Should Insertion of Intramedullary Nails for Tibial Fractures Be With or Without Reaming?: A Prospective, Randomized Study With 3.8 Years' Follow-up

OBJECTIVETo determine if any differences exist in healing and complications between reamed and unreamed nailing in patients with tibial shaft fractures. DESIGNProspective, randomized. SETTINGLevel 1 trauma center. PATIENTSForty-five patients with displaced closed and open Gustilo type I–IIIA fractures of the central two thirds of the tibia. INTERVENTIONStabilization of tibial fractures either with a slotted, stainless steel reamed nail or a solid, titanium unreamed nail. MAIN OUTCOME MEASUREMENTSNonunions, time to fracture healing, and rate of malunions. RESULTSThe average time to fracture healing was 16.7 weeks in the reamed group and 25.7 weeks in the unreamed group. The difference was statistically significant (P = 0.004). There were three nonunions, all in the unreamed nail group. Two of these fractures healed after dynamization by removing static interlocking screws. The third nonunion did not heal despite exchange reamed nailing 2 years after the primary surgery and dynamization with a fibular osteotomy after an additional 1 year. There were two malunions in the reamed group and four malunions in the unreamed group. There were no differences for all other outcome measurements. CONCLUSIONUnreamed nailing in patients with tibial shaft fractures may be associated with higher rates of secondary operations and malunions compared with reamed nailing. The time to fracture healing was significantly longer with unreamed nails.