The treatment of segmental tibial fractures: does patient preference differ from surgeon choice?

• Published in: Injury Vol. 48; no. 10; pp. 2306 - 2310
• Main Authors: Little, Z., Smith, T.O., McMahon, S.E., Cooper, C., Trompeter, A., Pearse, M., Britten, S., Rogers, B., Sharma, H., Narayan, B., Costa, M., Beard, D.J., Hing, C.B.
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Ltd 01.10.2017
• Subjects: Adult; Attitude of Health Personnel; Choice Behavior; Clinical Decision-Making; External Fixators - statistics & numerical data; Female; Fracture; Fracture Fixation - methods; Fracture Fixation - psychology; Fracture Fixation, Intramedullary - statistics & numerical data; Fracture Healing - physiology; Health Care Surveys; Humans; Male; Middle Aged; Patient Education as Topic; Patient Preference - psychology; Patient Preference - statistics & numerical data; Preference; Segmental; Surgeon; Surgeons; Tibia; Tibial Fractures - psychology; Tibial Fractures - surgery; Treatment Outcome; Trial; Fracture; Trial; Tibia; Segmental; Preference; Surgeon
• ISSN: 0020-1383; 1879-0267
• DOI: 10.1016/j.injury.2017.08.014

Segmental tibial fractures are complex injuries with a prolonged recovery time. Current definitive treatment options include intramedullary fixation or a circular external fixator. However, there is uncertainty as to which surgical option is preferable and there are no sufficiently rigorous multi-centre trials that have answered this question. The objective of this study was to determine whether patient and surgeon opinion was permissive for a randomised controlled trial (RCT) comparing intramedullary nailing to the application of a circular external fixator. A convenience questionnaire survey of attending surgeons was conducted during the United Kingdom’s Orthopaedic Trauma Society annual meeting 2017 to determine the treatment modalities used for a segmental tibial fracture (n=63). Patient opinion was obtained from clinical patients who had been treated for a segmental tibial fracture as part of a patient and public involvement focus group with questions covering the domains of surgical preference, treatment expectations, outcome, the consent process and follow-up regime (n=5). Based on the surgeon survey, 39% routinely use circular frame fixation following segmental tibial fracture compared to 61% who use nail fixation. Nail fixation was reported as the treatment of choice for a closed injury in a healthy patient in 81% of surgeons, and by 86% for a patient with a closed fracture who was obese. Twenty-one percent reported that they would use a nail for an open segmental tibia fracture in diabetics who smoked, whilst 57% would opt for a nail for a closed injury with compartment syndrome, and only 27% would use a nail for an open segmental injury in a young fit sports person. The patient and public preference exercise identified that sleep, early functional outcomes and psychosocial measures of outcomes are important. We concluded that a RCT comparing definitive fixation with an intramedullary nail and a circular external fixator is justified as there remains uncertainty on the optimal surgical management for segmental tibial fractures. Furthermore, psychosocial factors and early post-operative outcomes should be reported as core outcome measures as part of such a trial.