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Prognostic Factors for Predicting Outcomes After Intramedullary Nailing of the Tibia

Schemitsch, Emil H., MD, FRCS(C)1; Bhandari, Mohit, MD, PhD, FRCS(C)2; Guyatt, Gordon, MD2; Sanders, David W., MD, MSc, FRCS(C)3; Swiontkowski, Marc, MD4; Tornetta, Paul III, MD5; Walter, Stephen D., PhD2; Zdero, Rad, PhD6; Goslings, J.C., MD, PhD7; Teague, David, MD8; Jeray, Kyle, MD9; McKee, Michael D., MD, FRCS(C)1; Schemitsch, Emil H., MD, FRCS(C); Bhandari, Mohit, MD, PhD, FRCS(C); Guyatt, Gordon, MD; Sanders, David W., MD, MSc, FRCS(C); Swiontkowski, Marc, MD; Tornetta, Paul III, MD; Walter, Stephen D., PhD; Zdero, Rad, PhD; Goslings, J.C., MD, PhD; Teague, David, MD; Jeray, Kyle, MD; McKee, Michael D., MD, FRCS(C); Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) Investigators

doi: 10.2106/JBJS.J.01418
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Background: Prediction of negative postoperative outcomes after long-bone fracture treatment may help to optimize patient care. We recently completed the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT), a large, multicenter trial of reamed and unreamed intramedullary nailing of tibial shaft fractures in 1226 patients. Using the SPRINT data, we conducted an investigation of baseline and surgical factors to determine any associations with an increased risk of adverse events within one year of intramedullary nailing.

Methods: Using multivariable logistic regression analysis, we investigated fifteen baseline and surgical factors for any associations with an increased risk of negative outcomes.

Results: There was an increased risk of negative events in patients with a high-energy mechanism of injury (odds ratio [OR] = 1.57; 95% confidence interval [CI], 1.05 to 2.35), a stainless steel compared with a titanium nail (OR = 1.52; 95% CI, 1.10 to 2.13), a fracture gap (OR = 2.40; 95% CI, 1.47 to 3.94), and full weight-bearing status after surgery (OR = 1.63; 95% CI, 1.00 to 2.64). There was no increased risk with the use of nonsteroidal anti-inflammatory agents, late or early time to surgery, or smoking status. Open fractures had a higher risk of events among patients treated with reamed nailing (OR = 3.26; 95% CI, 2.01 to 5.28) but not in patients treated with unreamed nailing (OR = 1.50; 95% CI, 0.92 to 2.47). Patients with open fractures who had wound management either without any additional procedures or with delayed primary closure had a decreased risk of events compared with patients who required subsequent, more complex reconstruction (OR = 0.18 [95% CI, 0.09 to 0.35] and 0.29 [95% CI, 0.14 to 0.62], respectively).

Conclusions: We identified several baseline fracture and surgical characteristics that may increase the risk of adverse events in patients with tibial shaft fractures. Surgeons should consider the predictors identified in our analysis to inform patients treated for tibial shaft fractures.

Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

1Division of Orthopaedics, Department of Surgery, University of Toronto, St. Michael’s Hospital, Suite 800, 55 Queen Street East, Toronto, ON M5C 1R6, Canada. E-mail address for E.H. Schemitsch: schemitsche@smh.ca

2Division of Orthopaedic Surgery, Department of Surgery (M.B.) and Department of Clinical Epidemiology & Biostatistics (M.B., G.G., and S.D.W.), McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 2X2, Canada

3Orthopedic Surgery, London Health Sciences Centre and the University of Western Ontario, 800 Commissioners Road East, Room E4-123 London, ON N6A 4G5, Canada

4Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, R200, Minneapolis, MN 55454

5Department of Orthopedic Surgery, Boston Medical Center, 850 Harrison Avenue, D2N, Boston, MA, 02118

6Martin Orthopaedic Biomechanics Laboratory, Li Ka Shing Building (West Basement Room B116), St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada

7Department of Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands

8Department of Orthopedic Surgery, University of Oklahoma Health Sciences Center, 920 Stanton L Young Boulevard, Suite WP 1380, Oklahoma City, OK 73104

9Department of Orthopaedic Surgery, Greenville Hospital System, 701 Grove Road, 2nd Floor Support Tower, Greenville, SC 29605

*The Writing Committee included Emil H. Schemitsch, MD, FRCS(C), Mohit Bhandari, MD, PhD, FRCS(C), Gordon Guyatt, MD, David W. Sanders, MD, MSc, FRCS(C), Marc Swiontkowski, MD, Paul Tornetta III, MD, Stephen D. Walter, PhD, Rad Zdero, PhD, J.C. Goslings, MD, PhD, David Teague, MD, Kyle Jeray, MD, and Michael D. McKee, MD, FRCS(C). Please see note preceding reference section for additional details regarding the authors and investigators.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Incorporated
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