Reamed Nailing Versus Taylor Spatial Frame in Tibia Shaft Fractures

Study Overview
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Brief Summary
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This is a randomised, bi-centre, prospective, clinical trial in patients with closed tibia shaft fractures. The fracture should be fresh/acute and seen within 3 weeks after the injury. Patients will be randomised to surgery with either a Taylor Spatial Frame (Smith & Nephew, England) or a reamed intramedullar nail (according to local choice) with locking screws. Primary outcome measure is the physical component summary (PCS) of RAND Short form 36 (SF-36) after 2 years. Among secondary outcomes: Visual Analogue Scale (VAS) for pain, complications, healing, malunion, and resource use.

Detailed Description
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Fractures of the lower leg (fractures of the tibia shaft with or without concurrent fracture of the fibula) are a common injury. According to our fracture register 95 patients with closed tibia fractures were operated the last 3 years at our department. Fractures with moderate or no displacement can be successfully treated with a cast and subsequent Sarmiento brace. Displaced fractures are commonly treated with an intramedullary nail. Intramedullary nailing yields a high rate of union. More than 50 % of operated patients do, however, develop chronic anterior knee pain and one third of the patients have pain at rest. This contributes a big problem for many patients both at spare time and at work. Another problem is significant rates of malunion. The use of ring fixators utilizing rings and 1,8 mm. wires was introduced by Gavril Ilizarov more than 50 years ago, and the technique has been further developed through the introduction of six adjustable struts (Taylor Spatial Frame). This hexapod circular frame allows accurate reduction as well as a high stability. The ring fixator is less invasive and allows early weight bearing, but may be cumbersome to the patient. There is also concern about pin-tract infection, osteomyelitis and joint contracture. Only one prior study has compared ring fixator (Ilizarov) and intramedullar nail in closed tibia fractures. The results showed significant less anterior knee pain in the patients operated with ring fixator, but the study design did not allow clear conclusion.

Official Title
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Reamed Nailing Versus Taylor Spatial Frame in Tibia Shaft Fractures

Conditions
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Tibial Fractures

Intervention / Treatment
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* Device: Taylor Spatial Frame
* Device: Intramedullary nail


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Closed tibia shaft fractures suited for both study treatments. A patient who is informed of the purpose of the investigation and who has given informed consent and willingness to accept randomisation either to Taylor Spatial Frame or intramedullary nailing. Willingness and ability to comply with all investigation procedures Age between 18 to 70 years Skeletally mature Previous unaided walking Exclusion Criteria: Participation in other clinical investigations that will interfere with this study Mental illness or other conditions that preclude ring fixator in the judgment of the investigator Any other concurrent condition(s) that, in the judgment of the investigator, would prohibit the patient from participation in the study No other injury or previous disease that would be likely to seriously influence the long term outcome (this will exclude e.g. osteomyelitis, vascular or neurological disorder of the lower extremities, rheumatoid artist, malignancy that could influence on bone healing) Compartment syndrome before randomisation Pathologic fracture Ongoing or previous use the last year of drugs that can be bone anabolic (e.g. anabolic steroids, growth hormone, parathyroid hormone)

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 70 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Prospective randomized two-group clinical trial with block randomization.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Circular frame external fixator<br>A Taylor Spatial Frame should consist of 2 rings with 4 half pins/K-wire attached to each ring. If possible 3, not hydroxyapatite-coated, half pins and one K-wire should be attached to each ring. The half pins/K-wire should be spread in distance and direction for optimum stability. | Device: Taylor Spatial Frame<br>* Circular external fixator<br>* Other names: Circular frame;|
| Active Comparator: Intramedullary nail<br>Nailing technique according to Karladani and Styf published technique (ref: Karladani AH, Styf J. Percutaneous intramedullary nailing of tibial shaft fratures: a new approach for prevention of anterior knee pain. Injury, Int. J. Care Injury 32 (2001) 736-39) | Device: Intramedullary nail<br>* Antegrade intramedullary nail<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Physical Component summary of RAND SF 36 (Short Form 36) | Generic Health Related Quality of Life. Mean value 50, standard deviation 10. Higher score better. | 24 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Vitality Subscore of RAND (SF) 36 | Generic Health Related Quality of Life. Range 0 (worst) to 100 (best). | 6, 12, 24 months | 
| Physical functioning, subscore of RAND (SF) 36 | Generic Health Related Quality of Life. Range 0 (worst) to 100 (best). | 6, 12, 24 months | 
| Bodily pain, subscore of RAND (SF) 36 | Generic Health Related Quality of Life. Range 0 (worst) to 100 (best). | 6, 12, 24 months | 
| General health perceptions, subscore of RAND (SF) 36 | Generic Health Related Quality of Life. Range 0 (worst) to 100 (best). | 6, 12, 24 months | 
| Physical role functioning, subscore of RAND (SF) 36 | Generic Health Related Quality of Life. Range 0 (worst) to 100 (best). | 6, 12, 24 months | 
| Emotional role functioning, subscore of RAND (SF) 36 | Generic Health Related Quality of Life. Range 0 (worst) to 100 (best). | 6, 12, 24 months | 
| Social role functioning, subscore of RAND (SF) 36 | Generic Health Related Quality of Life. Range 0 (worst) to 100 (best). | 6, 12, 24 months | 
| Mental health, subscore of RAND (SF) 36 | Generic Health Related Quality of Life. Range 0 (worst) to 100 (best). | 6, 12, 24 months | 
| Physical Component summary of RAND (SF) 36 | Generic Health Related Quality of Life. Mean value 50, standard deviation 10. Higher score better. | 6, 12 months | 
| Pain around the knee | VAS scale 0-10 | 6, 12, 24 months | 
| Pain around the fracture site | VAS scale 0-10 | 6, 12, 24 months | 
| Pain around the ankle | VAS scale 0-10 | 6, 12, 24 months | 
| Complications major (composite) | Compartment syndrome, sequela compartment syndrome (e.g. short foot, clawing, neurological disorder), infection that needs operation, any unexpected reoperation (except removal of single pins or screws) | 24 months | 
| Complications minor (composite) | pin tract infection that needs antibiotics, wound complication that don't need reoperation, unexpected minor reoperations (i.e. removal of single pins or screws) | 24 months | 
| Reoperations minor (composite) | Minor reoperation (e.g. remove/exchange pins, remove/exchange screws) | 6, 12, 24 months | 
| Reoperations major (composite) | Major reoperation (e.g. fasciotomy, exchange nail, surgery for refracture, revision for infection, surgery for non-union) | 6, 12, 24 months | 
| Time to union (composite) | Time to fracture union in days. We require both radiographical union defined by callus bridging 3 of 4 cortices AND clinical union defined by full, pain free and unaided weight bearing. | 6, 12, 24 months | 
| Resource use; Away from work | Number of days away from work for employed patients | 24 months | 
| Resource use; Emergency contacts | Number of unscheduled contacts with hospital regarding tibia fracture | 24 months | 
| Resource use; Length of stay | Hospital stay in days for index stay | 24 months | 
| Resource use; Operation time | Surgery time in minutes for index surgery | 24 months |