Factors Influencing the Outcome of Closed Tibial Fractures Treated With Functional Bracing

Sarmiento, Augusto; Sharpe, Frances; Ebramzadeh, Edward; Normand, Patricia; Shankwiler, James A.

doi:10.1097/00003086-199506000-00003

Cited by 74 publications

(61 citation statements)

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“…Certain variables thought to potentially contribute to nonunion were included despite lack of support in the literature. These variables were race, Comminuted Pro [26,34,40] Con [35] Oblique None…”

Section: Methodsmentioning

confidence: 99%

Will My Tibial Fracture Heal? Predicting Nonunion at the Time of Definitive Fixation Based on Commonly Available Variables

O’Halloran

Coale

Costales

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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Background Accurate prediction of tibial nonunions has eluded researchers. Reliably predicting tibial nonunions at the time of fixation could change management strategies and stimulate further research. Questions/purposes We asked (1) whether data from medical records, fracture characteristics, and radiographs obtained at the time of fixation would identify features predictive of tibial fracture nonunion; and (2) whether this information could be used to create a model to assess the chance of nonunion at the time of intramedullary (IM) nail fixation of the tibia. Methods We retrospectively reviewed all tibial shaft fractures treated at our center from 2007 to 2014. We conducted a literature review and collected data on 35 factors theorized to contribute to delayed bone healing. Patients were followed to fracture healing or surgery for nonunion. Patients with planned prophylactic nonunion surgery were excluded because their nonunions were anticipated and our focus was on unanticipated nonunions. Our cohort consisted of 382 patients treated with IM nails for tibial shaft fractures (nonunion, 56; healed, 326). Bivariate and multivariate regression techniques and stepwise modeling approaches examined the relationship between variables available at definitive fixation. Factors were included in our model if they were identified as having a modest to large effect size (odds ratio [ 2) at the p \ 0.05 level. Results A multiple variable logistic regression model was developed, including seven factors (p \ 0.05; odds ratio [ 2.0). With these factors, we created the Nonunion Risk Determination (NURD) score. The NURD score assigns 5 points for flaps, 4 points for compartment syndrome, 3 points for chronic condition(s), 2 points for open fractures, 1 point for male gender, and 1 point per grade of American Society of Anesthesiologists Physical Status and percent cortical contact. One point each is subtracted for spiral fractures and for low-energy injuries, which were found to be predictive of union. A NURD score of 0 to 5 had a 2% chance of nonunion; 6 to 8, 22%; 9 to 11, 42%; and[12, 61%. Conclusions The proposed nonunion prediction model (NURDS) seems to have potential to allow clinicians to better determine which patients have a higher risk of nonunion. Future work should be directed at prospectively validating and enhancing this model. Level of Evidence Level III, diagnostic study.

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Section: Methodsmentioning

confidence: 99%

Will My Tibial Fracture Heal? Predicting Nonunion at the Time of Definitive Fixation Based on Commonly Available Variables

O’Halloran

Coale

Costales

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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“…Therefore, bending displacement between the fragments occurs, resulting in cyclic distractive as well as compressive interfragmentary displacements. The mechanical environment, especially the amount of interfragmentary displacement, has a decisive effect on the amount of callus formation [ 19,23,24]. As far as compressive interfragmentary micromotion is concerned, it has been shown that active displacements applied daily can enhance fracture healing [4,9,27,29].…”

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confidence: 99%

The influence of cyclic compression and distraction on the healing of experimental tibial fractures

Hente

Füchtmeier

Schlegel

et al. 2004

Journal Orthopaedic Research

126

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Interfragmentary displacement has a main effect on callus formation in fracture healing. To test whether compressive or distractive displacements have a more pronounced effect on new bone formation, a sheep osteotomy model was created whereby the gap tissue was subjected to constant bending displacement. A diaphyseal osteotomy with a gap of 2 mm was created in 18 sheep tibiae and stabilized with a special unilateral actuator-driven external fixator. Two experimental groups with six sheep each received either 10 or 1000 cycles evenly distributed over 24 h. The third group of six sheep served as a control group without actively induced displacement. The amount and direction of cyclic displacement was kept constant throughout the observation period, resulting in 50% compressive and 50'%) distractive displacement within the osteotomy gap. At sacrifice, six weeks after surgery, bending stiffness was measured and new bone formation was assessed radiologically and microradiographically. In all cycled groups, the amount of periosteal callus formation was up to 25 times greater on the compression compared to the distraction side (p < 0.001). The application of the higher number of daily cycles resulted in an up to 10-fold greater amount of periosteal new bone formation on the compression side ( p < 0.012), while the difference on the distraction side was not significant. Ten cycles applied a day were sufficient to create an abundant periosteal callus on the compression side. In the 1000 cycle group, bending stiffness revealed slightly lower values but the difference was not significant. Solid periosteal bridging of the gap was observed in two sheep in the control group, whereas bridging in the cycled groups was observed exclusively at the medullary side. In conclusion, cyclic compressive displacements were found to be superior over distractive displacements. A higher number of enforced and maintained compressive displacements enhanced periosteal callus formation but did not allow bony bridging of the gap.

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“…Similar to our investigation, two prognostic studies found that patients with open compared with closed fractures were at higher risk for reoperation 34,54 . Of several studies that have evaluated fracture type as a risk factor [40][41][42] , Sarmiento et al found that segmental fractures increased the risk of nonunion and reoperation 41 . TytherleighStrong et al found an association of risk with fracture type (segmental and comminuted proximal tibial shaft fractures) 46 .…”

Section: Discussionmentioning

confidence: 99%

Prognostic Factors for Predicting Outcomes After Intramedullary Nailing of the Tibia

Schemitsch¹,

Bhandari²,

Guyatt³

et al. 2012

Journal of Bone and Joint Surgery

112

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Background: Prediction of negative postoperative outcomes after long-bone fracture treatment may help to optimize patient care. We recently completed the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT), a large, multicenter trial of reamed and unreamed intramedullary nailing of tibial shaft fractures in 1226 patients. Using the SPRINT data, we conducted an investigation of baseline and surgical factors to determine any associations with an increased risk of adverse events within one year of intramedullary nailing.Methods: Using multivariable logistic regression analysis, we investigated fifteen baseline and surgical factors for any associations with an increased risk of negative outcomes.Results: There was an increased risk of negative events in patients with a high-energy mechanism of injury (odds ratio[OR] = 1.57; 95% confidence interval [CI], 1.05 to 2.35), a stainless steel compared with a titanium nail (OR = 1.52; 95% CI, 1.10 to 2.13), a fracture gap (OR = 2.40; 95% CI, 1.47 to 3.94), and full weight-bearing status after surgery (OR = 1.63; 95% CI, 1.00 to 2.64). There was no increased risk with the use of nonsteroidal anti-inflammatory agents, late or early time to surgery, or smoking status. Open fractures had a higher risk of events among patients treated with reamed nailing (OR = 3.26; 95% CI, 2.01 to 5.28) but not in patients treated with unreamed nailing (OR = 1.50; 95% CI, 0.92 to 2.47). Patients with open fractures who had wound management either without any additional procedures or with delayed primary closure had a decreased risk of events compared with patients who required subsequent, more complex reconstruction (OR = 0.18 [95% CI, 0.09 to 0.35] and 0.29 [95% CI, 0.14 to 0.62], respectively). Conclusions:We identified several baseline fracture and surgical characteristics that may increase the risk of adverse events in patients with tibial shaft fractures. Surgeons should consider the predictors identified in our analysis to inform patients treated for tibial shaft fractures.

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Factors Influencing the Outcome of Closed Tibial Fractures Treated With Functional Bracing

Cited by 74 publications

References 0 publications

Will My Tibial Fracture Heal? Predicting Nonunion at the Time of Definitive Fixation Based on Commonly Available Variables

Will My Tibial Fracture Heal? Predicting Nonunion at the Time of Definitive Fixation Based on Commonly Available Variables

The influence of cyclic compression and distraction on the healing of experimental tibial fractures

Prognostic Factors for Predicting Outcomes After Intramedullary Nailing of the Tibia

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