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- The Problem:
     - External fixation is perceived as an inferior treatment method for management of tibia fractures even though there is scant evidence to support this in prospective studies.
     - in the JTO 2000 special report by Seligson, et al, the authors conducted an international survey of treatment methods for tibia fractures.
            - methods: a one page survey was administered at the 1997 OTA meeting.
            - the survey described a healthy patient with a non displaced midshaft closed tibia fracture.
                   - the surgeon was asked to indicate the treatent of choice.
            - 178 orthopaedic surgeons fully answered the survey
            - "a significantly greater number of respondents picked IM nailing as the treatment of choice."
                   - this was true for North American surgeons as well as for international surgeons.
                   - "none of the in-training respondents chose external fixation"
                   - 1% of the respondents in practice both in the US and abroad chose plating or external fixation.
             - Treatment of closed tibia shaft fractures: a survey from the 1997 Orthopaedic Trauma Association and Osteosynthesis International--Gerhard Küntscher Kreis meeting.
 
- Question:
     - Can outcomes research change this perception?
            - prospective, multi-institutional, multinational data, on going trials
     - in the study by Skoog, et al (2001), the authors report on a prospective tibial shaft fracture registry;
            - followed 64 patients with one year prospective followup;
            - knee pain was reported in about 40% of patients treated with an IM nail;
            - none of the patient was treated with an external fixator;
            - authors noted difficulty in retrieving data;
                  - 4 month follow up was done by mail with stamped envelope
                  - despite telephone reminders, only half returned the forms;
                  - "We think that a continuous fracture registry, with patients followed up prospectively regarding outcome, appears to be to great an effort for the benefit it may have in clinical practice."
             - One-year outcome after tibial shaft fractures: results of a prospective fracture registry.

    - What methods are there to deliver this data and Can the data be made interactive?
          - Wheeless' Textbook of Orthopaedics
                   - almost one million visitors, recognized through out the world
                   - updated on a weekly basis, using over one dozen journals as the primary resource
                   - excellent for cross referencing text such as comparing IM nails to external fixators
          - On line Outcomes study
                   - uses CGI Script to create on-line research form (no different from a pen and paper form);
                   - allows surgeons all over the world to use the same research form to collaborate on a prospective study.
                   - a surgeon submits clinical data on a secure password protected research form;
                   - the data is then transmitted to a secure site, where it can be analyzed and exported to a database (Excel);
                   - once in the database and analyzed, the data is transfered to the outcomes research web site, where it is updated on an continual basis. (see Form No 1)

    - Summary:
            - there is a significant perception that external fixation is an inferior form of treatment for tibial fractures;
                  - this perception is expected to continue since residents in training perceive that IM nailing is the gold standard;
            - in general, good qualitity data presented to physicians in a logical manner will change decision making;
            - there is difficulty in setting up and maintaining a fracture registry even on a single campus;
                  - the idea of tracking thousands of tibial fractures from several countries with data collected in a real time format would seem impossible