Tibial Malalignment Is an Independent Predictor of Nonunion After Intramedullary Nailing of Tibial Shaft Fractures

OBJECTIVES:This study aimed to assess the relationship between postoperative alignment and nonunion in patients with tibial shaft fractures treated with intramedullary nailing. Design:Retrospective case-control study. Setting:Single academic trauma center. Patients Selection Criteria:Adult patients with closed or open tibial shaft fractures (42A-C) treated with intramedullary nailing from 2007 to 2018. Outcomes Measures and Comparisons:Case patients with nonunion were compared with control patients with radiographic evidence of healing in terms of the postoperative tibial alignment measured in the coronal and sagittal planes. RESULTS:Of the 192 included patients (median age, 38 years; 76% male), 51 patients had a nonunion, and 141 patients had united fractures and served as the control group. A strong association between postoperative tibial malalignment in 1 plane and nonunion (odds ratio, 3.0; 95% confidence interval, 1.1-8.3; P = 0.03) was demonstrated. This association was even greater for malalignment in both coronal and sagittal planes (odds ratio, 5.7; 95% confidence interval, 2.1-16.1; P < 0.001) after controlling for confounders. CONCLUSIONS:After controlling for confounding factors, postoperative malalignment in the coronal or sagittal plane was associated with significantly increased odds of tibial shaft nonunion after intramedullary nailing. LEVEL OF EVIDENCE:Prognostic, Level III. See Instructions for Authors for a complete description of levels of evidence.