title: Can tibial nonunion be predicted at 3 months after intramedullary nailing?
abstract: OBJECTIVE
  The purpose of this study was to determine if surgeons could reliably predict if patients with tibia fractures treated with intramedullary nails will proceed to nonunion based on their clinical scenario and radiographs at 3 months.
  
  
  METHODS
  Blinded randomized questionnaire based on a retrospective cohort.
  
  
  METHODS
  University level 1 trauma center.
  
  
  METHODS
  Fifty-six patients who underwent intramedullary fixation for tibia fractures with incomplete healing at 3 months.
  
  
  METHODS
  A questionnaire was applied to 56 consecutive patients treated between 2005 and 2009 with intramedullary fixation for tibia fractures who had incomplete healing at 3 months. Each case was developed into a vignette that included the 3-month radiographs and detailed clinical histories. The questionnaire was distributed to 3 fellowship-trained trauma surgeons who were asked to predict if the fracture would go onto nonunion.
  
  
  METHODS
  Diagnostic accuracy of predicting nonunion in patients with incomplete healing of their tibia fracture at 3 months.
  
  
  RESULTS
  The combined overall diagnostic accuracy of all 3 surgeons was 74%. Sensitivity and specificity was 62% and 77%, respectively. Radiographic features and injury mechanism were the most commonly cited clinical information used to predict fracture healing. The average positive predictive value was 73%. In 9 patients with diabetes, the diagnostic accuracy was 88%.
  
  
  CONCLUSIONS
  Clinical judgment at 3 months allows for correct prediction of eventual nonunion development in a majority of patients. We suggest that analysis of the entire clinical picture be used to predict fracture healing at 3 months. A protocol of waiting for 6 months before reoperation in all patients treated with intramedullary nailing for tibia fractures may subject patients to prolonged disability and discomfort.
  
  
  METHODS
  Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Orthopaedic Trauma Service, Department of Orthopaedics, Washington University School of Medicine, St Louis, MO.
authors.forename: Justin S
authors.initials: JS
authors.lastname: Yang
authors.forename: Jesse
authors.initials: J
authors.lastname: Otero
authors.forename: Christopher M
authors.initials: CM
authors.lastname: McAndrew
authors.forename: William M
authors.initials: WM
authors.lastname: Ricci
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Gardner
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D005594:Fracture Fixation, Intramedullary; D017102:Fracture Healing; D017759:Fractures, Malunited / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011237:Predictive Value of Tests; D011859:Radiography; D011897:Random Allocation; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D011795:Surveys and Questionnaires; D013978:Tibial Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome