Prospective comparative study of functional outcome of treatment of tibial shaft fracture in adult by cast versus intramedullary nailing

Abstract

All patients with an isolated closed unilateral fracture of the tibial diaphysis admitted in our institution between November 2009 and October 2010 were evaluated for inclusion in the present study. Inclusion criteria were displaced closed fractures. The fractures of type A and B, according to the AO-classification system, were considered suitable for the study.16 The following exclusion criteria were used: 1) Patients who had other major injuries which could influence the final functional result, 2) patients with cardiopulmonary, rheumatological, neurological, or metabolic disease, 3) patients with previous injuries which influenced their general function, 4) patients with fractures within 5 cm distal to the tibial tuberosity or 7 cm proximal to the ankle joint, 5) open fractures, and 6) those with open growth plates. Thirty-four patients (26 men) having a mean age of 38 years fulfilled the criteria and entered the study. The patients gave their informed written consent before inclusion in the study, which was approved by the hospital’s ethics committee. Patients who agreed to participate in the study were randomized using the technique of stratified randomization by minimization.17 This method ensures that the treatment groups are similar as regard to the percentage of patient factors that are considered of major prognostic importance. The aim is to balance the marginal treatment totals for each level of each patient factor. Using a computer minimization program, each patient was allocated according to high-energy, soft-tissue injury (closed), age (under or over 50 years), smoking (yes or no), alcoholism (yes or no), and occupation (sedentary, mobile, heavy, unemployed). Fractures caused by traffic accident or a fall from a height of at least 3 meters were classified as highenergy trauma.18 Patients in each stratum were randomly allocated for treatment by unreamed intramedullary nailing or plaster cast. Seventeen patients were randomized to have an intramedullary nail (group I), and 17 patients were randomized to have a plaster cast (group II). All fractures were unilateral. Nineteen involved the right leg and 4 patients were injured by falling accidents. Traffic accidents caused the injuries in 26 patients, 11 of them were pedestrians, 2 were automobile drivers, and 13 were motorcycle drivers. Two patients were injured in sporting accidents and 2 others were injured at work. The severity of the closed injuries was classified according to (Table 1).19 Eight fractures were caused by low-energy trauma, while 26 fractures were caused by high-energy trauma (Table 1). The type of fracture was classified according to the AO system (Table 2). Seven fractures involved the proximal third of the tibia, 21 the middle third, and 6 the distal third. Twentynine patients had an associated fibula fracture, 8 at the same level as the tibia fracture, and 21 at a different one (Table 2). The median time of delay to operation was 5 days for group I and no days for group II. Gender, smoking habits, age, type of trauma, severity of soft-tissue damage, and degrees of comminution of the fractures were similar in the 2 groups. Closed tibial nailing was performed with the patient lying supine. A calcaneal pin was used if traction was required. We used a longitudinal medial parapatellar incision and approach to the Prospective comparative study of functional outcome of treatment of tibial shaft fracture in adult by cast versus intramedullary nailing