Reamed versus nonreamed intramedullary nailing of lower extremity long bone fractures: A systematic overview and meta-analysis

Objective: To determine the effect of reamed versus nonreamed intramedullar y (IM) nailing of lower extremity long bone fractures on the rates of nonun ion, implant failure, malunion, compartment syndrome, pulmonary embolus, an d infection. Design: Quantitative systematic review of prospective, randomized controlle d trials. Data Identification: MEDLINE and SCISEARCH computer searches provided lists of published randomized clinical trials from 1969 to 1998. Extensive hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts, and personal files identified additional studies. Study Selection and Data Extraction: Of 676 citations initial ly identified , sixty proved potentially eligible, of which four published and five unpub lished randomized trials met all eligibility criteria. Each of three invest igators assessed study quality and abstracted relevant data. Results: The pooled relative risk of reamed versus nonreamed nails (nine tr ials, n = 646 patients) was 0.33 [95% confidence interval (CI), 0.16 to 0.6 8; p = 0.004]. The absolute risk difference in nonunion rates with reamed I M nailing was 7.0 percent (95% CI, 1 to 1 1 percent), Thus, one nonunion co uld be prevented for every fourteen patients treated with reamed IM nailing [number needed to treat (NNT) = 14.28]. The risk ratios for secondary outc ome measures were: implant failure, 0.30 (95% CI, 0.16 to 0.58; p < 0.001); malunion, 1.06 (95% CI, 0.32 to 3.57); pulmonary embolus, 1.10 (95% CI, 0. 26 to 4.76); compartment syndrome, 0.45 (95% CI, 0.13 to 1.56); and infecti on, 0.98 (95% CI, 0.21 to 4.76). Sensitivity analyses suggested that report ed rates of nonunion and implant failure were higher in studies of lower qu ality. The type of long bone fractured (tibia or femur), the decree of soft tissue injury (open or closed), study quality, and whether a study was pub lished or unpublished did not significantly alter the relative risk of nonu nion between reamed and nonreamed IM nailing. Conclusions: There is evidence from a pooled analysis of randomized trials that reamed IM nailing of lower extremity long bone fractures significantly reduces rates of nonunion and implant failure in comparison with nonreamed nailing.