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Treatment of infection following intramedullary nailing of tibial shaft fractures—results of the ORS/ISFR expert group survey

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Abstract

Objective

The lack of universally accepted treatment principles and protocols to manage infected intramedullary (IM) nails following tibial fractures continues to challenge us, eliciting a demand for clear guidelines. Our response to this problem was to create an ORS/ISFR taskforce to identify potential solutions and trends based on published evidence and practices globally.

Materials and methods

A questionnaire of reported treatment methods was created based on a published meta-analysis on the topic. Treatment methods were divided in two groups: A (retained nail) and B (nail removed). Experts scored the questionnaire items on a scale of 1–4 twice, before and after revealing the success rates for each stage of infection. Inter- and intra-observer variability analysis among experts’ personal scores and between experts’ scores was performed. An agreement mean and correlation degree between experts’ scores was calculated. Finally, a success rate report between groups was performed.

Results

Experts underestimated success rate of an individual treatment method compared to published data. The mean difference between experts’ scores and published results was + 26.3 ± 46 percentage points. Inter-observer agreement mean was poor (< 0.2) for both rounds. Intra-observer agreement mean across different treatment methods showed a wide variability (18.3 to 64.8%). Experts agree more with published results for nail removal on stage 2 and 3 infections.

Conclusions

Experts’ and published data strongly agree to retain the implant for stage 1 infections. A more aggressive approach (nail removal) favoured for infection stages 2 and 3. However, literature supports both treatment strategies.

Evidence

Clinical Question

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Authors and Affiliations

  1. Department of Orthopaedics, Denver Health Medical Center, 777 Bannock Street, Denver, CO, 80204, USA

    Cyril Mauffrey, David J. Hak, Peter Giannoudis, Volker Alt, Christoph Nau, Ingo Marzi, Peter Augat, JK Oh, Johannes Frank, Andreas Mavrogenis, Xavier Flecher, Jean-Noel Argenson, Ashok Gavaskar, David Rojas & Yehia H. Bedeir

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  1. Cyril Mauffrey
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  2. David J. Hak
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  3. Peter Giannoudis
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  4. Volker Alt
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  5. Christoph Nau
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  6. Ingo Marzi
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  7. Peter Augat
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  9. Johannes Frank
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  10. Andreas Mavrogenis
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  11. Xavier Flecher
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  12. Jean-Noel Argenson
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  13. Ashok Gavaskar
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  14. David Rojas
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  15. Yehia H. Bedeir
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From the ORS/ISFR expert group on Tibial bone defects

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Correspondence to Cyril Mauffrey.

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Mauffrey, C., Hak, D.J., Giannoudis, P. et al. Treatment of infection following intramedullary nailing of tibial shaft fractures—results of the ORS/ISFR expert group survey. International Orthopaedics (SICOT) 43, 417–423 (2019). https://doi.org/10.1007/s00264-018-3964-1

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  • DOI: https://doi.org/10.1007/s00264-018-3964-1

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