To The Editor:
We are writing with regard to certain important omissions in the recent article by the SPRINT investigators, "Randomized Trial of Reamed and Unreamed Intramedullary Nailing of Tibial Shaft Fractures" (2008;90:2567-78).
No conclusions were presented regarding the infection rate or healing time of the 1319 adult patients.
No data were presented on final shortening. Shortening after intramedullary nailing has been reported by a number of investigators. Bone and Johnson reported 10 mm of shortening in 5% of patients1, and Hooper et al. reported shortening in 3.4% of patients2.
Final angulation was not reported. It must have occurred, particularly in cases of proximal fractures, as this problem is well known to occur frequently.
Perhaps the most important omission was the failure to discuss chronic knee pain following nailing and the response to removal of the implant. Court-Brown et al. reported that 56.2% of patients had knee pain and that 24.4% of patients required removal of the nail3. Keating et al. reported that 80% of patients had removal of the nail because of knee pain and that, after sixteen months, the pain had not resolved in 36% of the patients4. Toivanen et al. reported knee pain in 86% of patients who had been managed with a transtendinous approach and in 81% of those who had been managed with a paratendinous approach5. In that study, 69% of the patients had anterior knee pain at an average of 1.5 years after nail removal. Quraishi et al. reported that 93.7% of patients had anterior knee sensory disturbance; 96.8% had pain on kneeling6. Twenty-six percent of the patients in that study had the nail removed. Of these, 53.5% had persistent anterior knee pain, 89.5% had anterior sensory knee disturbance, and 71.4% had pain on kneeling. Metal removal did not facilitate the desired reduction of symptoms. Karladani et al. reported that nail removal resulted in less pain in 54% of patients, but the patients were not asymptomatic; pain remained unaltered in 10.7% of the patients, and 25% of the patients had increased pain7.