Lower rate of nonunion with reamed vs. unreamed IM nailing for closed tibial fractures
A Meta-analysis of Reamed Versus Unreamed Intramedullary Nailing for the Treatment of Closed Tibial FracturesOrthopedics. 2014 Apr 1;37(4):e332-8
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Nine studies (randomized controlled trials or quasi-RCTs) were included in this meta-analysis comparing reamed and unreamed intramedullary nailing for closed tibial fractures. Of note, pooled nonunion rate was significantly lower for reamed intramedullary nailing vs. unreamed nailing. Additionally, rates of secondary surgeries, particularly implant exchange and dynamization, were also lower with reamed nailing. Pooled incidences of infection, compartment syndrome, and postoperative knee pain were similar between reamed and unreamed intramedullary nailing.
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Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
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Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
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Why was this study needed now?
Debate exists between intramedullary nailing with and without reaming in tibial fractures. Cited advantages of reaming include stability with expedited union, although disadvantages include high risk of complications such as bone necrosis, compartment syndrome and infection. Unreamed intramedullary nailing has been suggested to avoid these complications and reduce operative time, but has been associated with poor mechanical stability and longer time to union. Previous meta-analysis have addressed this comparison, although have been limited by their inclusion of both closed and open tibial fractures. Therefore, this study aimed to investigate outcomes in closed fractures specifically.
What was the principal research question?
How does intramedullary nailing with and without reaming compare in the treatment of closed tibial fractures?
What were the important findings?
- Nine studies with 1229 tibial fractures (643 reamed; 586 unreamed) were included in the study. Eight outcomes were pooled: Rates of nonunion, delayed union, malunion, secondary surgery, implant failure, infection, compartment syndrome, and knee pain.
- A significantly higher rate of nonunion was observed with unreamed nailing (3 studies; OR 0.43 [95%CI 0.21, 0.28]; p=0.02). The rates of delayed union (2 studies; OR 0.53 [95%CI 0.20, 1.41]; p=0.20) and malunion (2 studies; OR 0.48 [95%CI 0.13, 1.81]; p=0.28) were similar between groups.
- Overall, rate a secondary surgery was significantly lower with unreamed nailing (OR 0.53 [95%CI 0.35, 0.81]; p=0.003). By surgery type, implant exchange (OR 0.37 [95%CI 0.16, 0.81]; p=0.01) and dynamization (OR 0.57 [95%CI 0.34, 0.98]; p=0.04) were significantly lower. The incidence of bone graft as a secondary procedure did not significantly differ between groups (OR 1.33 [95%CI 0.26, 6.80]; p=0.73).
- Rate of implant failure was significantly lower with reamed nailing (OR 0.34 [95%CI 0.21, 0.57]; p<0.0001). This was predominantly due to failure of the screws (Reamed 20/514; Unreamed 54/498) (OR 0.32 [95%CI 0.19, 0.55]; p<0.0001) as opposed to failure of the nail (p=0.94).
- There were no significant differences observed in rates of infection (7 studies; OR 1.36 [95%CI 0.70, 2.65]; p=0.36), compartment syndrome (5 studies; OR 0.69 [95%CI 0.31, 1.53]; p=0.36) or knee pain (2 studies; OR 0.97 [95%CI 0.47, 2.00]; p=0.93).
What should I remember most?
Reamed intramedullary nailing exhibited a lower rate of nonunion than unreamed nailing following fixation of closed tibial fractures, along with lower rates of secondary implant exchange and dynamization. Incidence of screw failure in reamed nailing was also significantly lower than in unreamed nailing. Other complications (infection, compartment syndrome, postoperative knee pain) did not significantly differ between groups.
How will this affect the care of my patients?
The results from this analysis suggest that reamed intramedullary nailing may offer a more advantageous outcome than unreamed nailing in treatment of closed fractures of the tibia with respect to nonunion and associated secondary surgeries. Inconsistent with previous literature, there did not appear to be an increased risk of complications with reamed nailing, as pooled rates of infection, compartment syndrome and knee pain were similar between methods. Unfortunately, current literature still lacks sufficient data to conduct comparisons on other pertinent complications, such as fat embolism and pulmonary embolism. These are topics that should be considered in future studies.
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