0
Scientific Articles   |    
Prognostic Factors for Predicting Outcomes After Intramedullary Nailing of the Tibia
Emil H. Schemitsch, MD, FRCS(C)1; Mohit Bhandari, MD, PhD, FRCS(C)2; Gordon Guyatt, MD2; David W. Sanders, MD, MSc, FRCS(C)3; Marc Swiontkowski, MD4; Paul Tornetta, III, MD5; Stephen D. Walter, PhD2; Rad Zdero, PhD6; J.C. Goslings, MD, PhD7; David Teague, MD8; Kyle Jeray, MD9; Michael D. McKee, MD, FRCS(C)1; Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) Investigators
1 Division of Orthopaedics, Department of Surgery, University of Toronto, St. Michael’s Hospital, Suite 800, 55 Queen Street East, Toronto, ON M5C 1R6, Canada. E-mail address for E.H. Schemitsch: schemitsche@smh.ca
2 Division of Orthopaedic Surgery, Department of Surgery (M.B.) and Department of Clinical Epidemiology & Biostatistics (M.B., G.G., and S.D.W.), McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 2X2, Canada
3 Orthopedic Surgery, London Health Sciences Centre and the University of Western Ontario, 800 Commissioners Road East, Room E4-123 London, ON N6A 4G5, Canada
4 Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, R200, Minneapolis, MN 55454
5 Department of Orthopedic Surgery, Boston Medical Center, 850 Harrison Avenue, D2N, Boston, MA, 02118
6 Martin Orthopaedic Biomechanics Laboratory, Li Ka Shing Building (West Basement Room B116), St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
7 Department of Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
8 Department of Orthopedic Surgery, University of Oklahoma Health Sciences Center, 920 Stanton L Young Boulevard, Suite WP 1380, Oklahoma City, OK 73104
9 Department of Orthopaedic Surgery, Greenville Hospital System, 701 Grove Road, 2nd Floor Support Tower, Greenville, SC 29605
View Disclosures and Other Information
  • Disclosure statement for author(s): PDF

Investigation performed at McMaster University, Hamilton, Ontario, Canada

The Writing Committee included Emil H. Schemitsch, MD, FRCS(C), Mohit Bhandari, MD, PhD, FRCS(C), Gordon Guyatt, MD, David W. Sanders, MD, MSc, FRCS(C), Marc Swiontkowski, MD, Paul Tornetta III, MD, Stephen D. Walter, PhD, Rad Zdero, PhD, J.C. Goslings, MD, PhD, David Teague, MD, Kyle Jeray, MD, and Michael D. McKee, MD, FRCS(C). Please see note preceding reference section for additional details regarding the authors and investigators.



Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Division of Orthopaedics, Department of Surgery, University of Toronto, St. Michael’s Hospital, Suite 800, 55 Queen Street East, Toronto, ON M5C 1R6, Canada. E-mail address for E.H. Schemitsch: schemitsche@smh.caDivision of Orthopaedic Surgery, Department of Surgery (M.B.) and Department of Clinical Epidemiology & Biostatistics (M.B., G.G., and S.D.W.), McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 2X2, CanadaOrthopedic Surgery, London Health Sciences Centre and the University of Western Ontario, 800 Commissioners Road East, Room E4-123 London, ON N6A 4G5, CanadaDepartment of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, R200, Minneapolis, MN 55454Department of Orthopedic Surgery, Boston Medical Center, 850 Harrison Avenue, D2N, Boston, MA, 02118Martin Orthopaedic Biomechanics Laboratory, Li Ka Shing Building (West Basement Room B116), St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8, CanadaDepartment of Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The NetherlandsDepartment of Orthopedic Surgery, University of Oklahoma Health Sciences Center, 920 Stanton L Young Boulevard, Suite WP 1380, Oklahoma City, OK 73104Department of Orthopaedic Surgery, Greenville Hospital System, 701 Grove Road, 2nd Floor Support Tower, Greenville, SC 29605

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Oct 03;94(19):1786-1793. doi: 10.2106/JBJS.J.01418
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: 

Prediction of negative postoperative outcomes after long-bone fracture treatment may help to optimize patient care. We recently completed the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT), a large, multicenter trial of reamed and unreamed intramedullary nailing of tibial shaft fractures in 1226 patients. Using the SPRINT data, we conducted an investigation of baseline and surgical factors to determine any associations with an increased risk of adverse events within one year of intramedullary nailing.

Methods: 

Using multivariable logistic regression analysis, we investigated fifteen baseline and surgical factors for any associations with an increased risk of negative outcomes.

Results: 

There was an increased risk of negative events in patients with a high-energy mechanism of injury (odds ratio [OR] = 1.57; 95% confidence interval [CI], 1.05 to 2.35), a stainless steel compared with a titanium nail (OR = 1.52; 95% CI, 1.10 to 2.13), a fracture gap (OR = 2.40; 95% CI, 1.47 to 3.94), and full weight-bearing status after surgery (OR = 1.63; 95% CI, 1.00 to 2.64). There was no increased risk with the use of nonsteroidal anti-inflammatory agents, late or early time to surgery, or smoking status. Open fractures had a higher risk of events among patients treated with reamed nailing (OR = 3.26; 95% CI, 2.01 to 5.28) but not in patients treated with unreamed nailing (OR = 1.50; 95% CI, 0.92 to 2.47). Patients with open fractures who had wound management either without any additional procedures or with delayed primary closure had a decreased risk of events compared with patients who required subsequent, more complex reconstruction (OR = 0.18 [95% CI, 0.09 to 0.35] and 0.29 [95% CI, 0.14 to 0.62], respectively).

Conclusions: 

We identified several baseline fracture and surgical characteristics that may increase the risk of adverse events in patients with tibial shaft fractures. Surgeons should consider the predictors identified in our analysis to inform patients treated for tibial shaft fractures.

Level of Evidence: 

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

     
    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org

    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe





    Augusto Sarmiento, MD
    Posted on October 22, 2012
    Issues requiring clarification
    Miami, Florida, USA

    I would like to share some constructive comments with the authors. References 41 and 42 are two publications of mine. The authors of this article inferred that I had found that segmental fractures treated with intramedullary nailing “increase the risk of nonunion and reoperation.”  This is not correct.  I never made such a statement, and whatever comments I have made in the past about segmental fractures dealt with non-surgically treated fractures.

    The reference list did not include another article of mine, "Functional Treatment of Closed Segmental Fractures of the Tibia" (Acta Chir Orthop Traumatol Cech. 2008 Oct;75(5):325-31) or the section on Segmental Fracture in my recently published book, "The Nonsurgical Treatment of Fractures in Contemporary Orthopaedics", p: 126-136. (authors: Augusto Sarmiento and Loren L. Latta.  Jaypee Brothers, 2011).

    Since the topic at hand is of great interest to me, I carefully studied this article and found several things that warrant discussion. Despite the comprehensiveness of the publication, I found a number of omissions that seriously weaken the merits of the study. For example, there is no mention of the incidence of nonunions; the criteria used to determine “union”; the time to union; the different fractures according to their geometry; the number of infections and the outcome of these fractures; the initial condition of the fibula; the number of ultimately required amputations; the final condition of the adjacent joints, and the presence of pain; the ubiquitous chronic knee pain; the final shortening, angulation and malrotation; or socioeconomic considerations, such as return to work and sports.

    One of the conclusions of the study was the “surprising” better results with titanium nails, but the authors made no attempts to look into the biomechanics that led to their development. Their lower modulus of elasticity was the main and perhaps the most important factor. I mention this because I was the individual who, as far I know, was the first to work in the development of nails made of this alloy. Working in the Laboratories at USC, with the support of Biomet, we designed and thoroughly tested titanium I.M. nails for the femur, tibia, and humerus. They are marketed by the firm as Uniflex nails.

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    Guidelines
    Evaluating infants and young children with multiple fractures. -American Academy of Pediatrics | 2/9/2007
    Results provided by:
    PubMed
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    04/16/2014
    Connecticut - Yale University School of Medicine
    04/02/2014
    Illinois - Hinsdale Orthopaedics
    02/05/2014
    Oregon - The Center - Orthopedic and Neurosurgical Care and Research