Path analysis of factors for delayed healing and nonunion in 416 operatively treated tibial shaft fractures

A prospective observational study was done in 41 trauma centers. Four hundred sixteen patients with tibial shaft fractures were treated operatively and followed up for at least 6 months. Fifty-two (13%) cases of delayed healing or nonunion were reported. In such nonrandomized observational studies, multiple interrelationships exist between prognostic factors and patient outcomes. We used path analyses to investigate prognostic factors associated with the occurrence of delayed healing or nonunion. The most important factors were identified using multivariate regression analyses, and interrelationships between factors were illustrated using a path diagram. Fractures with open injuries less than and greater than 5 cm were 3.6 and 5.7 times as likely, respectively, to have delayed healing or nonunion as fractures with no skin injuries. The Muller-AO classification of fractures did not provide additional prognostic information. The risk of healing problems was doubled for fractures of the distal shaft and for fractures showing a postoperative diastasis. Treatment options showed an indirect effect on outcome with the occurrence of diastasis. A model for predicting delayed healing or nonunion is proposed. We encourage the use of path analysis in orthopaedics as a powerful visual technique to interpret data from observational studies.