Journal of orthopaedic trauma | 2021
Definitive fixation outcomes of open tibial shaft fractures: Systematic review and network meta-analysis.
Abstract
OBJECTIVES\nTo delineate if there were differences in outcomes between definitive fixation strategies in open tibial shaft fractures.\n\n\nDATA SOURCES\nMEDLINE, EMBASE, CENTRAL, OpenGrey.\n\n\nSTUDY SELECTION\nRandomized and Quasi-randomized studies analyzing adult patients (>18 years) with open tibial shaft fractures (AO-42), undergoing definitive fixation treatment of any type.\n\n\nDATA EXTRACTION\nData regarding patient demographics, definitive bony/soft-tissue management, irrigation, type of antibiotics and follow up. Definitive intervention choices included unreamed intramedullary nailing (UN), reamed intramedullary nailing (RN), plate fixation, multiplanar, and uniplanar external fixation (EF). The primary outcome was unplanned reoperation rate. Cochrane risk of bias tool and GRADE systems were used for quality analysis.\n\n\nDATA SYNTHESIS\nA random-effects meta-analysis of head-to-head evidence, followed by a network analysis that modelled direct and indirect data was conducted to provide precise estimates (relative risks (RR) and associated 95% confidence intervals (95% CI)).\n\n\nRESULTS\nIn open tibial shaft fractures, direct comparison UN showed a lower risk of unplanned reoperation versus EF (RR 0.67, 95% CI 0.43 - 1.05, p=0.08, moderate confidence). In Gustilo type III open fractures, the risk reduction with nailing compared to EF was larger (RR 0.61, 95% CI 0.37 - 1.01, p=0.05, moderate confidence). UN had a lower reoperation risk compared to RN (RR 0.91, 95% CI 0.58 - 1.4, p=0.68, low confidence), however this was not significant and did not demonstrate a clear advantage.\n\n\nCONCLUSION\nIntramedullary nailing reduces the risk of unplanned reoperation by a third compared to EF, with a slightly larger reduction in type III open fractures. Future trials should focus on major complication rates and health-related quality of life in high-grade tibial shaft fractures.\n\n\nLEVEL OF EVIDENCE\nTherapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.