McMaster University

McMaster University

The Critical Sized Defect in the Tibia: Is it Critical?

We are pleased to share with you a recent publication in the Journal of Orthopaedic Trauma. This publication is entitled "The Critical Sized Defect in the Tibia: Is it Critical? Results from the SPRINT Trial."

Find the abstract below and click here to access the full-version of the article.

Sanders DW, Bhandari M, Guyatt G, Heels-Ansdell D, Schemitsch EH, Swiontkowski M, Tornetta P 3rd, Walter S. The critical sized defect in the tibia: Is it critical? Results from the SPRINT trial. J Orthop Trauma. 2014 Sep 17. [Epub ahead of print]

Abstract

OBJECTIVES:
The purpose of this study was to determine if the SPRINT definition of a "critical-sized defect" (fracture gap at least 1 cm in length and involving over 50 % of the cortical diameter) was accurate, to discern which factors predict reoperation in patients with these defects, and to compare the patient-based outcomes of these patients to patients without a critical defect.
DESIGN:
Therapeutic Cohort Study SETTING:: Level 1 and level 2 trauma centers PATIENTS:: Thirty-seven patients in the SPRINT trial with a "critical-sized defect". We evaluated these patients for planned and unplanned secondary intervention to gain union. Additionally, we evaluated which other factors predicted the need for reoperation. Finally, the 37 patients with a critical defect were compared to the larger cohort of patients without a defect with respect to demographics, mechanism of injury, fracture characteristics, and patient based outcome.
INTERVENTION:
revision surgery for tibial nonunion RESULTS:: Of the 37 patients with a large fracture gap, 7 patients had a planned secondary procedure. Of the remaining 30 patients in whom the attending surgeon adopted a "watch and wait" strategy, 14 patients (47 %) never required additional surgery to gain union. Additional surgery to gain union was less likely in patients treated with a reamed nail (p=0.04) and in female patients (p=0.04). Patients with a critical sized defect were more likely to have a high energy mechanism of injury (p=0.001), AO-OTA fracture type 42 B or C (p<0.001), and location involving the middle third of the tibia (p=0.02). The 12-month SF-36 PCS score in patients with a critical sized defect was 38.2 ± 10.5 (mean ± SD), compared to 43.3 ± 10.7 in those without (p=0.02, difference = 5.2, 95% confidence interval =(0.8, 9.6)).
CONCLUSIONS:
Tibial diaphyseal defects of >1 cm and > 50% cortical circumference healed without additional surgery in 47% of cases. This definition of a critical sized defect is not "critical". However, as compared with the overall cohort of tibial fractures, patients with these bone defects had a higher rate of reoperation and worse patient based outcomes. Further investigation is required to determine which factors predict union in this challenging fracture to avoid unnecessary secondary surgery.

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