A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft

Objectives: To determine if there are differences in healing, complications , or number of procedures required to obtain union among open and closed ti bia fractures treated with intramedullary (IM) nails inserted with and with out reaming. Design: Prospective, surgeon-randomized comparative study. Setting: Level One trauma center. Patients: Ninety-four consecutive patients with unstable closed and open (e xcluding Gustilo Grade IIIB and IIIC) fractures of the tibial shaft treated with IM nail insertion between November 1, 1994, and June 30, 1997. Intervention: Interlocked IM nail insertion with and without medullary cana l reaming. Main Outcome Measures: Time to union, type and incidence of complications, and number of secondary procedures performed to obtain union. Results: For open fractures, there were no significant differences in the t ime to union or number of additional procedures performed to obtain union i n patients with reamed nail insertion compared with those without reamed in sertion. A higher percentage of closed fractures were healed at four months after reamed nail insertion compared with unreamed insertion (p = 0.040), but there was not a difference at six and twelve months. More secondary pro cedures were needed to obtain union after unreamed nail insertion for the t reatment of closed tibia fractures, but the difference was not statisticall y significant given the limited power of our study (p = 0.155). Broken scre ws were seen only in patients treated with smaller-diameter nails inserted without reaming, and the majority occurred in patients who were noncomplian t with weight-bearing restrictions. There were no differences in rates of i nfection or compartment syndrome. Conclusion: Our findings support the use of reamed insertion of IM nails fo r the treatment of closed tibia fractures, which led to earlier time to uni on without increased complications. In addition, canal reaming did not incr ease the risk of complications in open tibia fractures.