Question: In patients with open tibial shaft
fractures, what is the effectiveness of external fixation, plating,
and reamed or unreamed intramedullary nailing on rates of reoperation,
nonunion, and infection?
Data sources: Studies were identified by searching Medline (1969
to 1998), SCISEARCH, and the Cochrane Library; by hand-searching
major orthopaedic journals and proceedings; and by contacting experts
in the field.
Study selection: Randomized or quasi-randomized
controlled trials (RCTs or QRTs) comparing external fixation, plate
fixation, and reamed or unreamed intramedullary nailing in patients
with open fractures of the tibial diaphysis. The primary outcome
was reoperation.
Data extraction: Data on patient characteristics,
interventions, and outcomes were extracted. Study quality was assessed
with respect to randomization procedures, blinding, follow-up, and
analysis. An overall quality score was graded as a percentage.
Main results: 8 trials (4 RCTs and 4 QRTs) were included.
The quality scores ranged from 18% to 71%. 1 QRT
(56 patients) compared plate fixation with external fixation. The
rates of reoperation were lower in the external-fixation group (6.7% vs.
50%, P < 0.01). The groups did
not differ for nonunion or deep infection rates. 5 RCTs (396 patients)
compared unreamed nailing with external fixation. Reoperation rates
were lower in the unreamed-nailing group (P < 0.001)
(table). The
rates of nonunion and deep infection were also lower in the nailing group,
but the differences did not reach statistical significance (P = 0.067
and P = 0.054, respectively) (table). 2 RCTs (132
patients) compared reamed nailing with unreamed nailing. The groups
did not differ for rates of reoperation (P = 0.32),
nonunion (P = 0.24), or deep infection
(P = 0.98).
Conclusions: In patients with open tibial shaft
fractures, the use of unreamed intramedullary nailing reduces reoperation
rates more than does the use of external fixation. Reamed and unreamed
nailing do not differ for the outcomes of reoperation, nonunion,
or deep infection.