***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Ninety-one patients who had ninety-four open fractures of the tibial shaft were r and omized into two treatment groups . Fifty fractures ( nine type-I , eighteen type-II , sixteen type-IIIA , and seven type-IIIB fractures , according to the classification of Gustilo et al. ) were treated with nailing after reaming , and forty-four fractures ( five type-I , sixteen type-II , nineteen type-IIIA , and four type-IIIB fractures ) were treated with nailing without reaming . The average diameter of the nail was 11.5 millimeters ( range , nine to fourteen millimeters ) in the group treated with reaming and 9.2 millimeters ( range , eight to ten millimeters ) in the group treated without reaming . Follow-up information was adequate for forty-five patients ( forty-seven fractures ) who had been managed with reaming and forty patients ( forty-one fractures ) who had been managed without reaming .  No clinical ly important differences were found between the two groups with regard to the technical aspects of the procedure or the rate of early postoperative complications . The average time to union was thirty weeks ( range , thirteen to seventy-two weeks ) in the group treated with reaming and twenty-nine weeks ( range , thirteen to fifty weeks ) in the group treated without reaming . Four ( 9 per cent ) of the fractures treated with reaming and five ( 12 per cent ) of the fractures treated without reaming did not unite ( p = 0.73 ) . There were two infections in the group treated with reaming and one in the group treated without reaming . Significantly more screws broke in the group treated without reaming ( twelve ; 29 per cent ) than in the group treated with reaming ( four ; 9 per cent ) ( p = 0.014 ) . There was no difference between the two groups with regard to the frequency of broken nails ( two nails that had been inserted after reaming broke , compared with one that had been inserted without reaming ) . The functional outcome , in terms of pain in the knee , range of motion , return to work , and recreational activity , did not differ significantly between the groups . We concluded that the clinical and radiographic results of nailing after reaming are similar to those of nailing without reaming for fixation of open fractures of the tibial shaft , although more screws broke when reaming had not been done The objective was to determine whether the number of interlocking screws have an impact on hardware failure . In a clinical prospect i ve r and omized study of skeletally mature patients with diaphyseal tibial fractures , 44 were r and omized pre-operatively into the two treatment arms over a two-year period . Two patients , one from each group , were excluded later . Of eligible patients , 22 had one distal locking screw and 20 had two distal locking screws .  One distal screw failed ( 59.1 per cent ) significantly more often than two distal screws ( 5 per cent ) . Screw failure occurred more often in heavier patients and usually between six and 12 weeks . Proximal screw failure was seen in 17 per cent of patients . There was no significant difference between groups with respect to fracture union Objective To determine if any differences exist in healing and complications between reamed and unreamed nailing in patients with tibial shaft fractures . Design Prospect i ve , r and omized . Setting Level 1 trauma center . Patients Forty-five patients with displaced closed and open Gustilo type I – IIIA fractures of the central two thirds of the tibia . Intervention Stabilization of tibial fractures either with a slotted , stainless steel reamed nail or a solid , titanium unreamed nail . Main Outcome Measurements Nonunions , time to fracture healing , and rate of malunions . Results The average time to fracture healing was 16.7 weeks in the reamed group and 25.7 weeks in the unreamed group . The difference was statistically significant ( P = 0.004 ) . There were three nonunions , all in the unreamed nail group . Two of these fractures healed after dynamization by removing static interlocking screws . The third nonunion did not heal despite exchange reamed nailing 2 years after the primary surgery and dynamization with a fibular osteotomy after an additional 1 year . There were two malunions in the reamed group and four malunions in the unreamed group . There were no differences for all other outcome measurements . Conclusion Unreamed nailing in patients with tibial shaft fractures may be associated with higher rates of secondary operations and malunions compared with reamed nailing . The time to fracture healing was significantly longer with unreamed nails OBJECTIVE To compare ender nails and unreamed interlocking nails in a r and omized clinical trial study . METHODS From March 2001 to March 2003 , 131 patients with tibial fractures of the central two thirds of the tibia were admitted to the emergency ward of Shohada Hospital , Tabriz , Iran and were r and omized to either an ender tibial nail or an undreamed interlocking tibial nail as their primary treatment . Age , gender , types of fracture , and surgical outcomes were recorded at the time of surgery , during hospital stay , and during the course of 9 months follow-up . RESULTS Sixty-seven patients underwent surgery with interlocking nails and 64 with ender nails .  No statistically significant difference was found between the 2 groups concerning mal-union , delayed union , and device failure . Duration s of hospital stay , and time needed to achieve union was significantly higher in the unreamed interlocking group . Non-union and infection rate were higher in the ender group ( p<0.05 ) . CONCLUSION The results of our study support those of other studies that indicate the choice between the 2 methods of unreamed nailing is mainly controversial , depending on the priorities of the patient and surgeon BACKGROUND There remains a compelling biological rationale for both reamed and unreamed intramedullary nailing for the treatment of tibial shaft fractures . Previous small trials have left the evidence for either approach inconclusive . We compared reamed and unreamed intramedullary nailing with regard to the rates of reoperations and complications in patients with tibial shaft fractures . METHODS We conducted a multicenter , blinded r and omized trial of 1319 adults in whom a tibial shaft fracture was treated with either reamed or unreamed intramedullary nailing .  Perioperative care was st and ardized , and reoperations for nonunion before six months were disallowed . The primary composite outcome measured at twelve months postoperatively included bone-grafting , implant exchange , and dynamization in patients with a fracture gap of < 1 cm . Infection and fasciotomy were considered as part of the composite outcome , irrespective of the postoperative gap . RESULTS One thous and two hundred and twenty-six participants ( 93 % ) completed one year of follow-up . Of these , 622 patients were r and omized to reamed nailing and 604 patients were r and omized to unreamed nailing .  Among all patients , fifty-seven ( 4.6 % ) required implant exchange or bone-grafting because of nonunion . Among all patients , 105 in the reamed nailing group and 114 in the unreamed nailing group experienced a primary outcome event ( relative risk , 0.90 ; 95 % confidence interval , 0.71 to 1.15 ) . In patients with closed fractures , forty-five ( 11 % ) of 416 in the reamed nailing group and sixty-eight ( 17 % ) of 410 in the unreamed nailing group experienced a primary event ( relative risk , 0.67 ; 95 % confidence interval , 0.47 to 0.96 ; p = 0.03 ) . This difference was largely due to differences in dynamization . In patients with open fractures , sixty of 206 in the reamed nailing group and forty-six of 194 in the unreamed nailing group experienced a primary event ( relative risk , 1.27 ; 95 % confidence interval , 0.91 to 1.78 ; p = 0.16 ) . CONCLUSIONS The present study demonstrates a possible benefit for reamed intramedullary nailing in patients with closed fractures . We found no difference between approaches in patients with open fractures . Delaying reoperation for nonunion for at least six months may substantially decrease the need for reoperation OBJECTIVES To develop a question naire that focuses only on physical tasks related to lower-limb function and , within that question naire , to explore the psychometric properties of a series of questions that are related specifically to activities of daily living ( ADLs ) and a series of activities more often associated with recreation . DESIGN Inception cohort . SETTING Private practice . PARTICIPANTS Data were primarily from patients who had experienced a lower-limb injury that would typically involve rehabilitation up to 6 weeks . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Through 5 studies , the following psychometric qualities were evaluated : content and factor validity , construct and concurrent validity , test-retest reliability ( intraclass correlation coefficient [ ICC ] , typical error ) , responsiveness ( effect size , st and ardized response mean , Guyatt 's responsiveness statistic ) , and the minimum important difference ( distribution , anchor-based approaches ) . RESULTS Factor analysis supported the theoretical perspective that ADLs and recreational activities can be treated as different domains within the construct of function . Internal consistency was high ( Cronbach alpha : ADLs , .91 ; recreational activities , .95 ) and the 2 domains explained a moderate level of the response variance ( 61 % ) . In the ADL domain , 7 tasks had greater than 80 % of participants regarding them as having some importance . For recreational activities , 6 tasks had 79 % or more of participants regarding them as having some importance . Both domains were moderately correlated to actual performance of tasks ( r = .62 , r = .72 ) , and to other question naires used for lower-limb injuries ( r range , .51-.86 ) . The floor and ceiling effects of the domains followed an expected pattern that could be related to the loading forces experienced on the injured limb during activities . The reliability of the 2 domains was high ( ICCs > .95 ) , and the Bl and -Altman plots showed that the distribution of error across the range of scores was r and om with low bias scores ( < 1.0 point ) . Typical error scores were 2 points for each domain . All measures of responsiveness were high ( 1.2 - 6.7 ) . Measures of the minimal important difference varied ( 3 - 10 points ) according to the method ologic approach used . CONCLUSIONS The question naire possesses good factor structure and composition , relates well with other measures of function , differentiates patients with regard to certain characteristics or processes known to occur after injury , shows high levels of reliability and responsiveness , and shows evidence of good minimal important difference scores . The findings support the use of the question naire in both clinical scenarios and in research BACKGROUND Anterior knee pain is the most common complication after intramedullary nailing of the tibia . Dissection of the patellar tendon and its sheath during transtendinous nailing is thought to be a contributing cause of chronic anterior knee pain . The purpose of this long-term follow-up of a prospect i ve , r and omized study was to assess whether the prevalence and intensity of anterior knee pain after intramedullary nailing of a tibial shaft fracture is different in transtendinous versus paratendinous incision technique . METHODS Fifty patients with a tibial shaft fracture requiring intramedullary nailing were r and omized equally ( 25 plus 25 ) to treatment with paratendinous or transtendinous nailing .  Forty-two patients ( 21 plus 21 ) were reexamined an average of 3 years after nailing , whereas 28 patients ( 14 plus 14 ) could be now reexamined an average of 8 years after the nailing . As in the first reexamination , the patients at the 8-year follow-up used visual analog scales to report the level of anterior knee pain and the impairment caused by the pain . The scales described by Lysholm and Gillquist and by Tegner et al. , the Iowa knee scoring system , and simple functional tests were used to quantitate the functional results . Isokinetic thigh-muscle strength was also measured . RESULTS Four ( 29 % ) of the 14 patients treated with transtendinous nailing reported anterior knee pain at the 8-year follow-up evaluation . The number was the same for patients treated with paratendinous nailing . The Lysholm , Tegner , and Iowa knee scoring systems , the muscle-strength measurements , and the functional tests showed no significant differences between the two groups . CONCLUSION Compared with a transpatellar tendon approach , a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture . In long term , anterior knee pain seems to disappear from many patients INTRODUCTION Recently , results from the large , r and omized study to prospect ively evaluate reamed intramedullary nails in patients with tibial fractures ( SPRINT ) trial suggested a benefit for reamed intramedullary nail insertion in patients with closed tibial shaft fractures largely based on cost-neutral autodynamizations and a potential advantage for unreamed intramedullary nailing in open fractures . We performed an economic evaluation to compare re source use and effectiveness of reamed and unreamed intramedullary nailing using a cost-utility analysis . METHODS We calculated quality -adjusted life years ( QALYs ) for each patient from a self-administered health utility index 3 question naire for the first 12 months following the intramedullary nailing . A convenience sample of 235 SPRINT patients provided data on costs associated with health 
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There were very few data on functional outcomes ; and often incomplete data on re-operations .
While inconclusive , the evidence from a subgroup analysis suggests that reamed nailing is more likely to reduce the incidence of major re-operations related to non-union in closed fractures than in open fractures .
Implant failure , such as broken screws , occurred less often in the reamed nailing group ( 35/789 versus 79/756 ; RR 0.42 , 95 % CI 0.28 to 0.61).There was insufficient evidence established to determine the effects of interlocking nail with one distal screw versus with two distal screws , interlocking nail versus exp and able nail and paratendinous approach versus transtendinous approach for treating tibial shaft fractures in adults .
Overall , there is insufficient evidence to draw definitive conclusions on the best type of , or technique for ,  intramedullary nailing  for tibial shaft fractures in adults .
' Moderate ' quality evidence suggests that there is no clear difference in the rate of major re-operations and complications between reamed and unreamed intramedullary nailing .
Reamed intramedullary nailing has , however , a lower incidence of implant failure than unreamed nailing .
' Low ' quality evidence suggests that reamed nailing may reduce the incidence of major re-operations related to non-union in closed fractures rather than in open fractures . '
Low ' quality evidence suggests that the Ender nail has poorer results in terms of re-operation and malunion than an interlocking nail