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Using reamed, unreamed nails for tibia fractures did not impact functional results

Investigators found open or multiple injuries treated with nailing affected return to activities, work more.

Issue: May 2008

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SAN FRANCISCO — It has long been thought that patients whose tibial fractures were reamed prior to being nailed did better overall postoperatively than ones treated with unreamed nails. But results of an analysis of patients in the multicenter SPRINT trial showed neither group regained very good functional activity at any time point through the 1-year follow-up.

Investigators from centers involved in the Study to Prospectively evaluate Reamed Intramedullary Nails in Tibia fractures (SPRINT) found patients’ general outcome and postoperative activity level, including return to work, did not improve much. This was unrelated to whether their fractures were treated with reamed or unreamed nails.

“There seems to be no difference comparing reamed to unreamed nails with respect to functional outcome,” said investigator David W. Sanders, MD, FRCSC, who presented the findings at the American Academy of Orthopaedic Surgeons 75th Annual Meeting, here.

He said he and his and colleagues were surprised by the results.

The differences Sanders and colleagues identified were more between multitrauma patients who had open fractures and those with closed, isolated tibial fractures.

1-year follow-up

The study involved 1,319 patients treated at 17 U.S. and 11 Canadian hospitals and medical centers. About two-thirds of the tibial fractures were closed and another two-thirds isolated, Sanders said. To assess functional outcomes at follow-up, investigators used the SF-36 and its subscales and the subscales and activity questionnaire of the Short-Form Musculoskeletal Functional Assessment (SMFA) at time 0; 2 weeks; 3, 6 and 9 months; and 1 year.

A lower SMFA score represented a better outcome.

After controlling for surgeon bias and continuous variables, results with the SF-36 instrument “are almost exactly identical right down to the standard deviation” of about 1 point, Sanders said discussing the preliminary evaluation results. Preop scores were about 52.5 and 53.1 for the reamed and unreamed groups, respectively, which improved to only about 42.9 and 43.5 at 1 year.

Because these results were so surprising to investigators they checked the study power to eliminate possible data errors.

“We were actually powered to 100% to detect a 5-point difference in SF-36 and an 8-point different in SMFA, which is almost ridiculous power based on 1,300 patients,” he explained.

Injury factor

Given the similar functional results between the groups with the reamed vs. unreamed analysis, Sanders and colleagues pooled their data for the remainder of the study to analyze functional differences after nailing open vs. closed fractures and treating isolated vs. multiple injuries.

“In contrast to the reamed vs. unreamed question, the injury factor played a much more important role. The open fractures did much worse on both the SF-36 and SMFA,” Sanders said. The difference was significant (P<.001).

“Reaming seems to have no important effect on functional outcome or return to activity. But in contrast, open fractures and multiple injuries are the injury factors that have independent, additive and important effects on outcome and return to activity,” he said.

Sanders said the fact that other studies detected improved function in these patients after 1 year was encouraging.

For more information:

• David W. Sanders, MD, FRCSC, is associate professor of orthopedic surgery, London Health Sciences Centre – Victoria Hospital and can be reached at E4-123, 800 Commissioners Road East, London, Ontario N6A 5W9; 519-685-8086; e-mail: david.sanders@lhsc.on.ca. He received institutional/research support from the National Institutes of Health, Canadian Institutes of Health Research, Orthopaedic Research and Education Foundation, and the Orthopaedic Trauma Association.

Reference:

• Sanders D, Tornetta P, Bhandari M, et al. Functional, general, and disability outcomes after tibial nailing: A randomized trial by the SPRINT investigators. Paper #496. Presented at the American Academy of Orthopaedic Surgeons 75th Annual Meeting. March 5-9, 2008. San Francisco.