with tightly fitted interlocking intramedullary nailing. There were three grade I, eight grade II, nine grade IIIa, and three grade IIIb open fractures. Nail diameters were decided on using preoperative and intraoperative radiographs. Nails were introduced after gentle passage with a 7- to 8-mm hand reamer. Union was obtained in all cases. Nine (37.5%) fractures, however, required additional procedures before union. Three of them gained union through exchange nailing, bone graft, and bone transport, respectively. The remaining six underwent dynamisation. Two of them required an additional exchange nailing for non-union; thereafter one healed and the other gained union through an additional bone graft. Deep infection occurred in one case. Screw breakage occurred in one case only. Tightly fitted nailing produced a significantly lower incidence of locking screw breakage. However, even with this advantage, this technical modification has failed to show clinical advantage in terms of higher healing rate or lower rate of secondary procedures.

Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures

As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient-, injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis. The patients were reviewed until clinical and radiological evidence of union at a mean of 13.3 months (4 to 60). Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 2.38 times for highly comminuted fractures, by 3.14 times when nail dynamisation was applied, and by 1.65 times when the locking screws failed. In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was ≥ 3 mm.

Como são tratadas as fraturas diafisárias fechadas do fêmur no Brasil? Estudo transversal

Realizou-se um estudo transversal no 36º Congresso Brasileiro de Ortopedia e Traumatologia, onde foi pesquisada a opinião de ortopedistas brasileiros sobre aspectos do tratamento de fraturas diafisárias do fêmur no adulto. Quinhentos e sete questionários foram respondidos integralmente e encontrou-se concordância entre os ortopedistas em relação aos seguintes aspectos: configuração do traço de fratura e lesão de partes moles ou de estruturas neurovasculares como parâmetros principais para decisão sobre o tratamento; classificação das fraturas, em que a AO foi a mais adotada; haste intramedular anterógrada bloqueada fresada para tratamento das fraturas transversas e oblíquas curtas no istmo; placa ponte para o tratamento das fraturas com traço complexo; tração esquelética pré-operatória; infecção como complicação mais freqüente e uso de heparina de baixo peso molecular no pós-operatório. Houve conflito de opiniões nas seguintes questões: uso de mesa de tração para realização de osteossíntese intramedular; intervalo de tempo entre o trauma e a cirurgia; tempo de utilização de antibióticos e tempo médio de hospitalização. Em relação à literatura, houve concordância em relação aos parâmetros principais para decisão sobre o tratamento; método de fixação das fraturas com traço simples no istmo; classificação adotada; profilaxia antitrombótica. Diferiram da literatura questões como o método de fixação das fraturas com traço complexo; tempo de utilização dos antibióticos, intervalo médio entre o trauma e a osteossíntese e tempo de internação.

Development and validation of a new approach for computer-aided long bone fracture reduction using unilateral external fixator

An innovative computer-aided method to plan and execute long bone fracture reduction using Dynafix unilateral external fixator (EF) is presented and validated. A matrix equation, which represents a sequential transformation from proximal to distal ends, was derived and solved for the amount of rotation and translation required at each EF joint to correct for a displaced fracture using a non-linear least square optimization method. Six polyurethane-foam models of displaced fracture tibiae were used to validate the method. The reduction accuracy was quantified by calculating the residual translations (xr, yr, zr), the residual displacement (dr), and the residual angulations (alphar, betar, gammar) based on the X-Y-Z Euler angle convention. The experiment showed that the mean+/-S.D. of alphar, betar, gammar, xr, yr, zr and dr were 1.57+/-1.14 degrees, 1.33+/-0.90 degrees, 0.71+/-0.70 degrees, 0.98+/-1.85, 0.80+/-0.67, 0.30+/-0.27, and 0.50+/-0.77 mm, respectively, which demonstrated the accuracy and reliability of the method. Instead of adjusting the fixator joints in-situ, our method allows for off-site adjustment of the fixator joints and employs the adjusted EF as a template to guide the surgeons to manipulate the fracture fragments to complete the reduction process. Success of this method would allow surgeons to perform fracture reduction more objectively, efficiently and accurately yet reduce the radiation exposure to both the involved clinicians and patients and lessen the extent of periosteum and soft tissue disruption around the fracture site.

Path analysis of factors for delayed healing and nonunion in 416 operatively treated tibial shaft fractures

A prospective observational study was done in 41 trauma centers. Four hundred sixteen patients with tibial shaft fractures were treated operatively and followed up for at least 6 months. Fifty-two (13%) cases of delayed healing or nonunion were reported. In such nonrandomized observational studies, multiple interrelationships exist between prognostic factors and patient outcomes. We used path analyses to investigate prognostic factors associated with the occurrence of delayed healing or nonunion. The most important factors were identified using multivariate regression analyses, and interrelationships between factors were illustrated using a path diagram. Fractures with open injuries less than and greater than 5 cm were 3.6 and 5.7 times as likely, respectively, to have delayed healing or nonunion as fractures with no skin injuries. The Müller-AO classification of fractures did not provide additional prognostic information. The risk of healing problems was doubled for fractures of the distal shaft and for fractures showing a postoperative diastasis. Treatment options showed an indirect effect on outcome with the occurrence of diastasis. A model for predicting delayed healing or nonunion is proposed. We encourage the use of path analysis in orthopaedics as a powerful visual technique to interpret data from observational studies.

LEVEL OF EVIDENCE

Prognostic study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Como são tratadas as fraturas expostas da tíbia no Brasil? Estudo transversal

Este estudo transversal foi realizado durante o 36º Congresso Brasileiro de Ortopedia e Traumatologia, para identificar a opinião do ortopedista brasileiro a respeito das preferências de tratamento das fraturas expostas da tíbia nos adultos. Foram respondidos 507 questionários, sendo que os resultados demonstram consenso em relação aos seguintes aspectos: classificação, 78,5% utilizam a de Gustilo-Anderson; indicação de tratamento cirúrgico, 76,3% preferem operar todos as fraturas; pressão de irrigação e produto utilizado, 80,3% utilizam irrigação manual e 85,4% solução salina; método de estabilização da fratura, fixador externo foi apontado em 52,1% das fraturas expostas tipo II, 74,4% nas IIIA, 88,6% nas IIIB e 89% nas IIIC; e indicação de fechamento primário, escolhido em 74,2% nas tipo I. Não houve consenso em relação ao tempo para cobertura de partes moles e tempo de uso de antibióticos. Os principais aspectos que discordaram da literatura foram: método de estabilização, tempo de uso de antibióticos e indicações de fechamento primário.

Internet versus mailed questionnaires: a controlled comparison (2)

Background

Low response rates among surgeons can threaten the validity of surveys. Internet technologies may reduce the time, effort, and financial resources needed to conduct surveys.

Objective

We investigated whether using Web-based technology could increase the response rates to an international survey.

Methods

We solicited opinions from the 442 surgeon–members of the Orthopaedic Trauma Association regarding the treatment of femoral neck fractures. We developed a self-administered questionnaire after conducting a literature review, focus groups, and key informant interviews, for which we used sampling to redundancy techniques. We administered an Internet version of the questionnaire on a Web site, as well as a paper version, which looked similar to the Internet version and which had identical content. Only those in our sample could access the Web site. We alternately assigned the participants to receive the survey by mail (n=221) or an email invitation to participate on the Internet (n=221). Non-respondents in the mail arm received up to three additional copies of the survey, while non-respondents in the Internet arm received up to three additional requests, including a final mailed copy. All participants in the Internet arm had an opportunity to request an emailed Portable Document Format (PDF) version.

Results

The Internet arm demonstrated a lower response rate (99/221, 45%) than the mail questionnaire arm (128/221, 58%) (absolute difference 13%, 95% confidence interval 4%-22%, P<0.01).

Conclusions

Our Internet-based survey to surgeons resulted in a significantly lower response rate than a traditional mailed survey. Researchers should not assume that the widespread availability and potential ease of Internet-based surveys will translate into higher response rates.

Internet versus mailed questionnaires: a randomized comparison (2)

BACKGROUND

Low response rates among surgeons can threaten the validity of surveys. Internet technologies may reduce the time, effort, and financial resources needed to conduct surveys.

OBJECTIVE

We investigated whether using Web-based technology could increase the response rates to an international survey.

METHODS

We solicited opinions from the 442 surgeon-members of the Orthopaedic Trauma Association regarding the treatment of femoral neck fractures. We developed a self-administered questionnaire after conducting a literature review, focus groups, and key informant interviews, for which we used sampling to redundancy techniques. We administered an Internet version of the questionnaire on a Web site, as well as a paper version, which looked similar to the Internet version and which had identical content. Only those in our sample could access the Web site. We alternately assigned the participants to receive the survey by mail (n=221) or an email invitation to participate on the Internet (n=221). Non-respondents in the mail arm received up to three additional copies of the survey, while non-respondents in the Internet arm received up to three additional requests, including a final mailed copy. All participants in the Internet arm had an opportunity to request an emailed Portable Document Format (PDF) version.

RESULTS

The Internet arm demonstrated a lower response rate (99/221, 45%) than the mail questionnaire arm (129/221, 58%) (absolute difference 13%, 95% confidence interval 4%-22%, P<0.01).

CONCLUSIONS

Our Internet-based survey to surgeons resulted in a significantly lower response rate than a traditional mailed survey. Researchers should not assume that the widespread availability and potential ease of Internet-based surveys will translate into higher response rates.

Predictors of reoperation following operative management of fractures of the tibial shaft

BACKGROUND

Accurate prediction of likelihood of reoperation in patients with tibial shaft fractures would facilitate optimal management. Previous studies were limited by small sample sizes and noncomprehensive examination of possible risk factors.

OBJECTIVE

We conducted an observational study to determine which prognostic factors were associated with an increased risk of reoperation following operative treatment in a heterogeneous population of patients with tibial shaft fractures.

DESIGN

Retrospective observational study.

SETTING

Level 1 trauma center.

METHODS

We identified 200 patients with tibial shaft fractures from two university-affiliated centers. Two reviewers independently abstracted data regarding 20 possible prognostic variables, reviewed preoperative and postoperative radiographs, and documented reoperations (defined as any surgical procedure </=1 year after the initial surgery that was aimed specifically at achieving bony union of the fracture, including bone grafts, implant exchanges, or débridement for infections). We chose a Cox proportion hazards model to conduct a survival analysis for time to reoperation and constructed a multivariable model to estimate the relative risk of reoperation and associated 95%confidence interval (CI) for each predictor variable.

MAIN OUTCOME MEASURES

Time to reoperation following the initial surgery.

RESULTS

Complete follow-up information was available for 192 of 200 (96%) patients. Three variables predicted reoperation: the presence of an open fracture wound (relative risk 4.32, 95% CI 1.76 to 11.26), lack of cortical continuity between the fracture ends following fixation (relative risk 8.33, 95% CI 3.03 to 25.0), and the presence of a transverse fracture (relative risk 20.0, 95% CI 4.34 to 142.86).

CONCLUSIONS

We identified a set of three simple prognostic variables (open fracture, transverse fracture, and postoperative fracture gap) that can assist surgeons in predicting reoperation following operative treatment of tibial shaft fractures.