L.X. Webb, M.J. Bosse, and R.C. Castillo reply:
Dr. Om is correct in stating that details about the nature and type of the fractures were not included in our publication. These and other details delineated in a number of tables would have resulted in a more lengthy manuscript and were withheld at the suggestion of the reviewers. These injury characteristics included fracture classification (AO/OTA), soft-tissue injury classification (AO and Tscherne), and Gustilo and Anderson open fracture classification, all prospectively gathered according to the LEAP protocol1.
As stated in the Results section, "…the injury as well as the treatment characteristics of these two groups of limb-salvage patients (those managed with intramedullary fixation and those managed with external fixation) [were analyzed]. Although the external fixation group had a slightly more severe injury (largely because of a higher proportion of bone loss), this difference was not significant. The mean p-amp score (a score combining all injury characteristics into a single probability of amputation) was 0.080 for the intramedullary nail group and 0.105 for the external fixation group (p = 0.23). In all cases, the differences between the intramedullary nailing and external fixator groups remained after comparison across equivalent injury groups, with adjustment for injury characteristics in multivariate regression models."
The major point of our paper was to analyze the influence of surgeon-controlled variables on outcomes. Since nearly all patients in the study cohort and all patients evaluated in this analysis had definitive treatment with an external fixator or an intramedullary nail, this comparison was statistically meaningful. Those definitively managed with an external fixator took a longer time to weight bear and spent more time in the hospital (most commonly because of infection or delayed union). For those treated with a muscle flap and external fixation, the functional outcome, prevalence of major complications, and level of physical impairment at two years were worse than they were for those treated with a muscle flap and an intramedullary nail.
These letters originally appeared, in slightly different form, on . They are still available on the web site in conjunction with the article to which they refer.