'British Editorial Society of Bone & Joint Surgery'
Abstract
Aims: To explore staff’s experience of a multi-centre pilot randomised controlled trial (RCT)
comparing intramedullary nails and circular frame external fixation for segmental tibial fractures.
Patients and Methods: A purposeful sample of 19 staff (nine surgeons) involved in the study
participated in an interview. Interviews explored participants’ experience and views of the study and
the treatments. The interviews drew on phenomenology, were face-to-face or by telephone and
were analysed using thematic analysis.
Results: The findings identify that for the treatment of segmental tibial fractures equipoise was a
theoretical ideal that was most likely unattainable in clinical practice. This was conveyed through
three themes i) the ambiguity of equipoise, where multiple definitions of equipoise and a belief in
community equipoise were evident, ii) an illusion of equipoise, created by strong treatment
preferences and variation in collective surgical skills and iii) treating the whole patient, where the
complexity and severity of the injury required a patient-centred approach and doing the best for the
individual patient took priority over trial recruitment.
Conclusion: Equipoise can be unattainable for rare injuries such as segmental tibial fractures, where
there are substantially different surgical treatments requiring specific expertise, high levels of
complexity and a concern for poor outcomes. Surgeons are familiar with community equipoise.
However, a shared understanding of factors that limit the feasibility of RCTs may identify instances
where community equipoise is unlikely to translate into practice
