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Zhao Z, Shu H, Jia P, Chen X, Guo F, Liu Y, Shi B, Ji G, Cai C, Shen Y. Hexaxial external fixator versus intramedullary nail in treating segmental tibial fractures: a retrospective study. BMC Surg 2024; 24:44. [PMID: 38302963 PMCID: PMC10835845 DOI: 10.1186/s12893-024-02327-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/17/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND It's difficult to treat segmental tibial fractures (STFs), which are intricate injuries associated with significant soft tissue damage. The aim of this study was to compare the clinical effect of hexaxial external fixator (HEF) and intramedullary nail (IMN) in treatment of STFs. METHODS A total of 42 patients with STFs were finally recruited between January 2018 and June 2022. There were 25 males and 17 females with age range of 20 to 60 years. All fractures were classified as type 42C2 using the Arbeitsgemeinschaftfür Osteosythese/Orthopaedic Trauma Association (AO/OTA) classification. 22 patients were treated with HEF and 20 patients were treated with IMN. The condition of vascular and neural injuries, time of full weight bearing, bone union time and infection rate were documented and analyzed between the two groups. The mechanical medial proximal tibial angle (mMPTA), mechanical posterior proximal tibial angle (mPPTA), mechanical lateral distal tibial angle (mLDTA), mechanical anterior distal tibial angle (mADTA), hospital for special surgery (HSS) knee joint score, American Orthopaedic Foot and Ankle Society (AOFAS) ankle joint score, range of motion (ROM) of flexion of keen joint and ROM of plantar flexion and dorsal flexion of ankle joint were compared between the two groups at the last clinical visit. RESULTS There were no vascular and neural injuries or other severe complications in both groups. All 22 patients in HEF group underwent closed reduction but 3 patients in IMN group were treated by open reduction. The time of full weight bearing was (11.3 ± 3.2) days in HEF group and (67.8 ± 5.8) days in IMN group(P < 0.05), with bone union time for (6.9 ± 0.8) months and (7.7 ± 1.4) months, respectively(P < 0.05). There was no deep infection in both groups. In the HEF group and IMN group, mMPTA was (86.9 ± 1.5)° and (89.7 ± 1.8)°(P < 0.05), mPPTA was (80.8 ± 1.9)° and (78.6 ± 2.0)°(P < 0.05), mLDTA was (88.5 ± 1.7)° and (90.3 ± 1.7)°(P < 0.05), while mADTA was (80.8 ± 1.5)° and (78.4 ± 1.3)°(P < 0.05). No significant differences were found between the two groups at the last clinical visit concerning HSS knee joint score and AOFAS ankle joint score, ROM of flexion of keen joint and ROM of plantar flexion of ankle joint (P > 0.05). The ROM of dorsal flexion of ankle joint in IMN group was (30.4 ± 3.5)°, better than (21.6 ± 2.8)° in HEF group (P < 0.05). CONCLUSION In terms of final clinical outcomes, the use of either HEF or IMN for STFs can achieve good therapeutic effects. While HEF is superior to IMN in terms of completely closed reduction, early full weight bearing, early bone union and alignment. Nevertheless, HEF has a greater impact on the ROM of dorsal flexion of the ankle joint, and much more care and adjustment are needed for the patients than IMN.
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Affiliation(s)
- Zhiming Zhao
- Department of Traumatic Orthopaedics, Tianjin Hospital, No 406, South Jiefang Road, Hexi District, Tianjin, 300211, China
| | - Hengsheng Shu
- Department of Traumatic Orthopaedics, Tianjin Hospital, No 406, South Jiefang Road, Hexi District, Tianjin, 300211, China
| | - Peng Jia
- Department of Traumatic Orthopaedics, Tianjin Hospital, No 406, South Jiefang Road, Hexi District, Tianjin, 300211, China
| | - Xu Chen
- Department of Traumatic Orthopaedics, Tianjin Hospital, No 406, South Jiefang Road, Hexi District, Tianjin, 300211, China
| | - Feng Guo
- Department of Traumatic Orthopaedics, Tianjin Hospital, No 406, South Jiefang Road, Hexi District, Tianjin, 300211, China
| | - Yabin Liu
- Department of Traumatic Orthopaedics, Tianjin Hospital, No 406, South Jiefang Road, Hexi District, Tianjin, 300211, China
| | - Bowen Shi
- Department of Traumatic Orthopaedics, Tianjin Hospital, No 406, South Jiefang Road, Hexi District, Tianjin, 300211, China
| | - Guoqi Ji
- Department of Traumatic Orthopaedics, Tianjin Hospital, No 406, South Jiefang Road, Hexi District, Tianjin, 300211, China
| | - Chengkuo Cai
- Department of Traumatic Orthopaedics, Tianjin Hospital, No 406, South Jiefang Road, Hexi District, Tianjin, 300211, China
| | - Yidong Shen
- Department of Orthopaedics, The First People's Hospital of Yancheng (Yancheng First Hospital, Affiliated Hospital of Nanjing University Medical School), Yancheng, China.
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Yasuda T, Sato K, Yamazaki K, Arai M, Shinohara D, Taisuke Y, Minagawa Y, Samejima Y, Okamoto K, Irie Y, Shiobara K, Kusaba A, Kawasaki K, Hayashi J, Obara S, Kanzaki K, Inagaki K. Nail insertion points in semi-extended nailing of tibial fractures and their influence on alignment: A retrospective cohort study comparing two nail insertion techniques. Injury 2022; 53:3508-3516. [PMID: 35803744 DOI: 10.1016/j.injury.2022.06.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 05/13/2022] [Accepted: 06/21/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Semi-extended tibial nailing techniques include the extra-articular technique (EAT) and the patellar eversion technique (PET). These approaches differ regarding the exposure of the patellar retinaculum and the size of the surgical field. This study compared the postoperative alignment and intramedullary nailing entry points between the EAT and PET for tibial fractures. PATIENTS AND METHODS A total of 54 patients (aged ≥18 years) who had undergone intramedullary nailing by the EAT (n = 29) or PET (n = 25) for a tibial shaft fracture were evaluated. The intramedullary nailing entry point and postoperative alignment were measured, and the 1-year postoperative follow-up results were compared. RESULTS For the EAT and PET, the intramedullary nailing entry point was located at a mean distance of 4.04 mm medial to the optimal entry point and 0.27 mm lateral to the optimal entry point, respectively. The mean angular deformation observed in anteroposterior radiographs following surgery using the EAT and PET were 2.49° and 0.32° valgus, respectively. CONCLUSION The intramedullary nailing entry point affected postoperative alignment. Intramedullary nailing may result in malalignment while performing the EAT due to the interference of the patella at the time of nailing.
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Affiliation(s)
- Tomohiro Yasuda
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Kaoru Sato
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Ken Yamazaki
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan.
| | - Masayuki Arai
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Daichi Shinohara
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan.
| | - Yoneya Taisuke
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Yuuto Minagawa
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Yuki Samejima
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Keiji Okamoto
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan.
| | - Yuko Irie
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan.
| | - Kyosuke Shiobara
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan.
| | - Atsushi Kusaba
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan.
| | - Keikichi Kawasaki
- Department of Orthopedic Surgery, Showa University Northern Yokohama Hospital, Yokohama, Japan.
| | - Junji Hayashi
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan.
| | - Shu Obara
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan.
| | - Koji Kanzaki
- Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan.
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Phelps EE, Tutton E, Costa M, Hing C. Unattainable equipoise in randomized controlled trials : staff views of a feasibility study of surgical treatments for segmental tibial fractures. Bone Jt Open 2021; 2:486-492. [PMID: 34236209 PMCID: PMC8325976 DOI: 10.1302/2633-1462.27.bjo-2021-0055.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Aims To explore staff experiences of a multicentre pilot randomized controlled trial (RCT) comparing intramedullary nails and circular frame external fixation for segmental tibial fractures. Methods A purposeful sample of 19 staff (nine surgeons) involved in the study participated in an interview. Interviews explored participants’ experience and views of the study and the treatments. The interviews drew on phenomenology, were face-to-face or by telephone, and were analyzed using thematic analysis. Results The findings identify that for the treatment of segmental tibial fractures equipoise was a theoretical ideal that was most likely unattainable in clinical practice. This was conveyed through three themes: the ambiguity of equipoise, where multiple definitions of equipoise and a belief in community equipoise were evident; an illusion of equipoise, created by strong treatment preferences and variation in collective surgical skills; and treating the whole patient, where the complexity and severity of the injury required a patient-centred approach and doing the best for the individual patient took priority over trial recruitment. Conclusion Equipoise can be unattainable for rare injuries such as segmental tibial fractures, where there are substantially different surgical treatments requiring specific expertise, high levels of complexity, and a concern for poor outcomes. Surgeons are familiar with community equipoise. However, a shared understanding of factors that limit the feasibility of RCTs may identify instances where community equipoise is unlikely to translate into practice. Cite this article: Bone Jt Open 2021;2(7):486–492.
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Affiliation(s)
- Emma Elizabeth Phelps
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Elizabeth Tutton
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Trauma and MTC, Oxford University NHS Foundation Hospital Trust, John Radcliffe, Oxford, UK
| | - Matthew Costa
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Caroline Hing
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK
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Hing CB, Tutton E, Smith TO, Glaze M, Stokes JR, Cook J, Dritsaki M, Phelps E, Cooper C, Trompeter A, Pearse M, Law M, Costa ML. Reamed intramedullary nailing versus circular frame external fixation for segmental tibial fractures (STIFF-F): a mixed methods feasibility study. Pilot Feasibility Stud 2021; 7:93. [PMID: 33838694 PMCID: PMC8035735 DOI: 10.1186/s40814-021-00821-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 03/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Segmental tibial fractures are fractures in two or more areas of the tibial diaphysis resulting in a separate intercalary segment of the bone. Surgical fixation is recommended for patients with segmental tibial fractures as non-operative treatment outcomes are poor. The most common surgical interventions are intramedullary nailing (IMN) and circular frame external fixation (CFEF), but evidence about which is better is of poor quality. An adequately powered randomised controlled trial (RCT) to determine optimum treatment is required. STIFF-F aimed to assess the feasibility of a multicentre RCT comparing IMN with CFEF for segmental tibial fracture. METHODS STIFF-F was a mixed-methods feasibility study comprising a pilot RCT conducted at six UK Major Trauma Centres, qualitative interviews drawing on Phenomenology and an online survey of rehabilitation. The primary outcome was recruitment rate. Patients, 16 years and over, with a segmental tibial fracture (open or closed) deemed suitable for IMN or CFEF were eligible to participate. Randomisation was stratified by site using random permuted blocks of varying sizes. Participant or assessor blinding was not possible. Interviews were undertaken with patients about their experience of injury, treatment, recovery and participation. Staff were interviewed to identify contextual factors affecting trial processes, their experience of recruitment and the treatment pathway. An online survey was developed to understand the rehabilitation context of the treatments. RESULTS Eleven patients were screened and three recruited to the pilot RCT. Nineteen staff and four patients participated in interviews, and 11 physiotherapists responded to the survey. This study found the following: (i) segmental tibial fractures were rarer than anticipated, (ii) the complexity of the injury, study setup times and surgeon treatment preferences impeded recruitment, (iii) recovery from a segmental tibial fracture is challenging, and rehabilitation protocols are inconsistent and (iv) despite the difficulty recruiting, staff valued this research question and strived to find a way forward. CONCLUSION The proposed multicentre RCT comparing IMN with CFEF is not feasible. This study highlighted the difficulty of recruiting patients to an RCT of a complex rare injury over a short time period. TRIAL REGISTRATION The study was registered with the International Standard Randomised Controlled Trials Number Registry: ISRCTN11229660.
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Affiliation(s)
- Caroline B Hing
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK.
| | - Elizabeth Tutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Toby O Smith
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, Norfolk, UK
| | - Molly Glaze
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jamie R Stokes
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jonathan Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Emma Phelps
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alex Trompeter
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Michael Law
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Matthew L Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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When observational studies are as helpful as randomized trials: Examples from orthopedic trauma. J Trauma Acute Care Surg 2019; 87:730-732. [DOI: 10.1097/ta.0000000000002347] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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