Rates and odds ratios for complications in closed and open tibial fractures treated with unreamed, small diameter tibial nails: A multicenter analysis of 467 cases

Objective: A multicenter trial analyzed complications and odds for complica tions in open and closed tibial fractures stabilized by small diameter nail s. Design: Retrospective. Setting: Four Level I trauma centers. Patients: Four hundred sixty-seven tibial fractures were included in the st udy. There were fifty-two proximal fractures, 219 midshaft fractures, and 1 96 distal fractures. Breakdown into different AO/OTA groups showed 135 Type A fractures, 216 Type B fractures, and 116 Type C fractures. Two hundred s ixty-five were closed fractures and 202 were open fractures. Outcome Measurements: Clinical and radiographic analysis. Methods: 467 patients' tibial fractures were stabilized with small diameter tibial nails using an unreamed technique. Indications for the use of small diameter tibial nails using an unreamed technique included all types of op en or closed diaphyseal fractures. The operating surgeons decided whether o r not to ream based on personal experience, fracture type, and soft-tissue damage. Surgeons of Center I preferred to treat AO Type A and B fractures w ith unreamed nails, and surgeons of Centers 2, 3, and 4 preferred to treat AO Type B and C fractures with unreamed nails. Closed and open fractures we re treated in approximately the same ratio. Results: Analysis showed five (1.1 percent) deep infections (with a 5.4 per cent rate of deep infections in Gustito Grade III open fractures), forty-th ree delayed unions (9.2 percent), and twelve (2.6 percent) nonunions. Compa rtment syndromes occurred in sixty-two cases (13.3 percent), screw fatigue in forty-seven cases (10 percent), and fatigue failure of the tibial nail i n three cases (0.6 percent). Conclusions: Fracture distraction of more than three millimeters should not be tolerated when stabilizing tibial fractures with unreamed, small-diamet er nails as this increases the odds of having a delayed union by twelve tim es (p < 0.001) and a nonunion by four times (p = 0.057). There was a signif icant increase of complications in the group of Grade III open fractures (p < 0.001), AO/OTA Type C fractures (p = 0.002), and to a lesser extent in d istal fractures. However, the rate of severe complications resulting in maj or morbidity was low.