Functional outcomes not affected by use of reamed IM nail in tibia fractures

Patients experienced low rates of reoperation for nonunion after treatment with reamed intramedullary nail.

Issue: September 2016

Although functional outcomes were not affect by the use of a reamed intramedullary nail for treatment of diaphyseal tibia fractures, study results found baseline function was not reached 1 year following surgery.

“The physical recovery of people with tibia fractures takes longer than we think,” Carol A. Lin, MD, MA, of the Cedars-Sinai Orthopedic Trauma Facility, told Orthopedics Today. “It takes at least a year to get back to where the patients want to be, and I think that is important for us in our patient discussions and management of expectations afterward.”

Reamed vs unreamed

Lin and her colleagues randomly assigned 1,319 skeletally mature patients with closed and open diaphyseal tibia fractures from the study to prospectively evaluate Reamed Intramedullary (IM) Nails in Patients with Tibial Fractures (SPRINT) to receive fracture fixation with an IM nail after reaming of the IM canal or with an IM nail without previous reaming. Main outcome measures included the SF-36 and short musculoskeletal function assessment obtained during the initial hospitalization for preinjury status and again at 2 weeks, 3 months, 6 months and 1 year postoperatively.

At the 1-year follow-up, results showed 768 patients completed at least one of the four functional outcomes scores with no differences in functional outcomes between reamed and unreamed patients. Researchers also found neither reamed or unreamed patients returned to baseline function at 1 year for the SF-36 physical component score, short musculoskeletal function assessment dysfunction index and short musculoskeletal function assessment bothersome index. Functional outcome was significantly associated with time and fracture type.

“When we looked at [functional outcomes] and followed patients closely, we saw even at 1 year, even though mentally people are [mostly] back to their baseline, physically they are still maybe 70% to 80% of what they were before the injury,” Lin said. “I think that [gives] us an idea of how to talk to patients about patient expectations and function recovery beyond just healing. It also [gives] us a better understanding of patients’ recovery and maybe they need more physical therapy or more counseling. In terms of returning to work, maybe it does take a lot longer than we used to think.”

Unenrolled patients

In a separate study, Lin and her colleagues wanted to see if patients who were eligible for the SPRINT study but were not enrolled were being managed similarly to patients who were enrolled.

“The real question was if we compare these [results] to the people who were not enrolled in the study, ‘Are they being operated on much earlier than the other [patients] and what were their outcomes? Does it make a difference?’ ” Lin said.

Researchers compared the rates and timing of reoperation of 328 patients enrolled in the SPRINT study to 114 patients who were eligible for but not enrolled in the study.

Overall, results showed 6.1% of non-SPRINT patients underwent reoperation vs. 5.2% of SPRINT patients, showing no significant difference between the groups. Researchers noted 43% of reoperations for nonunion were performed before 6 months in the non-SPRINT group vs. 29% in the SPRINT group.

“Ultimately what we found was [people] who were enrolled in the study had similar rates of reoperation at similar times to those not enrolled in the study,” Lin said.

She observed almost every patient not enrolled in the SPRINT study received a reamed IM nail compared with half of the patients in the SPRINT study due to the randomization.

“It supports the overwhelming bias toward reamed nailing in the United States and that is what the clinical practice seems to be,” Lin said. – by Casey Tingle

References:
Lin CA, et al. J Orthop Trauma. 2016:doi:10.1097/BOT.0000000000000497.
Lin CA, et al. J Orthop Trauma. 2016;doi:10.1097/BOT.0000000000000533.

For more information:
Carol A. Lin, MD, MA, can be reached at Cedars-Sinai Orthopedic Trauma Facility, 444 S. San Vicente Blvd., Mark Goodson Building, Suite 603, Los Angeles, CA 90048; email: carol.lin@cshs.org.

Disclosure: Lin reports no relevant financial disclosures.