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Synopsis Nine studies (randomized controlled trials or quasi-RCTs) were included in this meta-analysis comparing reamed and unreamed intramedullary nailing for closed tibial fractures. Of note, pooled nonunion rate was significantly lower for reamed intramedullary nailing vs. unreamed nailing. Additionally, rates of secondary surgeries, particularly implant exchange and dynamization, were also lower with reamed nailing. Pooled incidences of infection, compartment syndrome, and postoperative knee pain were similar between reamed and unreamed intramedullary nailing.

Publication Funding Details + Funding: Non-Industry funded Sponsor: Science and Technology Projects of Guangzhou Conflicts: None disclosed

Risk of Bias 9.5/10 Reporting Criteria 16/20 Fragility Index N/A Were the search methods used to find evidence (original research) on the primary question or questions stated? Was the search for evidence reasonably comprehensive? Were the criteria used for deciding which studies to include in the overview reported? Was the bias in the selection of studies avoided? Were the criteria used for assessing the validity of the included studies reported? Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)? Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported? Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses? Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview? How would you rate the scientific quality of this evidence? Yes = 1 Uncertain = 0.5 Not Relevant = 0 No = 0 The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below. 4/4 Introduction 4/4 Accessing Data 2/4 Analysing Data 3/4 Results 3/4 Discussion Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65 The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now? Debate exists between intramedullary nailing with and without reaming in tibial fractures. Cited advantages of reaming include stability with expedited union, although disadvantages include high risk of complications such as bone necrosis, compartment syndrome and infection. Unreamed intramedullary nailing has been suggested to avoid these complications and reduce operative time, but has been associated with poor mechanical stability and longer time to union. Previous meta-analysis have addressed this comparison, although have been limited by their inclusion of both closed and open tibial fractures. Therefore, this study aimed to investigate outcomes in closed fractures specifically.

What was the principal research question? How does intramedullary nailing with and without reaming compare in the treatment of closed tibial fractures?

Study Characteristics - Data Source: The electronic databases PubMed, EMBASE, BIOSIS, and Cochrane Controlled Trial Register were searched for articles published from 1980 to June 2012. Index Terms: The following terms were used in the search strategy: "ream", "unream", "non ream", "closed tibia", and "fracture". Study Selection: Criteria for inclusion were randomized or quasi-randomized controlled trials which compared reamed and unreamed intramedullary nailing in adult patients with a closed fracture of the tibia and reported one of the following outcomes: operative time, time to weight-bearing, time to callus formation, blood loss, nonunion/delayed union/malunion, secondary surgery, implant failure, compartment syndrome, infection, knee pain. Study selection was performed by two independent reviewers, with disagreement being resolved through consultation with a third reviewer. Data Extraction: Data on patient demographics, trial methodology, intervention descriptions, and outcomes were extracted into a standardized table. Extraction was performed independently by two reviewers, with disagreement resolved through discussion and, if necessary, a third reviewer. Data Synthesis: Meta-analysis was performed using Review Manager software (RevMan v5.1). Odds ratios (OR) and 95% confidence intervals were calculated for dichotomous outcomes. Heterogeneity was assessed using the I^2 statistic. A fixed-effects model was used in the absence of significant heterogeneity, and a random-effects model was used when heterogeneity was significant.

What were the important findings? Nine studies with 1229 tibial fractures (643 reamed; 586 unreamed) were included in the study. Eight outcomes were pooled: Rates of nonunion, delayed union, malunion, secondary surgery, implant failure, infection, compartment syndrome, and knee pain.

A significantly higher rate of nonunion was observed with unreamed nailing (3 studies; OR 0.43 [95%CI 0.21, 0.28]; p=0.02). The rates of delayed union (2 studies; OR 0.53 [95%CI 0.20, 1.41]; p=0.20) and malunion (2 studies; OR 0.48 [95%CI 0.13, 1.81]; p=0.28) were similar between groups.

Overall, rate a secondary surgery was significantly lower with unreamed nailing (OR 0.53 [95%CI 0.35, 0.81]; p=0.003). By surgery type, implant exchange (OR 0.37 [95%CI 0.16, 0.81]; p=0.01) and dynamization (OR 0.57 [95%CI 0.34, 0.98]; p=0.04) were significantly lower. The incidence of bone graft as a secondary procedure did not significantly differ between groups (OR 1.33 [95%CI 0.26, 6.80]; p=0.73).

Rate of implant failure was significantly lower with reamed nailing (OR 0.34 [95%CI 0.21, 0.57]; p<0.0001). This was predominantly due to failure of the screws (Reamed 20/514; Unreamed 54/498) (OR 0.32 [95%CI 0.19, 0.55]; p<0.0001) as opposed to failure of the nail (p=0.94).

There were no significant differences observed in rates of infection (7 studies; OR 1.36 [95%CI 0.70, 2.65]; p=0.36), compartment syndrome (5 studies; OR 0.69 [95%CI 0.31, 1.53]; p=0.36) or knee pain (2 studies; OR 0.97 [95%CI 0.47, 2.00]; p=0.93).

What should I remember most? Reamed intramedullary nailing exhibited a lower rate of nonunion than unreamed nailing following fixation of closed tibial fractures, along with lower rates of secondary implant exchange and dynamization. Incidence of screw failure in reamed nailing was also significantly lower than in unreamed nailing. Other complications (infection, compartment syndrome, postoperative knee pain) did not significantly differ between groups.

How will this affect the care of my patients? The results from this analysis suggest that reamed intramedullary nailing may offer a more advantageous outcome than unreamed nailing in treatment of closed fractures of the tibia with respect to nonunion and associated secondary surgeries. Inconsistent with previous literature, there did not appear to be an increased risk of complications with reamed nailing, as pooled rates of infection, compartment syndrome and knee pain were similar between methods. Unfortunately, current literature still lacks sufficient data to conduct comparisons on other pertinent complications, such as fat embolism and pulmonary embolism. These are topics that should be considered in future studies.