Which Surgical Treatment for Open Tibial Shaft Fractures Results in the Fewest Reoperations? A Network Meta-analysis

Abstract

Background Open tibial shaft fractures are one of the most devastating orthopaedic injuries. Surgical treatment options include reamed or unreamed nailing, plating, Ender nails, Ilizarov fixation, and external fixation. Using a network meta-analysis allows comparison and facilitates pooling of a diverse population of randomized trials across these approaches in ways that a traditional meta-analysis does not. Questions/purposes Our aim was to perform a network meta-analysis using evidence from randomized trials on the relative effect of alternative approaches on the risk of unplanned reoperation after open fractures of the tibial diaphysis. Our secondary study endpoints included malunion, deep infection, and superficial infection. Methods A network meta-analysis allows for simultaneous consideration of the relative effectiveness of multiple treatment alternatives. To do this on the subject of surgical treatments for open tibial fractures, we began with systematic searches of databases (including EMBASE and MEDLINE) and performed hand searches of orthopaedic journals, bibliographies, abstracts from orthopaedic conferences, and orthopaedic textbooks, for all relevant material published between 1980 and 2013. Two authors independently screened abstracts and manuscripts and extracted the data, three evaluated the risk of bias in individual studies, and two applied Grading of Recommendation Assessment, Development and Evaluation (GRADE) criteria to bodies of evidence. We included all randomized and quasirandomized trials comparing two (or more) surgical treatment options for open tibial shaft fractures in predominantly (ie, [ 80%) adult patients. We calculated pooled estimates for all direct comparisons and conducted a network meta-analysis combining direct and indirect evidence for all 15 comparisons between six stabilization strategies. Fourteen trials published between Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. This study was performed at

Network Meta-analysis: Users’ Guide for Surgeons: Part II - Certainty

“…In the open tibial shaft management NMA by Foote et al [7], only two pairwise comparisons included a sufficient number of studies for a meaningful assessment of heterogeneity. An initial visual assessment of the forest plots comparing unreamed nailing with external fixation (Fig.…”

“…Returning to the NMA of open tibial shaft fracture management by Foote et al [7] in the case scenario presented in Part I of the Users' Guide for Surgeons, we saw that the NMA had restricted eligibility to RCTs and quasirandomized trials and that the authors reported the risk of bias for each article. More to the point, the article also presented the risk of bias associated with the body of evidence addressing each treatment effect estimate.…”

“…Fig. 1 In the forest plot comparing unreamed intramedullary nailing and external fixation (based on data from the open tibial shaft NMA [7]), initial visual assessment indicates that heterogeneity is low, as odds ratios are similar and CIs are widely overlapping.…”

Editorial: “Pencil and Paper” Research? Network Meta-analysis and Other Study Designs That Do Not Enroll Patients

“…Alongside these User's Guides, we also present a well-performed network meta-analysis on the care of a common fracture [7]. We hope that readers will take advantage of this opportunity to try something new, and to learn.…”

“…If you are familiar with network meta-analyses, I am confident you will enjoy the paper by Foote et al [7] on tibial fractures in this issue of CORR 1 . But if this study design is new to you, I hope you will take advantage of this opportunity to learn how to read and enjoy network meta-analyses by taking advantage of the User's Guides [2,6].…”