Original Article

Can Tibial Nonunion be Predicted at 3 Months After Intramedullary Nailing?

Yang, Justin S. MD; Otero, Jesse MD; McAndrew, Christopher M. MD; Ricci, William M. MD; Gardner, Michael J. MD

Orthopaedic Trauma Service, Department of Orthopaedics, Washington University School of Medicine, St Louis, MO.

Reprints: Michael J. Gardner, MD, Orthopaedic Trauma Service, Washington University in St Louis School of Medicine, 660 S Euclid Avenue, Campus Box 8233, St Louis, MO 63110-1010 (e-mail: [email protected]).

No funding was received for this research. W. M. Ricci is a consultant and receives royalties from Wright Medical and Smith and Nephew. M. J. Gardner is a consultant for Synthes, Stryker, Amgen, DGI Med, and RTI biologic. For the remaining authors none were declared.

This study and the database involved have been approved by the Washington University School of Medicine Human Studies Committee (Institutional Review Board).

Presented in part at the Annual Meeting of the Orthopaedic Trauma Association, October 12–15, 2011, San Antonio, TX.

Accepted February 12, 2013

Journal of Orthopaedic Trauma 27(11):p 599-603, November 2013. | DOI: 10.1097/BOT.0b013e31828f5821

Abstract

Objective:

The purpose of this study was to determine if surgeons could reliably predict if patients with tibia fractures treated with intramedullary nails will proceed to nonunion based on their clinical scenario and radiographs at 3 months.

Design:

Blinded randomized questionnaire based on a retrospective cohort.

Setting:

University level 1 trauma center.

Patients/Participants:

Fifty-six patients who underwent intramedullary fixation for tibia fractures with incomplete healing at 3 months.

Methods:

A questionnaire was applied to 56 consecutive patients treated between 2005 and 2009 with intramedullary fixation for tibia fractures who had incomplete healing at 3 months. Each case was developed into a vignette that included the 3-month radiographs and detailed clinical histories. The questionnaire was distributed to 3 fellowship-trained trauma surgeons who were asked to predict if the fracture would go onto nonunion.

Main Outcome Measurements:

Diagnostic accuracy of predicting nonunion in patients with incomplete healing of their tibia fracture at 3 months.

Results:

The combined overall diagnostic accuracy of all 3 surgeons was 74%. Sensitivity and specificity was 62% and 77%, respectively. Radiographic features and injury mechanism were the most commonly cited clinical information used to predict fracture healing. The average positive predictive value was 73%. In 9 patients with diabetes, the diagnostic accuracy was 88%.

Conclusions:

Clinical judgment at 3 months allows for correct prediction of eventual nonunion development in a majority of patients. We suggest that analysis of the entire clinical picture be used to predict fracture healing at 3 months. A protocol of waiting for 6 months before reoperation in all patients treated with intramedullary nailing for tibia fractures may subject patients to prolonged disability and discomfort.

Level of Evidence:

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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Can Tibial Nonunion be Predicted at 3 Months After Intramedullary Nailing?