Appendix 3. Definitions of Tibial Shaft Nonunion

Appendix 3. Definitions of tibial shaft nonunion

Indication Intervention

Shayesteh Azar et al. [10] Not defined Bach & Hansen [1] Not defined Bhandari et al. [2] Failure of bridging of 3 of 4 cortices on orthogonal radiographs with clinical pain on weightbearing or palpation of the fracture site, evaluated 6 months after the index surgery. Nonunion was not adjudicated in this trial Nonunion not defined. Union was reported as bridging callus on 2 radiographic views without painful Finklemeier et al. [4] weightbearing Less than 3 bridged cortices on 9-month followup Esmaeilnejad Ganji et al. [3] radiographs and no pain clinically

Henley et al. [5] Established nonunion defined as ununited fracture 270 days after injury, and remaining ununited through final documented followup Holbrook et al. [6] Bone healing greater than 9 months postoperatively Keating et al. [7] Unplanned implant removal, implant exchange, and bone grafting. Definition explicitly excluded dynamization Larsen et al. [8] Dynamization, exchange nailing, or bone grafting performed more than 6 months after initial surgery Soleimanpour et al. [11] No signs of boney healing at 9 months Mohseni et al. [9] Less than 3 of 4 bridged cortices observed on 6-month radiographs Tornetta et al. [12] Bridging callus seen 2 on radiographs and no pain on weightbearing Tu et al. [13] Not defined

Vallier et al. [14] No evidence of healing at 6 months and secondary intervention required

References 1. Bach AW, Hansen ST Jr. Plates versus external fixation in severe open tibial shaft fractures: a randomized trial. Clin Orthop Relat Res. 1989;241:89-94. 2 Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch EH. Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg Br. 2001;83:62-68.

3. Esmaeilnejad Ganji SM, Bahrami M, Joukar F. Ilizarov versus AO external fixator for the treatment of tibia open fractures. Iran Red Crescent Med J. 2011;13:868-872.

4. Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF. A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma. 2000;14:187-193.

5. Henley MB, Chapman JR, Agel J, Harvey EJ, Whorton AM, Swiontkowski MF. Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: a prospective comparison of unreamed interlocking intramedullary nails and half-pin external fixators. J Orthop Trauma. 1998;12:1-7.

6. Holbrook JL, Swiontkowski MF, Sanders R. Treatment of open fractures of the tibial shaft: Ender nailing versus external fixation. A randomized, prospective comparison. J Bone Joint Surg Am. 1989;71:1231-1238.

7. Keating JF, O'Brien PJ, Blachut PA, Meek RN, Broekhuyse HM. Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft: a prospective, randomized study. J Bone Joint Surg Am. 1997;79:334-341.

8. Larsen LB, Madsen JE, Hoiness PR, Ovre S. Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years' follow-up. J Orthop Trauma. 2004;18:144-149.

9. Mohseni MA, Soleimanpour J, Mohammadpour H, Shahsavari A. AO tubular external fixation vs. unreamed intramedullary nailing in open grade IIIA-IIIB tibial shaft fractures: a single-center randomized clinical trial. Pak J Biol Sci. 2011;14:490-495.

10. Shayesteh Azar M, Karimi Nasab MH, Sajadi Saravi M, Shafiee SE, Daneshpoor SM, Hadian A, Khademloo M. Comparison of intramedullary nailing and external fixation in the treatment of open tibial fractures. J Mazand Univ Med Sci. 2011;21:139-146.

11. Soleimanpour J, Feizi HH, Mohseni MA, Moradi A, Arzromchilar A. Comparison between ender and unreamed interlocking nails in tibial shaft fractures. Saudi Med J. 2008;29:1458-1462. 12. Tornetta P 3rd, Bergman M, Watnik N, Berkowitz G, Steuer J. Treatment of grade-IIIb open tibial fractures: a prospective randomised comparison of external fixation and non-reamed locked nailing. J Bone Joint Surg Br. 1994;76:13-19.

13. Tu YK, Lin CH, Su JI, Hsu DT, Chen RJ. Unreamed interlocking nail versus external fixator for open type III tibia fractures. J Trauma. 1995;39:361-367.

14. Vallier HA, Cureton BA, Patterson BM. Randomized, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fractures. J Orthop Trauma. 2011;25:736- 741.