Association Between Periprosthetic Joint Infection and Mortality Following Primary Total Hip Arthroplasty.

BACKGROUND: Periprosthetic joint infection (PJI) remains a dreaded and unpredictable complication after total hip arthroplasty (THA). In addition to causing substantial morbidity, PJI may contribute to long-term mortality risk. Our objective was to determine the long-term mortality risk associated with PJI following THA. METHODS: This population-based, retrospective cohort study included adult patients (≥18 years old) in Ontario, Canada, who underwent their first primary elective THA for arthritis between April 1, 2002, and March 31, 2021. The primary outcome was death within 10 years after the index THA. Mortality was compared between propensity-score-matched groups (PJI within 1 year after surgery versus no PJI within 1 year after surgery) with use of survival analyses. Patients who died within 1 year after surgery were excluded to avoid immortal time bias. RESULTS: A total of 175,432 patients (95,883 [54.7%] women) with a mean age (and standard deviation) of 67 ± 11.4 years underwent primary THA during the study period. Of these, 868 patients (0.49%) underwent surgery for a PJI of the replaced joint within 1 year after the index procedure. After matching, patients with a PJI within the first year had a significantly higher 10-year mortality rate than their counterparts (11.4% [94 of 827 patients] versus 2.2% [18 of 827 patients]; absolute risk difference, 9.19% [95% confidence interval (CI), 6.81% to 11.6%]; hazard ratio, 5.49 [95% CI, 3.32 to 9.09]). CONCLUSIONS: PJI within 1 year after surgery is associated with over a fivefold increased risk of mortality within 10 years. The findings of this study underscore the importance of prioritizing efforts related to the prevention, diagnosis, and treatment of PJIs. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Postfracture survival in a population-based study of adults aged ≥66 yr: a call to action at hospital discharge.

Postfracture survival rates provide prognostic information but are rarely reported along with other mortality outcomes in adults aged ≥50 yr. The timing of survival change following a fracture also needs to be further elucidated. This population-based, matched-cohort, retrospective database study examined 98 474 patients (73% women) aged ≥66 yr with an index fracture occurring at an osteoporotic site (hip, clinical vertebral, proximal non-hip non-vertebral [pNHNV], and distal non-hip non-vertebral [dNHNV]) from 2011 to 2015, who were matched (1:1) to nonfracture individuals based on sex, age, and comorbidities. All-cause 1- and 5-yr overall survival and relative survival ratios (RSRs) were assessed, and time trends in survival changes were characterized starting immediately after a fracture. In both sexes, overall survival was markedly decreased over 6 yr of follow-up after hip, vertebral, and pNHNV fractures, and as expected, worse survival rates were observed in older patients and males. The lowest 5-yr RSRs were observed after hip fractures in males (66-85 yr, 51.9%-63.9%; ≥86 yr, 34.5%), followed by vertebral fractures in males (66-85 yr, 53.2%-69.4%; ≥86 yr, 35.5%), and hip fractures in females (66-85 yr, 69.8%-79.0%; ≥86 yr, 52.8%). Although RSRs did not decrease as markedly after dNHNV fractures in younger patients, relatively low 5-yr RSRs were observed in females (75.9%) and males (69.5%) aged ≥86 yr. The greatest reduction in survival occurred within the initial month after hip, vertebral, and pNHNV fractures, indicating a high relative impact of short-term factors, with survival-reduction effects persisting over time. Therefore, the most critical period for implementing interventions aimed at improving post-fracture prognosis appears to be immediately after a fracture; however, considering the immediate need for introducing such interventions, primary fracture prevention is also crucial to prevent the occurrence of the initial fracture in high-risk patients.

Fasciotomy and rate of amputation after tibial fracture in adults: a population-based cohort study.

Objectives: Limb amputation is a possible outcome of acute compartment syndrome. We undertook this study to investigate the occurrence of fasciotomy and amputation in patients with tibial fractures in the Ontario adult population, aiming to evaluate variables that may be associated with each of these outcomes. Design: Retrospective, population-based cohort study (April 1, 2003-March 31, 2016). Setting: Canadian province of Ontario. Participants: Patients with tibial fracture, aged 14 years and older. Interventions: Fasciotomy after tibial fracture. Main Outcomes and Measures: The primary outcomes were fasciotomy and amputation within 1 year of fasciotomy. Secondary outcomes included repeat surgery, new-onset renal failure, and mortality, all within 30 days of fasciotomy. Results: We identified 76,299 patients with tibial fracture; the mean (SD) age was 47 (21) years. Fasciotomy was performed in 1303 patients (1.7%); of these, 76% were male and 24% female. Patients who were younger, male, or experienced polytrauma were significantly more likely to undergo fasciotomy. Limb amputation occurred in 4.3% of patients undergoing fasciotomy, as compared with 0.5% in those without fasciotomy; older age, male sex, presence of polytrauma, and fasciotomy were associated with an increased risk of amputation (age odds ratio [OR] of 1.03 [95% CI, 1.02-1.03], P < 0.0001; sex OR of 2.04 [95% CI, 1.63-2.55], P < 0.0001; polytrauma OR of 9.37 [95% CI, 7.64-11.50], P < 0.0001; fasciotomy OR of 4.35 [95% CI, 3.21-5.90], P < 0.0001), as well as repeat surgery within 30 days (sex OR of 1.54 [95% CI, 1.14-2.07], P = 0.0053; polytrauma OR of 4.24 [95% CI, 3.33-5.38], P < 0.0001). Conclusions: Among tibial fracture patients, those who were male and who experienced polytrauma were at significantly higher risk of undergoing fasciotomy and subsequent amputation. Fasciotomy was also significantly associated with risk of amputation, a finding that is likely reflective of the severity of the initial injury.

Orthopedic surgeons' transition into full-time practice over the last 20 years: an analysis using Ministry of Health billing data.

BACKGROUND: Underemployment is a reality for many new graduates, who accept locum or part-time work as an alternative to unemployment because of lack of opportunities. We sought to analyze orthopedic surgeons' Ontario Health Insurance Program (OHIP) billing data over a 20-year period as a proxy of practice patterns and hypothesized that billing in the first 6 years of practice would be affected by underemployment and locum. METHODS: We analyzed the annual average billing totals of orthopedic surgeons, broken down by year of graduation, year of billings, and number of surgeons billing in that year. We analyzed public census data of the Ontario population size as a proxy of orthopedic demand. RESULTS: A 2019 cross-sectional analysis showed that around 15 surgeons per graduating year were billing in Ontario from the 1995 to 2016 cohorts, while 2017 and 2018 saw an increase to 30 and 36 actively billing surgeons, respectively. The number returned to more historical numbers in 2019, with 20 actively billing surgeons. For those surgeons billing in Ontario, billing trends have been roughly stable, with average billings increasing each year for the first 6 years in practice (p < 0.001). Year of graduation did not have an effect on the first 6 years of billings (p > 0.5). Billings were stable after 6 years in practice (p > 0.09). CONCLUSION: The Ontario health care system has not expanded to support more orthopedic surgeons despite the aging and growing population; despite our growing population, the number of surgeons being trained and retained has not matched this growth. Further research needs to be done to guide optimal health human resource decision-making.

Cytotoxicity of novel hybrid composite materials for making bone fracture plates.

Bone fracture plates are usually made from steel or titanium, which are much stiffer than cortical bone. This may cause bone 'stress shielding' (i.e. bone resorption leading to plate loosening) and delayed fracture healing (i.e. fracture motion is less than needed to stimulate callus formation at the fracture). Thus, the authors previously designed, fabricated, and mechanically tested novel 'hybrid' composites made from inorganic and organic materials as potential bone fracture plates that are more flexible to reduce these negative effects. This is the first study to measure the cytotoxicity of these composites via the survival of rat cells. Cubes of carbon fiber/flax fiber/epoxy and glass fiber/flax fiber/epoxy had better cell survival vs. Kevlar fiber/flax fiber/epoxy (57% and 58% vs. 50%). Layers and powders made of carbon fiber/epoxy and glass fiber/epoxy had higher cell survival than Kevlar fiber/epoxy (96%-100% and 100% vs. 39%-90%). The presence of flax fibers usually decreased cell survival. Thus, carbon and glass fiber composites (with or without flax fibers), but not Kevlar fiber composites (with or without flax fibers), may potentially be used for bone fracture plates.

Position statement: management of proximal humerus fractures.

We sought to compare outcomes and reoperation rates for the surgical treatment of proximal humerus fractures (excluding head-splitting fractures, fracture-dislocations, and isolated greater-tuberosity fractures) in men and women older than 60 years. We searched MEDLINE, Embase, and Cochrane through to Feb. 1, 2022, and included all English-language randomized trials comparing operative versus nonoperative treatment; open reduction and internal fixation (ORIF) with locking plate versus intramedullary nail; arthroplasty versus ORIF; and reverse shoulder arthroplasty versus hemiarthroplasty. Outcomes of interest were functional outcomes (e.g., Constant score), pain outcomes (visual analogue scale scores), and reoperation rates for the interventions of interest when available. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. This guideline will benefit patients considering surgical intervention for fractures of the proximal humerus by improving counselling on surgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making.Nous avons cherché à comparer les résultats et les taux de réintervention à la suite d'un traitement chirurgical pour une fracture de l'humérus proximal (excluant les fractures de la tête humérale, les fractures-luxations et les fractures isolées de la grande tubérosité) chez les hommes et les femmes âgés de plus de 60 ans. Nous avons effectué des recherches dans les bases de données MEDLINE, Embase, et Cochrane jusqu'au 1er février 2022 et avons inclus tous les essais randomisés publiés en anglais comparant différents duos d'interventions : traitements chirurgicaux ou non chirurgicaux; réductions ouvertes avec fixation interne (ROFI) réalisées à l'aide d'une plaque verrouillée ou enclouages centromédullaires; arthroplasties ou ROFI; et arthroplasties inversées de l'épaule ou hémiarthroplasties. Les paramètres d'intérêt étaient la capacité fonctionnelle (p. ex., score de Constant), la douleur (p. ex., échelle analogique visuelle) et le taux de réintervention pour les interventions d'intérêt, selon les données disponibles. Nous avons évalué la qualité des données probantes et la solidité des recommandations à l'aide de l'approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Cette ligne directrice profitera aux patients qui envisagent une intervention chirurgicale après une fracture de l'humérus proximal en améliorant les consultations sur les options de traitement chirurgical et les résultats escomptés. Elle aidera aussi les chirurgiens en améliorant leurs connaissances sur différentes approches chirurgicales. Les données présentées pourraient servir à mettre au point des cadres et des outils pour une prise de décision partagée.

Geriatric trauma: there is more to it than just the implant!

Geriatric trauma continues to rise, corresponding with the continuing growth of the older population. These fractures continue to expand, demonstrated by the incidence of hip fractures having grown to 1.5 million adults worldwide per year. This patient population and their associated fracture patterns present unique challenges to the surgeon, as well as having a profound economic impact on the health care system. Pharmacologic treatment has focused on prevention, with aging adults having impaired fracture healing in addition to diminished bone mineral density. Intraoperatively, novel ideas to assess fracture reduction to facilitate decreased fracture collapse have recently been explored. Postoperatively, pharmacologic avenues have focused on future fracture prevention, while shared care models between geriatrics and orthopaedics have shown promise regarding decreasing mortality and length of stay. As geriatric trauma continues to grow, it is imperative that we look to optimize all phases of care, from preoperative to postoperative.

Biomechanical design optimization of proximal humerus locked plates: A review.

BACKGROUND: Proximal humerus locked plates (PHLPs) are widely used for fracture surgery. Yet, non-union, malunion, infection, avascular necrosis, screw cut-out (i.e., perforation), fixation failure, and re-operation occur. Most biomechanical investigators compare a specific PHLP configuration to other implants like non-locked plates, nails, wires, and arthroplasties. However, it is unknown whether the PHLP configuration is biomechanically optimal according to some well-known biomechanical criteria. Therefore, this is the first review of the systematic optimization of plate and/or screw design variables for improved PHLP biomechanical performance. METHODS: The PubMed website was searched for papers using the terms "proximal humerus" or "shoulder" plus "biomechanics/biomechanical" plus "locked/locking plates". PHLP papers were included if they were (a) optimization studies that systematically varied plate and screw variables to determine their influence on PHLP's biomechanical performance; (b) focused on plate and screw variables rather than augmentation techniques (i.e., extra implants, bone struts, or cement); (c) published after the year 2000 signaling the commercial availability of locked plate technology; and (d) written in English. RESULTS: The 41 eligible papers involved experimental testing and/or finite element modeling. Plate variables investigated by these papers were geometry, material, and/or position, while screw variables studied were number, distribution, angle, size, and/or threads. Numerical outcomes given by these papers included stiffness, strength, fracture motion, bone and implant stress, and/or the number of loading cycles to failure. But, no paper fully optimized any plate or screw variable for a PHLP by simultaneously applying four well-established biomechanical criteria: (a) allow controlled fracture motion for early callus generation; (b) reduce bone and implant stress below the material's ultimate stress to prevent failure; (c) maintain sufficient bone-plate interface stress to reduce bone resorption (i.e., stress shielding); and (d) increase the number of loading cycles before failure for a clinically beneficial lifespan (i.e., fatigue life). Finally, this review made suggestions for future work, identified clinical implications, and assessed the quality of the papers reviewed. CONCLUSIONS: Applying biomechanical optimization criteria can assist biomedical engineers in designing or evaluating PHLPs, so orthopaedic surgeons can have superior PHLP constructs for clinical use.

Optimal delivery of endothelial progenitor cells in a rat model of critical-size bone defects.

Nonunion and segmental bone defects are complex issues in orthopedic trauma. The use of endothelial progenitor cells (EPCs), as part of a cell-based therapy for bone healing is a promising approach. In preclinical studies, culture medium (CM) is commonly used to deliver EPCs to the defect site, which has the potential for immunogenicity in humans. The goal of this study was to find an effective and clinically translatable delivery medium for EPCs. Accordingly, this study compared EPCs delivered in CM, phosphate-buffered saline (PBS), platelet-poor plasma (PPP), and platelet-rich plasma (PRP) in a rat model of femoral critical-size defects. Fischer 344 rats (n = 35) were divided into six groups: EPC+CM, EPC+PBS, EPC+PPP, EPC+PRP, PPP alone, and PRP alone. A 5 mm mid-diaphyseal defect was created in the right femur and stabilized with a miniplate. The defect was filled with a gelatin scaffold impregnated with the corresponding treatment. Radiographic, microcomputed tomography and biomechanical analyses were performed. Overall, regardless of the delivery medium, groups that received EPCs had higher radiographic scores and union rates, higher bone volume, and superior biomechanical properties compared to groups treated with PPP or PRP alone. There were no significant differences in any outcomes between EPC subgroups or between PPP and PRP alone. These results suggest that EPCs are effective in treating segmental defects in a rat model of critical-size defects regardless of the delivery medium used. Consequently, PBS could be the optimal medium for delivering EPCs, given its low cost, ease of preparation, accessibility, noninvasiveness, and nonimmunogenic properties.

The Role of Revision Total Joint Arthroplasty for Periprosthetic Fractures With Unstable Implants.

The management of periprosthetic fractures with unstable prosthetic implants is a challenging and commonly encountered problem. It is important to address the many current issues and controversies regarding the treatment of periprosthetic fractures with revision total joint arthroplasty. Key strategies to optimize surgical decision making around the use of arthroplasty and management of complications following these complex injuries will be addressed.

Reducing the Burden of Disease Associated With Periprosthetic Fractures: Prevention and the Need for Improved Perioperative Care.

The management of periprosthetic fractures remains challenging and controversial. There continues to be a significant burden of disease and substantial resource implications associated with fractures following total joint arthroplasty. Achieving consensus opinions regarding the prevention and treatment of this problem has important implications given the profound effect on patient outcomes. Multidisciplinary care in the preoperative and postoperative settings is critical, with a specific focus on bone health.

Fixation Strategies for Periprosthetic Fractures With Stable Implants.

The fixation of periprosthetic fractures remains challenging and controversial. It is important to achieve consensus opinions regarding the management of stable periprosthetic fractures with internal fixation. Key strategies to optimize surgical decision making and fixation and manage complications following these difficult injuries are addressed.

Biomechanical effects of different loads and constraints on finite element modeling of the humerus.

Currently, there is no established finite element (FE) method to apply physiologically realistic loads and constraints to the humerus. This FE study showed that 2 'simple' methods involving direct head loads, no head constraints, and rigid elbow or mid-length constraints created excessive stresses and bending. However, 2 'intermediate' methods involving direct head loads, but flexible head and elbow constraints, produced lower stresses and bending. Also, 2 'complex' methods involving muscles to generate head loads, plus flexible head and elbow constraints, generated the lowest stresses and moderate bending. This has implications for FE modeling research on intact and implanted humeri.

Experimental Methods for Studying the Contact Mechanics of Joints.

Biomechanics researchers often experimentally measure static or fluctuating dynamic contact forces, areas, and stresses at the interface of natural and artificial joints, including the shoulders, elbows, hips, and knees. This information helps explain joint contact mechanics, as well as mechanisms that may contribute to disease, damage, and degradation. Currently, the most common in vitro experimental technique involves a thin pressure-sensitive film inserted into the joint space; but, the film's finite thickness disturbs the joint's ordinary articulation. Similarly, the most common in vivo experimental technique uses video recording of 3D limb motion combined with dynamic analysis of a 3D link-segment model to calculate joint contact force, but this does not provide joint contact area or stress distribution. Moreover, many researchers may be unaware of older or newer alternative techniques that may be more suitable for their particular research application. Thus, this article surveys over 50 years of English-language scientific literature in order to (a) describe the basic working principles, advantages, and disadvantages of each technique, (b) examine the trends among the studies and methods, and (c) make recommendations for future directions. This article will hopefully inform biomechanics investigators about various in vitro and in vivo experimental methods for studying the contact mechanics of joints.

Biomechanical stress analysis using thermography: A review.

Biomechanics investigators are interested in experimentally measuring stresses experienced by dental structures, whole bones, joint replacements, soft tissues, normal limbs, etc. To do so, various experimental methods have been used that are based on acoustic, optical, piezo-resistive, or other principles, like digital image correlation, fiber optic sensors, photo-elasticity, strain gages, ultrasound, etc. Several biomechanical review papers have surveyed these research technologies, but they do not mention thermography. Thermography can identify temperature anomalies indicating low- or high-stress areas on a bone, implant, prosthesis, etc., which may need to be repaired, replaced, or redesigned to avoid damage, degradation, or failure. In addition, thermography can accurately predict a structure's cyclic fatigue strength. Consequently, this article gives an up-to-date survey of the scientific literature on thermography for biomechanical stress analysis. This review (i) describes the basic physics of thermography, thermo-elastic properties of biomaterials, experimental protocols for thermography, advantages, and disadvantages, (ii) surveys published studies on various applications that used thermography for biomechanical stress measurements, and (iii) discusses general findings and future work. This article is intended to inform biomechanics investigators about the potential of thermography for stress analysis.

Biomechanical properties of artificial bones made by Sawbones: A review.

Biomedical engineers and physicists frequently use human or animal bone for orthopaedic biomechanics research because they are excellent approximations of living bone. But, there are drawbacks to biological bone, like degradation over time, ethical concerns, high financial costs, inter-specimen variability, storage requirements, supplier sourcing, transportation rules, etc. Consequently, since the late 1980s, the Sawbones® company has been one of the world's largest suppliers of artificial bones for biomechanical testing that counteract many disadvantages of biological bone. There have been many published reports using these bone analogs for research on joint replacement, bone fracture fixation, spine surgery, etc. But, there exists no prior review paper on these artificial bones that gives a comprehensive and in-depth look at the numerical data of interest to biomedical engineers and physicists. Thus, this paper critically reviews 25 years of English-language studies on the biomechanical properties of these artificial bones that (a) characterized unknown or unreported values, (b) validated them against biological bone, and/or (c) optimized different design parameters. This survey of data, advantages, disadvantages, and knowledge gaps will hopefully be useful to biomedical engineers and physicists in developing mechanical testing protocols and computational finite element models.

Open fractures: Current treatment perspective.

Severe open fractures present challenges to orthopaedic surgeons worldwide, with increased risks of significant complications. Although different global regions have different resources and systems, there continue to be many consistent approaches to open fracture care. Management of these complex injures continues to evolve in areas ranging from timing of initial operative debridement to the management of critical-sized bone defects. This review, compiled by representative members of the International Orthopaedic Trauma Association, focuses on several critical areas of open fracture management, including antibiotic administration, timing of debridement, bone loss, soft tissue management, and areas of need for future investigation.

Mechanical Properties of Synthetic Bones Made by Synbone: A Review.

Biomechanical engineers and physicists commonly employ biological bone for biomechanics studies, since they are good representations of living bone. Yet, there are challenges to using biological bone, such as cost, degradation, disease, ethics, shipping, sourcing, storage, variability, etc. Therefore, the Synbone® company has developed a series of synthetic bones that have been used by biomechanical investigators to offset some drawbacks of biological bone. There have been a number of published biomechanical reports using these bone surrogates for dental, injury, orthopedic, and other applications. But, there is no prior review paper that has summarized the mechanical properties of these synthetic bones in order to understand their general performance or how well they represent biological bone. Thus, the goal of this article was to survey the English-language literature on the mechanical properties of these synthetic bones. Studies were included if they quantitatively (a) characterized previously unknown values for synthetic bone, (b) validated synthetic versus biological bone, and/or (c) optimized synthetic bone performance by varying geometric or material parameters. This review of data, pros, cons, and future work will hopefully assist biomechanical engineers and physicists that use these synthetic bones as they develop experimental testing regimes and computational models.

Biomechanics of plate fixation following traditional olecranon osteotomy versus novel proximal ulna osteotomy for visualizing a distal humerus injury.

After a distal humeral injury, olecranon osteotomy (OO) is a traditional way to visualize the distal humerus for performing fracture fixation. In contrast, the current authors previously showed that novel proximal ulna osteotomy (PUO) allows better access to the distal humerus without ligamentous compromise. Therefore, this study biomechanically compared plating repair following OO versus PUO. The left or right ulna from eight matched pairs of human cadaveric elbows were randomly assigned to receive OO or PUO and repaired using pre-contoured titanium plates. Destructive and non-destructive mechanical tests were performed to assess stability. Mechanical tests on OO versus PUO groups yielded average results for ulna cantilever bending stiffness at a 90° elbow angle (29.6 vs 30.5 N/mm, p = 0.742), triceps tendon pull stiffness at a 90° elbow angle (28.2 vs 24.4 N/mm, p = 0.051), triceps tendon pull stiffness at a 110° elbow angle (61.9 vs 59.5 N/mm, p = 0.640), and triceps tendon pull failure load at a 110° elbow angle (1070.1 vs 1359.7 N, p = 0.078). OO and PUO elbows had similar failure mechanisms, namely, tendon tear or avulsion from the ulna with or without some fracture of the proximal bone fragment, or complete avulsion of the proximal bone fragment from the plate. The similar biomechanical stability (i.e., no statistical difference for 4 of 4 mechanical measurements) and failure mechanisms of OO and PUO plated elbows support the clinical use of PUO as a possible alternative to OO for visualizing the distal humerus.

Reamed compared with unreamed nailing of tibial shaft fractures: Does the initial method of nail insertion influence outcome in patients requiring reoperations?

BACKGROUND: Patients with a tibial shaft fracture experiencing their first postoperative complication following treatment with intramedullary nails may be at greater risk of subsequent complications than the whole population. We aimed to determine whether the initial method of nail insertion influences outcome in patients with a tibial shaft fracture requiring multiple reoperations. METHODS: Using the Study to Prospectively Evaluate Reamed Intramedullary Nails in Tibial Shaft Fractures trial data, we categorized patients as those not requiring reoperation, those requiring a single reoperation and those requiring multiple reoperations, and we compared them by nail insertion technique (reamed v. unreamed) and fracture type (open v. closed). We then determined the number of patients whose first reoperation was in response to infection, and we compared other clinical outcomes between the reamed and unreamed groups. RESULTS: Among 1226 patients included in this analysis, 175 (14.27%) experienced a single reoperation and 44 patients (3.59%) underwent multiple reoperations. Nail insertion techniques (reamed v. unreamed) did not play a role in the need to perform multiple reoperations. Seventy-five percent of patients requiring multiple reoperations had open tibial shaft fractures. An equal number of these were reamed and unreamed insertions. The majority of patients had their course complicated by infection and almost 50% of patients whose first reoperation was for infection required more than 2 reoperations for management. The rest required multiple procedures for nonunion or bone loss. CONCLUSION: Our findings corroborate those of other studies, in which open fracture type rather than nail insertion technique was found to be the cause of morbidity following intramedullary nailing of tibial fractures. CLINICAL TRIAL REGISTRATION: www. CLINICALTRIALS: gov, no. NCT00038129.