This systematic review by Bhandari and colleagues traces
the history of the operative stabilization of open tibial shaft
fractures over the past quarter of a century on the basis of a critical
analysis of relevant randomized trials. During this time, the preferred
device for the operative care of these lesions gradually evolved
from plates to external fixators and, most recently, to intramedullary
nails. Because many open fractures are unstable, the primary prerequisite
for all of these devices is their ability to control length and
alignment. Thus, intramedullary nails only became contenders once
reliable locking mechanisms had been developed.
This carefully conducted review highlights the difficulties of
carrying out a meta-analysis in a field characterized by a paucity
of randomized trials and on a topic that encompasses large differences
in disease severity and treatment modes. Indeed, there is a sense that
the authors were straining to find a sufficient number of reliable
publications. One of the included studies only exists as an abstract,
and three had quality ratings of less than 40%. In the largest
study that was included, grade-II lesions represented 49% of
the fractures that were treated with nailing but only 31% of
the fractures that were treated with external fixation. Grade III-B lesions
comprised 12% of the fractures treated with nailing and
20% of the fractures treated with external fixation; does
this represent "quasi-randomization" or selection
bias? The inclusion of a study with unlocked nails was unfortunate
because it limited the conclusions of the meta-analysis to the middle 55% of
the tibial shaft and to fractures that were at least partially stable.
Despite these concerns, this systematic review clearly shows
that, within the noted limitations, the use of locked intramedullary
nailing results in lower reoperation rates than does the use of external
fixation, particularly with respect to open fractures of grade-I
to III-A severity. Because of the small numbers and the lack of
an independent analysis, it is less clear to what extent this is
also true for grade III-B lesions, particularly those that are heavily
contaminated and those that require repeated débridement
of the deep posterior compartment, which is less accessible after
nail placement. The differences in outcome between reamed and unreamed
nailing appear to be small and probably will require a large multicenter
trial to determine if they are relevant at all.