There are more potential treatments for tibial
fractures and more potential complications of those treatments than
there are for any other type of fracture. The American Academy of
Orthopaedic Surgeons recently reviewed malpractice claims to identify
the procedures and diagnoses that have most commonly resulted in
legal action. Among all orthopaedic conditions, fractures of the tibia
and fibula ranked second with regard to the total number of patient malpractice
claims, accounting for over thirty million dollars in indemnity1.
The National Center for Health Statistics reported that more
than 490,000 fractures of the tibia and fibula occur each year in
the United States2. Although many
tibial fractures may be managed nonoperatively, fractures for which
nonoperative treatment has failed, open fractures, fractures with
an associated compartment syndrome, and high-energy fractures require
operative stabilization3. Surgical
options include external fixation, plate fixation, and intramedullary nailing
with or without reaming. Although there is a consensus among orthopaedic
surgeons with regard to the optimal treatment of fractures of the femoral
shaft, the appropriate treatment of closed and open tibial fractures remains
controversial.
Meta-analyses that include randomized trials provide the best
evidence regarding the results of operative treatment of fractures
of the tibial shaft4-7. In our
meta-analysis6, one randomized
trial8, involving fifty-six patients,
showed a significant reduction in the rate of reoperation after
external fixation compared with the rate after the use of plates
(relative risk reduction, 87%; 95% confidence
interval, 46% to 97%). Other trials showed that
nailing without reaming resulted in a significant reduction in the
risk of reoperation compared with the risk after external fixation
(relative risk reduction, 49%; 95% confidence interval,
31% to 63%). Nailing with reaming reduced the
risk of nonunion of closed and open fractures of the tibial shaft
by 57% compared with the rate after nailing without reaming
(95% confidence interval, 7% to 83%)5. Currently, there is little evidence
to support the insertion of intramedullary nails with reaming, rather
than without reaming, in the treatment of open fractures of the
tibial shaft6.
It is unclear whether current practice reflects this evidence.
Therefore, in an effort to clarify current opinion with regard to
the treatment of closed and open fractures of the tibial shaft,
we conducted an international survey of practicing orthopaedic surgeons
who have an interest in fracture care. We hypothesized that there
was considerable variability in the operative treatment of fractures
of the tibial shaft. We reasoned that the results of this -survey might
identify factors that in-fluence surgeons’ preferences
for a -particular treatment, might serve to -educate
the orthopaedic community about issues related to the treatment
of tibial fractures, and might assist in the planning of future
clinical trials to address issues that remain unresolved among orthopaedic
traumatologists.
To develop the questionnaire, we used the methods outlined by
Kitzinger9 to conduct a focus
group composed of four orthopaedic traumatologists. The items generated
from the focus group were augmented with data obtained by using
the text words "tibial fracture," "surgery," "implants," and "complications" to
conduct a MEDLINE search of articles published from 1969
to 1999. In addition, orthopaedic traumatologists who were authors
of published articles on the topic provided suggestions for items
to be included in the questionnaire. We employed a "sample-to-redundancy" strategy
by contacting additiona-l surgeons until no new items for
the questionnaire emerged10. The
clarity and comprehensiveness of the fina-l questionnaire
were assessed with use of a standard approach11,12.
We identified all surgeons who were members of the Orthopaedic
Trauma Association, surgeons at European clinics affiliated with
AO International -(Davos, Switzerland), and surgeons who
were international members of the American Academy of Orthopaedic
Surgeons from Africa, Asia, or South America. Surgeons were identified
from Internet-based web sites of each organization as well as from
membership listings in the published proceedings of annual meetings.
Each surgeon was mailed a packet that included a copy of the
six-page survey, a personalized cover letter, and a stamped return
en-velope. Eight weeks after the initial mailing, one of
us telephoned each nonrespondent as many as two times (four weeks
apart) and sent a duplicate packet if required. Individual responses
were confidential, and completion of the questionnaire was voluntary.
Our local ethics review board approved the study.
We summarized categorical and dichotomous variables as percentages.
Whenever the distribution of responses for a particular item in
the questionnaire had multiple empty cells, we collapsed the
categories in that particular item to achieve a more uniform
distribution of responses.
Because the outcome variable "operative technique" had
more than two levels (external fixation, plate -fixation, intramedullary
nailing with reaming, and intramedullary nailing without reaming),
we conducted -multinomial logistic regression with surgeon
age, type of practice, fellowship training, volume of trauma cases,
and geographic location as the independent variables. This analysis
was repeated for closed fractures (low-energ-y injuries,
high-energy injuries, and those associated with compartment syndrome)
and open fractures (grades I through IIIB according to the system
of Gustilo et al.13). We report
odds ratios (see Appendix).
For the independent variables found to be significantly associated
with each dependent variable, we conducted pairwise cross-tabulations
of each independent variable with the dependent variable and used
the chi-square test to compare proportions between groups. To account
for multiple comparisons, we set significance at p < 0.01.
Of the 577 surgeons who were sent the questionnaire, 444 (77%)
responded. The response rates did not differ according to the organization
to which the surgeon belonged (p = 0.36). The typical respondent
was a North American more than forty years of age in -academic
practice who supervised -residents, had fellowship training
in trauma, worked in a low-volume center (less than 100 tibial fractures
per year), and operated on 50% of the tibial -fractures
treated at his or her institution (see Appendix).
Closed Fractures of the Tibial Shaft
The overwhelming majority of surgeons preferred to use intramedullary nails
for the treatment of closed low-energ-y fractures (96.3%),
closed high-energy fractures (96%), and closed fracture-s
with associated compartment syndrome (80.4%) (Table I). Plate fixation
was the least popular technique for closed fractures of the tibial
shaft; it was preferred by 3.2%, 2.1%, and 7.4% of
the surgeons, respectively. Significantly more surgeons preferred
external fixators and nailing without reaming for high-energy fractures
and fractures associated with compartment syndrome than preferred
them for low-energy fractures (p < 0.01). The preferences
for nail-insertion technique varied: reaming, rather than nailing
without reaming, was less popular for high-energy fractures and
those associated with compartment syndrome than it was for low-energy
fractures (p < 0.01).
Open Fractures of the Tibial Shaft
The majority of surgeons preferred intramedullary nails for the
treatment of open fractures of the tibial shaft (Table I). However,
there was a progressive decline in the use of intramedullary nails
as the severity of the soft-tissue injury increased from Gustilo
et al.13 grade I to grade IIIB
(grade I, 95.5%; grade II, 88.1%; grade IIIA,
68.4%; and grade IIIB, 48.4%). As with closed fractures,
surgeons rarely preferred plates for the treatment of open fractures
(range of preference rates, 0.8% to 1.1%). The
popularity of external fixators increased significantly as the severity
of the soft-tissue injury increased from grade I (3.4%)
to grade IIIB (50.5%) (p < 0.01). Although the proportion
of surgeons who preferred to insert nails without reaming remained relatively
consistent across all open fracture grades (range of preference rates,
34.8% to 41.8%), we identified a significant decline
in the preference for intramedullary reaming as the grade of open
fracture increased (p < 0.01).
Predictors of Implant Preference
The most significant predictor of a -surgeon’s
preference for a particular implant was geographic location (Fig. 1). Compared with
North American surgeons, surgeons from continents other than North
America were sig-nificantly less likely to prefer nail -insertion
with reaming over nail in-sertion without reaming for all
types of closed fractures of the tibial shaft (p < 0.001)
(see Appendix).
North American surgeons were also significantly more likely to
insert nails after reaming, rather than inserting them without reaming,
to treat open fractures of the tibial shaft than were surgeons from
other continents (p < 0.001) (Fig. 2). Surgeons from
Asia, Africa, or South America were, in general, more likely to
use external fixators than were surgeons from North America, Europe,
or Australia. Surgeons who had received fellowship training in trauma
were significantly less likely than surgeons who lacked -fellowship
training to choose external fixation rather than intramedullary
nailing without reaming for all grades of open fractures (see Appendix).
The validity of our results are strengthened by (1) the inclusion
of trauma -surgeons in the development of the questionnaire
items, (2) a comprehensive sampling of surgeons who cared for traumatically
injured patients, (3) high internal consistency in the responses,
and (4) a high survey-response rate (77%) that limited
nonresponder bias14,15. Mailed
surveys are useful tools for the study of physicians’ beliefs,
attitudes, and concerns in health-care settings. The highest possible
response rate is necessary to ensure unbiased results. Strategies
to improve response rates, such as the use of prenotification letters,
faxes, personalized cover letters, monetary incentives, surveys
of limited length, and envelopes with a university return address,
have achieved varying success16,17.
Investigators have attributed the huge variability in the rates
of physicians’ responses to questionnaires to increases in
practice workloads, which force them to place a low priority on
the completion of surveys. This has been especially true for surveys
of surgeons, who have traditionally responded at rates ranging from
15% to 27%18-20.
The results of our survey may not be generalizable to
orthopaedic -surgeons who are not members of the -Orthopaedic
Trauma Association, AO-affiliated centers, or the American Academy
of Orthopaedic Surgeons. Moreover, because most members of the Orthopaedic
Trauma Association live in North America, our results may not reflect
the preferences of surgeons from other continents. The majority
of members of the Orthopaedic Trauma Association are traumatologists;
thus, our results may not be representative of the practice of general
orthopaedists in the United States. Nevertheless, we endeavored
to improve the generalizability of our results by sampling surgeons
at European clinics affiliated with AO International as well as
surgeons in Africa, Asia, and South America who were members of
the American Academy of Orthopaedic Surgeons.
Surgeons were nearly unanimous in their preference for intramedullary
nailing for the treatment of both low-energy (96.3%) and
high-energy (96%) closed fractures of the tibial shaft
for which nonoperative treatment was either inappropriate or unsuccessful. More
than 80% of the respondents -favored the use of
intramedullary nails to treat fractures of the tibial shaft with
associated compartment -syndrome.
Three published meta-analyses have evaluated treatment alternatives
for closed fractures of the tibial shaft; two pooled data that were
primarily from observational studies4,7,
and one pooled data from randomized trials5.
Littenburg et al.7, in a comprehensive
review of the available literature, identified 2005 patients treated
with a cast or brace, 474 patients treated with a plate and screws,
and 407 patients treated with intramedullary nails. Although plate fixation
achieved the fastest fracture union (median, thirteen weeks) when compared
with either a cast (median, 13.7 weeks) or intramedullary nails (median,
twenty weeks), there were no differences in the ultimate rates of
nonunion among groups. Rates of deep infection were lower with the
use of casts and intramedullary nails than they were with the use
of plates (ranges, 0% to 2%, 0% to 1.0%,
and 0% to 15%, respectively).
In a review of prospective studies (eight observational and five
randomized trials) evaluating treatment alternatives for fractures
of the tibial shaft, Coles and Gross4 found
that plate fixation resulted in the lowest nonunion rates (2.6%)
and the highest infection rates (9.0%) compared with other -treatment
alternatives. Despite the -apparent benefit of decreased
time to fracture-healing with plate fixation, only 2.1% to
7.4% of the respondents to our survey preferred plate fixation
for the treatment of closed fractures of the tibial shaft (low-energy,
high-energy, and those with associated compartment syndrome). This
finding likely -reflects the surgeons’ belief
that the high risk of infection with the use of plates
outweighs the benefit of decreased time to fracture union.
A substantial proportion of respondents chose external fixation
for closed fractures of the tibial shaft and closed fractures associated
with compartment syndrome. The role of external fixation in the
treatment of closed fractures of the tibial shaft has been evaluated
in a number of observational studies21-24.
Turen et al.21, in a review of
sixty-eight closed fractures, identified a longer healing time for
fractures associated with compartment syndrome than for those without such
a complication (30.2 weeks compared with 17.2 weeks, respectively). Moreover,
healing times for closed fractures associated with compartment syndrome
were similar to those for open fractures. Thus, it has been suggested
that closed fractures associated with compartment syndrome act more like
open fractures than like uncomplicated closed fractures. It was
not entirely surprising, then, that external fixators were used
by some surgeons for the treatment of closed fractures associated
with compartment syndrome.
Although most surgeons agreed that intramedullary nailing was
the operative treatment of choice for all closed fracture types,
there was considerable variability with regard to whether they preferred
to ream the canal. The proportion of surgeons who chose reaming for
high-energy fractures was lower than the proportion who chose it
for low-energy fractures, and the proportion who chose it for fractures
associated with compartment syndrome was lower still. The evidence
favoring nailing with reaming or nailing without reaming is suggestive
but not definitive. In a previous systematic review5, we found nine randomized trials
that compared the use of intramedullary nailing with and without
reaming for tibial and femoral fractures in 646 patients.
Reaming resulted in a 56% reduction in the relative risk
of nonunion compared with that associated with nailing without reaming
(95% confidence interval, 7% to 79%).
These trials had important methodological weaknesses: treatment
allocation was not adequately concealed, neither those who assessed
the outcomes nor the data analysts were blinded, and often the dropouts
and the withdrawals from the study were not reported. These limitations,
when con-sidered in light of the wide confidence interval
and the varying opinions and practices of orthopaedic traumatologists,
suggest the need for larger randomized trials to address this issue.
Although we identified a near consensus favoring intramedullary
nails for grade-I and grade-II open -fractures
of the tibial shaft, there was considerable variability in the choice of intramedullary
nails or external fixators to treat grade-III fractures.
We conducted another systematic review and meta-analysis of eight
randomized trials that compared alternative treatments for open
fractures of the tibial shaft6.
In one study of fifty-six patients8,
the use of external fixators significantly decreased the risk of
reoperation compared with the use of plates (relative risk, 0.13;
95% confidence interval, 0.03 to 0.54; p < 0.01).
In five studies, involving a total of 396 patients, nailing without
reaming reduced the risks of reoperation (relative risk, 0.51; 95% confidence
interval, 0.31 to 0.69), malunion (relative risk, 0.42; 95% confidence
interval, 0.25 to 0.71), and superficial infection (relative risk,
0.24; 95% confidence interval, 0.08 to 0.73) compared with
the risks after external fixation. Although these studies shared the
methodological limitations of the lack of concealment, the lack
of blinding, and the loss of subjects to follow-up, the narrow confidence
intervals make the results more definitive than those in the studies
comparing nailing with and without reaming. In the present study,
respondents who had -fellowship training were less likely
to prefer external fixators for treatment of open fractures
and thus were more likely to practice in a manner consistent with
the evidence.
In our previous meta-analysis6,
two trials of intramedullary nailing of open tibial fractures in
a total of 132 patients showed a trend toward a decrease in the
risk of reoperation when reaming had been used compared with when
it had not been used (relative risk, 0.75; 95% confidence
interval, 0.43 to 1.32). Because the confidence interval is very
wide, the relative effect of reaming before nailing of open tibial
fractures remains unresolved.
Deciding when the evidence is sufficient to establish the superiority
of one treatment over another is a subjective and inevitably somewhat
arbitrary process. Differences in patient management may reflect
ignorance of the evidence, inadequate evidence of the superiority
of one approach over another, or disagreement about the proper interpretation
of the eviden-ce.
If the evidence has established the superiority of one approach,
but treatment still varies in practice, education is needed. In
our opinion, this is the situation with regard to use of external fixation
rather than intramedullary nailing for open fractures. The results
of our survey suggest that education with regard to the superiority
of nailing for open tibial fractures should be directed primarily
at surgeons in Asia, Africa, and South America. However, the feasibility
of changing the treatment strategies of surgeons from these continents may
depend upon the availability and cost of these implants.
The evidence has not, in our opinion, definitively established
the -relative merits of reaming compared with no reaming
before nailing of either closed or open fractures. Given the -limited resources
available for research, the most compelling questions are those that
remain a source of uncertainty or controversy among practicing clinicians.
Thus, the magnitude of the variability in belief and practice with -regard to
reaming or not reaming before intramedullary nailing and the contrast in
practice between North American surgeons and those in the rest of
the world suggest that this issue should be a research question
of international interest.
The computation of odds ratios as well as tables describing
the characteristics of the surgeons who responded and the predictors
of implant selection for both closed and open fractures are available with
the electronic versions of this article, on our web site at www.jbjs.org
(go to the article citation and click on "Supplementary
Material") and on our quarterly CD-ROM (call our subscription department,
at 781-449-9780, to order the CD-ROM).
Note: The authors are grateful to Ketan Shankardass for assistance
with mailing of the initial survey and to Amena Syed for her assistance
with database preparation and data entry.
Femur fracture care frequent
cause of lawsuit. Am Acad Orthop Surg Bull,2001;49: 17-8. 4917
2001
Praemer A, Furner S, Rice DP, editors. Musculoskeletal
conditions in the United States. Park Ridge, IL: American
Academy of Orthopaedic Surgeons; 1992.
Lindsey RW,Blair SR. Closed tibial shaft fractures: which ones benefit from
surgical treatment?. J Am Acad Orthop Surg,1996;4: 35-43. 435
1996
[PubMed]
Coles CP,Gross M. Closed tibial shaft fractures: management and treatment
complications. A review of the prospective literature. -Can J Surg,2000;43: 256-62. 43256
2000
[PubMed]
Bhandari M, Guyatt GH, Tong D, Adili A,Shaughnessy SG. Reamed versus nonreamed intramedullary nailing of lower
extremity long bone fractures: a systematic overview and meta-analysis. J Orthop Trauma,2000;14: 2-9. 142
2000
[PubMed][CrossRef]
Bhandari M, Guyatt GH, Swiontkowski MF,Schemitsch EH. Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg Br,2001;83: 62-8. 8362
2001
[PubMed][CrossRef]
Littenburg B, Weinstein LP, McCarren M, Mead T, Swiontkowski MF, -Rudicel SA,Heck D. Closed fractures of the tibial shaft. A meta-analysi-s
of three methods of treatment. J Bone Joint Surg Am,1998;80: 174-83. 80174
1998
[PubMed]
Bach AW,Hansen ST Jr. Plates versus external fixation in severe open tibial
shaft fractures. A randomized trial. Clin Orthop,1989;241: 89-94. 24189
1989
[PubMed]
Kitzinger J. Qualitative research. Introducing focus groups. BMJ,1995;311: 299-302. 311299
1995
[PubMed]
Streiner DL, Norman GR, editors. Health
measurement scales: a practical guide to their development and use. 2nd
ed. New York: Oxford University Press; 1995. p 17
Feinstein AR. Clinimetrics. New
Haven, CT: Yale University Press; 1987. The theory of evaluation
of sensibility. p 141-66
Griffith LE, Cook DJ, Guyatt GH,Charles CA. Comparison of open and closed questionnaire formats in
obtaining demographic information from Canadian general internists. J Clin Epidemiol,1999;10: 997-1005. 10997
1999
[CrossRef]
Gustilo RB, Mendoza RM,Williams DN. Problems in the management of type III (severe) open fractures:
a new classification of type III open fractures. J Trauma,1984;24: 742-6. 24742
1984
[PubMed][CrossRef]
Armstrong D,Ashworth M. When questionnaire response rates do matter: a survey
of general practitioners and their views of NHS changes. Br J Gen Pract,2000;50: 479-80. 50479
2000
[PubMed]
Templeton L, Deehan A, Taylor C, Drummond C,Strang J. Surveying general practitioners: does a low response rate
matter?. Br J Gen Pract,1997;47: 91-4. 4791
1997
[PubMed]
Asch DA, Jedrziewski MK,Christakis NA. -Response rates to mail surveys published in medical
journals. J Clin Epidemiol,1997;50: 1129-36. 501129
1997
[PubMed][CrossRef]
Kellerman SE,Herold J. Physician response to surveys. A review of the literature. Am J Prev Med,2001;20: 61-7. 2061
2001
[PubMed][CrossRef]
Matarasso A, Elkwood A, Rankin M,Elkowitz M. National plastic surgery survey: face lift techniques
and complications. Plast Reconstr Surg,2000;106: 1185-95. 1061185
2000
[PubMed][CrossRef]
Almeida OD Jr. Current state of office laparoscopic surgery. J Am Assoc Gynecol Laparosc,2000;7: 545-6. 7545
2000
[PubMed][CrossRef]
Khalily C, Behnke S,Seligson D. Treatment of closed tibia shaft fractures: a survey
from the 1997 Orthopaedic Trauma Association and -Osteosynthesis
International—Gerhard Kuntscher Kreis meeting. J Orthop Trauma,2000;14: 577-81.. 14577
2000
[PubMed][CrossRef]
Turen CH, Burgess AR,Vanco B. Skeletal -stabilization for tibial fractures associated
with acute compartment syndrome. Clin Orthop,1995;315: 163-8. 315163
1995
[PubMed]
Checketts RG, Moran CG,Jennings AG. 134 tibial shaft fractures managed with the -Dynamic
Axial Fixator. Acta Orthop Scand,1995;66: 271-4.. 66271
1995
[PubMed][CrossRef]
Emami A, Mjoberg B, Karlstrom G,Larsson S. Treatment of closed tibial shaft fractures with unilateral
external fixators. Injury,1995;26: 299-303. 26299
1995
[PubMed][CrossRef]
Shaw DL,Lawton JO. External fixation for tibial fractures: clinical results
and cost-effectiveness. J R Coll Surg Edinb,1995;40: 344-6. 40344
1995
[PubMed]