Definitive Fixation Outcomes of Open Tibial Shaft Fractures: Systematic Review and Network Meta-analysis.

Area of Science:

• Orthopedic Surgery
• Trauma Surgery
• Evidence-Based Medicine

Background:

• Open tibial shaft fractures present complex challenges in definitive fixation.
• Choosing the optimal fixation strategy is crucial for minimizing reoperation rates and improving patient outcomes.
• Existing evidence comparing different fixation methods requires synthesis to guide clinical practice.

Purpose of the Study:

• To compare the effectiveness of various definitive fixation strategies for open tibial shaft fractures.
• To determine if differences in outcomes exist between unreamed intramedullary nailing (UN), reamed intramedullary nailing, plate fixation, and external fixation (EF).
• To identify the fixation method associated with the lowest risk of unplanned reoperation.

Main Methods:

• A systematic review and random-effects meta-analysis of randomized and quasi-randomized controlled trials.
• Inclusion of adult patients with open tibial shaft fractures (AO-42) undergoing definitive fixation.
• Network analysis to model direct and indirect evidence, assessing unplanned reoperation rates as the primary outcome.

Main Results:

• Unreamed intramedullary nailing (UN) demonstrated a trend towards a lower risk of unplanned reoperation compared to external fixation (EF) (RR 0.67, moderate confidence).
• In Gustilo type III open fractures, UN showed a statistically significant reduction in reoperation risk versus EF (RR 0.61, P=0.05, moderate confidence).
• No significant difference in reoperation risk was found between UN and reamed intramedullary nailing (low confidence).

Conclusions:

• Intramedullary nailing, particularly UN, appears to reduce the risk of unplanned reoperations for open tibial shaft fractures compared to external fixation.
• The benefit of nailing is more evident in severe (Gustilo type III) open fractures.
• Future research should investigate major complication rates and quality of life outcomes in high-grade tibial shaft fractures.