Changing practice patterns: flexed versus semi-extended positioning for tibial nailing

Abstract

Background: Recent studies have demonstrated several benefits to semi-extended leg position for intramedullary nailing (IMN) without increased complications. The purpose of this study was to evaluate how surgeon preference for flexed versus semi-extended positioning has changed over time. Methods: We distributed an anonymous online survey to orthopaedic surgeons via the Orthopaedic Trauma Association (OTA) website. We compared surgeon demographics and preferred leg positioning for tibial nailing. Results: Twenty-seven percent of surgeons reported substantial experience (>50% of cases) with semi-extended positioning during training, while 49% of surgeons preferred semi-extended nailing in current practice (P<0.001). Surgeons who practiced in the U.S. (P<0.001) or who completed a trauma fellowship (P<0.05) were more likely to have had exposure to the semi-extended positioning during training. Surgeons who practiced in the U.S. (P<0.001), supervised residents (P<0.05) or had completed a trauma fellowship (P<0.01) were significantly more likely to currently prefer the semi-extended positioning. Surgeons in the U.S. (P<0.01), or who supervised residents (P<0.05) were more likely to have changed from the hyper-flexed to semi-extended position. Facilitating reduction in proximal fractures was the most cited reason for switching to the semi-extended position (28%). Conclusions: Semi-extended has become the preferred position during intramedullary nailing of tibial fractures among U.S. surgeons, those supervising residents, or those completing a trauma fellowship. Flexed nailing remains the preferred technique for international surgeons. Further investigation of extended nailing techniques is necessary. However, given its preference for the conventional flexed nailing, the international community may benefit from further educational interventions, demonstrating the benefits of extended nailing.