Complications and subsequent surgery after intra-medullary nailing for tibial shaft fractures: Review of 8110 patients

Background: Intramedullary nailing of tibial shaft fractures has been common practice for decades. Nevertheless, complications occur frequently, and subsequent surgery is often required. To improve our understanding on how we may improve trauma care for patients with tibial shaft fractures, this study systematically reviewed all currently available evidence to assess the incidence of complications and rate of re-operations following intramedullary nailing of traumatic tibial fractures. Methods: Trip Database, Medline, Scopus and Cochrane Library were searched on September 7th, 2018. Searches were limited to English studies published after January 1st, 1998. Studies were included if authors included more than 50 patients treated with intramedullary nailing for traumatic tibial fractures. Inclusion of studies and critical appraisal of the evidence was performed by two independent authors. Incidence of complications and rate of re-operations were reported with descriptive statistics. Results: Fifty-one studies involving 8110 patients treated with intramedullary nailing for traumatic tibial fractures were included. Mean age of patients was 37.5 years. The most frequent complication was anterior knee pain (23%), followed by non-union (11%). Eighteen percent of patients required at least one subsequent surgery. The most frequent indication of subsequent surgery was screw removal due to pain or discomfort (9%). Dynamization of the nail to promote union was reported in 8% of the cases. Nail revision and bone-grafting to promote union were applied in 4% and 2% respectively. Discussion & Conclusion: Patients treated with intramedullary nailing for tibial fractures need to be consented for high probability of adverse events as anterior knee pain, subsequent surgical procedures and bone healing problems are relatively common. However, based on current data it remains difficult to identify specifiers and determinants of an individual patient with specific fracture characteristics at risk for complications. Future studies should aim to establish patient specific risks models for complications and re-operations, such that clinicians can anticipate them and adjust and individualize treatment strategies.