Reamed versus Non-Reamed Tibial Intramedullary Nailing

Background:While most surgeons agree that intramedullary nails are the implant of choice in the treatment of tibial shaft fractures, the decision to ream the intramedullary canal prior to nail insertion remains controversial. We therefore conducted an international survey of practicing orthopedic surgeons with an interest in fracture care (1) to identify surgeons’ beliefs regarding the risks of infection and nonunion with intramedullary reaming, and (2) to identify factors associated with surgeons’ beliefs.Material and Methods:We utilized focus groups, key informants and sampling to redundancy strategies to develop a survey to examine surgeons’ preferences in the treatment of tibial shaft fractures. We mailed this survey to members of the Orthopedic Trauma Association, American Academy of Orthopedic Surgeons, and European trauma centers affiliated with AO International.Results:Of the 577 surgeons surveyed, 444 (77%) responded. Of the respondents, 60% had an academic practice, 84% supervised residents, and 65.1% had fellowship training in trauma. Surgeons, in general, believed reamed nails decreased the risk of nonunion and had no effect on infection risk in closed tibial shaft fractures; however, surgeons, on average, believed that there was no difference in reducing the risk of nonunion or infection in patients with open tibial shaft fractures. Surgeons aged > 50 years, those with past trauma fellowship training, and those practicing in North America were more likely to believe reamed intramedullary nailing reduced nonunion rates.Conclusion:The continued disagreement and controversy reflect the lack of definitive evidence regarding the relative merits of the two approaches, and indicate that more studies are needed to resolve this issue.