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Changing practice patterns

flexed versus semi-extended positioning for tibial nailing

Goodnough, L. Henry MD, PhDa; Campbell, Sean T. MDa; Githens, Michael F. MD, MSb; Gardner, Michael J. MDc; Bishop, Julius A. MDc

doi: 10.1097/BCO.0000000000000763
Original Research

Background: Recent studies have demonstrated several benefits to semi-extended leg position for intramedullary nailing (IMN) without increased complications. The purpose of this study was to evaluate how surgeon preference for flexed versus semi-extended positioning has changed over time.

Methods: We distributed an anonymous online survey to orthopaedic surgeons via the Orthopaedic Trauma Association (OTA) website. We compared surgeon demographics and preferred leg positioning for tibial nailing.

Results: Twenty-seven percent of surgeons reported substantial experience (>50% of cases) with semi-extended positioning during training, while 49% of surgeons preferred semi-extended nailing in current practice (P<0.001). Surgeons who practiced in the U.S. (P<0.001) or who completed a trauma fellowship (P<0.05) were more likely to have had exposure to the semi-extended positioning during training. Surgeons who practiced in the U.S. (P<0.001), supervised residents (P<0.05) or had completed a trauma fellowship (P<0.01) were significantly more likely to currently prefer the semi-extended positioning. Surgeons in the U.S. (P<0.01), or who supervised residents (P<0.05) were more likely to have changed from the hyper-flexed to semi-extended position. Facilitating reduction in proximal fractures was the most cited reason for switching to the semi-extended position (28%).

Conclusions: Semi-extended has become the preferred position during intramedullary nailing of tibial fractures among U.S. surgeons, those supervising residents, or those completing a trauma fellowship. Flexed nailing remains the preferred technique for international surgeons. Further investigation of extended nailing techniques is necessary. However, given its preference for the conventional flexed nailing, the international community may benefit from further educational interventions, demonstrating the benefits of extended nailing.

aDepartment of Orthopaedic Surgery, Stanford University, Stanford, CA

bDepartment of Orthopaedic Surgery, University of Washington, Seattle, WA

cDepartment of Orthopaedic Surgery, Stanford University, Redwood City, CA

Financial Disclosure: The following authors disclose a financial relationship outside this work with, Depuy Synthes (Drs. Githens, Gardner, and Bishop); Globus Medical (Drs. Gardner and Bishop); KCI (Dr. Garner); Innomed (Dr. Bishop). The other authors have no disclosures. The authors report conflicts of interest.

Correspondence to L. Henry Goodnough, MD, PhD, 300 Pasteur Drive, Room R144, Stanford, CA 94305 Tel: +650-721-7638; fax: +650-498-6899; e-mail:

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