title: The management of segmental tibial shaft fractures: A systematic review.
abstract: BACKGROUND
  Segmental tibial fractures are complex injuries associated with significant soft tissue damage that are difficult to treat. This study aimed to identify the most effective method of treating segmental tibial fractures.
  
  
  METHODS
  A PRISMA compliant systematic review was conducted. Studies investigating the management of segmental tibial fractures with intramedullary nail fixation (IMN), open reduction and internal fixation (ORIF) or circular external fixation (CEF) were included for review. The primary outcome measure was time to fracture union. Secondary outcomes were complications and functional outcome. A narrative analysis was undertaken as meta-analysis was inappropriate due to heterogeneity of the data.
  
  
  RESULTS
  Thirteen studies were eligible and included. No randomised controlled trials were identified. Fixation with an intramedullary nail provided the fastest time to union, followed by open reduction and internal fixation and then CEF. The rate of deep infection was highest after IMN (5/162 [3%]), followed by open reduction and internal fixation (2/78 [2.5%]) and CEF (1/54 [2%]). However, some studies reported particularly high rates of infection following IMN for open segmental tibial fractures. There was limited reporting of postoperative deformities. From the studies that did include such data, there was a higher rate of deformity following ORIF (8/53 [15%]), compared to IMN (13/138 [9%]), and CEF (4/44 [9%]). Three studies, not including IMN, described patient reported outcome measures with results ranging from 'excellent' to 'fair'.
  
  
  CONCLUSIONS
  The available evidence was of poor quality, dominated by retrospective case series. This prevented statistical analysis, and precludes firm conclusions being drawn from the results available.
  
  
  CONCLUSIONS
  IMN has the fastest time to fracture union, however there are concerns regarding an increased deep infection rate in open segmental tibial fractures. In this subgroup, the data suggests CEF provides the most satisfactory results. However, the available literature does not provide sufficient detail to make this statement with certainty. We recommend a randomised controlled study to further investigate this challenging problem.
authors.affiliation: Royal Victoria Hospital, Belfast BT12 6NA, United Kingdom.
authors.forename: Samuel E
authors.initials: SE
authors.lastname: McMahon
authors.affiliation: Department of Trauma and Orthopaedics, St George's Hospital, London SW17 0QT, United Kingdom. Electronic address: zoe.little@doctors.org.uk.
authors.forename: Zoe E
authors.initials: ZE
authors.lastname: Little
authors.affiliation: University Lecturer, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich NR4 7TJ, United Kingdom.
authors.forename: Toby O
authors.initials: TO
authors.lastname: Smith
authors.affiliation: Department of Trauma and Orthopaedics, St George's Hospital, London SW17 0QT, United Kingdom; Department of Trauma and Orthopaedics, St George's, University of London, London SW17 0QT, United Kingdom.
authors.forename: Alex
authors.initials: A
authors.lastname: Trompeter
authors.affiliation: Department of Trauma and Orthopaedics, St George's Hospital, London SW17 0QT, United Kingdom; Department of Trauma and Orthopaedics, St George's, University of London, London SW17 0QT, United Kingdom.
authors.forename: Caroline B
authors.initials: CB
authors.lastname: Hing
mesh_terms: D001858:Bone Nails; D005594:Fracture Fixation, Intramedullary / Q000295:instrumentation / Q000379:methods; D017102:Fracture Healing; D005597:Fractures, Open / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D020127:Recovery of Function; D017695:Soft Tissue Injuries / Q000601:surgery*; D013978:Tibial Fractures / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome
keywords: Comparison; External fixation; Intramedullary nailing; Open reduction and internal fixation; Segmental; Systematic review; Tibial fracture