Box 1.

Clinical Scenario

You are asked to see an active 36-year-old male patient who recently presented to the emergency department with a Gustilo Grade IIIA open mid-shaft tibial fracture. In your practice, you commonly perform unreamed intramedullary nailing for this fracture type. You present the case at morning rounds and several of your colleagues believe that given the amount of tissue destruction, an external fixator is the preferred option. Another colleague cites several studies that report high malunion rates with external fixation and he believes reamed intramedullary nailing leads to better bony stability and biologically enhanced union rates. You perform an uneventful, unreamed intramedullary nailing in the patient, who reports good function at 2-week followup. However, 9 months postoperatively, the patient continues to report residual pain, and radiographs show evidence of nonunion. You consider adjunctive revision procedures and wonder if either reaming or using an external fixator would have been better initial management options. You perform a literature search and come across a recently published network meta-analysis that evaluates outcomes for surgical treatment of open tibial shaft fractures [6]. What approaches can you use to evaluate the credibility of this work?