Özkul, Emin; Gem, Mehmet; Arslan, Hüseyin; Alemdar, Celil; Azboy, İbrahim; Arslan, Seher G
The aim of this study is to investigate the effectiveness and reliability of limited-contact locking plates in minimally invasive percutaneous osteosynthesis (MIPO) of the lateral tibia. A retrospective study. The retrospective study included 14 patients who were operatively treated with an MIPO technique due to open tibial fractures between 2006 and 2012. The patients were 11 males and 3 females with a mean age of 13.2 (range, 9 to 16) years. The patients were followed up for a mean period of 2.4 (range, 1 to 5) years. The mechanism of the injuries included a motor vehicle accident (n=11), a shotgun injury (n=2), and a fall from height (n=1). According to the Gustilo-Anderson classification, 10 patients had type I (72%), 2 had type II (14%), and 2 had type III (14%) open fractures. The mean time to radiologic union was 18 (range, 11 to 32) weeks. No infection was detected that would require implant removal. No complications such as early epiphyseal closure, angulation, or limb-length inequality were observed. Limited-contact locking plates in MIPO of the lateral tibia is an effective alternative method in the treatment of open pediatric tibial fractures. Level IV-therapeutic.
Hoekstra, Harm; Smeets, Bart; Metsemakers, Willem-Jan; Spitz, Anne-Cécile; Nijs, Stefaan
In order to define strategies to curb the continuing increase in healthcare costs, we describe the cost breakdown of open tibial fractures. Twenty-seven clinical and process variables were recorded retrospectively, and five main hospital related cost categories were defined. Three multivariate linear models were fitted to the data. Total healthcare costs of open tibial fractures were almost twice as high compared to closed fractures and mainly existed of hospitalization costs. Length-of-stay (LOS) was found to be the most important variable driving the healthcare costs of open tibial fractures. Deep infection lead to a 6-fold increase of LOS and 5-fold increase in total healthcare costs of open tibial fractures. Therefore, appropriate international consensus guidelines are required to improve not only the patient outcome (infection prevention) but also reduce overall healthcare cost by focusing on reducing the LOS.
Templeman, D C; Gulli, B; Tsukayama, D T; Gustilo, R B
A retrospective study of 133 open tibial fractures in 129 patients treated at the Hennepin County Medical Center between 1986 and 1993 was done. The results of the treatment protocol in this patient group is presented and the current classification schemes, prevention of infection, debridement, antibiotics, soft tissue reconstruction, fracture stabilization methods, bone grafting, and exchange nailing are discussed. Recent studies that have documented interobserver disagreement in the classification of open fractures underscore the difficulties encountered in the initial assessment and treatment of open tibial shaft fractures. Despite repetitive and aggressive debridement, a certain number of fractures will remain contaminated and become infected. Infection after these severe injuries is probably multifactorial, and its prevention requires that the surgeon diligently adhere to the imperatives of open fracture care.
Chen, H-W; Pan, J; Yi, X-H; Huang, Y-X
The aim of this study was to evaluate the clinical outcomes of patients with posteromedial tibial plateau fractures treated by open reduction and internal fixation (ORIF) through a posteromedial approach. Thirty-six patients with posteromedial tibial plateau fracture underwent ORIF through a posteromedial approach and were retrospectively analyzed. Pre-operative X-ray pictures and CT images were -obtained. And there were 11 cases of posteromedial tibial plateau fracture and 25 cases of posteromedial and posterolateral tibial plateau fracture. All the -patients were treated surgically with posteromedial approach. The clinical outcomes were assessed -according to the Rasmussen knee function grading system. The patients were followed-up for an average of 17.5 months (range, 12-32 months). All the fractures attained satisfactory reduction. No major complications were observed. According to the Rasmussen knee function grading system, the results were graded as excellent in 21 cases, good in 13 cases, fair in 2 cases. The rate of excellent and good results was 94.4%. The posteromedial approach in our opinion is the best option to treat the posteromedial tibial plateau fractures because it can provide direct visualization of the fracture site and avoid dissection of neurovascular bundle in the popliteal fossa area with minimal soft tissue injury.
Simon, A-L; Apostolou, N; Vidal, C; Ferrero, E; Mazda, K; Ilharreborde, B
Elastic stable intramedullary nailing is increasingly used for surgical treatment of tibial shaft fractures, but frequently requires immobilization and delayed full weight-bearing. Therefore, external fixation remains interesting. The aim was to report clinico-radiological outcomes of monolateral external fixation for displaced and unstable tibial shaft fractures in children. All tibial fractures consecutively treated by monolateral external fixation between 2008 and 2013 were followed. Inclusion criteria included skeletal immaturity and closed and open Gustilo I fractures caused by a direct impact. Patients were seen until two years postoperatively. Demographics, mechanism of injury, surgical data and complications were recorded. Anteroposterior and lateral side radiographs were performed at each visit. Full-limb 3D reconstructions using biplanar stereroradiography was performed for final limb length and alignment measures. A total of 45 patients (mean age 9.7 years ± 0.5) were included. In all, 17 were Gustilo I fractures, with no difference between open and closed fractures for any data. Mean time to full weight bearing was 18.2 days ± 0.7. After 15 days, 39 patients returned to school. Hardware removal (mean time to union 15.6 weeks ± 0.8) was performed during consultation under analgesic gas. There were no cases of nonunion. No fracture healed with > 10° of angulation (mean 5.1° ± 0.4°). Leg-length discrepancy > 10 mm was found for six patients. This procedure can be a safe and simple surgical treatment for children with tibial shaft fractures. Few complications and early return to school were reported, with the limitations of non-comparative study. IV.
Li, Q; Zeng, B F; Luo, C F; Song, S; Zhang, C Q; Kong, W Q
The aim of this study was to compare the effects and indications of minimally invasive plate osteosynthesis (MIPO) and limited open reduction (LOR) for managing distal tibial shaft fractures. A total of 79 cases of distal tibial shaft fractures were treated surgically in our trauma center. The 79 fracture cases were classified into type A, B, and C (C1) according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, with 28, 32, and 19 cases, respectively. Among the 79 fracture cases, 52 were closed fractures and 27 were open fractures (GUSTILO, I-II). After adequate preparation, 48 cases were treated with LOR and 31 cases were treated with MIPO. All cases were followed up for 12 to 18 months, with an average of 16.4 months. During the follow-up period, 76 fracture cases were healed in the first stage, whereas the 3 cases that developed non-union were treated by changing the fixation device and autografting. For types A, B, and some of C simple fractures (C1), LOR accelerated the fracture healing and lowered the non-union rate. One case suffered from regional soft tissue infection, which was controlled by wound dressing and intravenous antibiotics. Another case that developed local skin necrosis underwent local flap transplant. LOR promoted bone healing and lowered the non-union rate of several simple-distal tibial shaft fractures. Thereafter, the incidence of soft tissue complication was not significantly increased. However, for complex and comminuted fractures, MIPO was the preferred method for correcting bone alignment and protecting soft tissue, leading to functional recovery.
Fakoor, Mohammad; Sarrafan, Naser; Naghizadeh-Tabrizi, Naser; Fakoor, Morteza
The fracture of the tibial shaft is the most common fracture of long bone in human. Considerable proportion of this fractures are open fractures. Treatment of open fractures is one of the orthopedic problems. In the developing country with economic problem, early mobilization and returning to work may be important for people. We compared result of treatment with addition of autogenus bone graft in two different time periods in two groups. In this study, 144 patients with open tibial fracture were randomly divided in two groups and were treated with autogenus bone graft at two different time intervals, the first group in the end of third week and second group in the end of sixth week. All Patients were followed up periodically in first two month every month and then every two weeks. T-test was used for comparison. SPSS ver. 13.0 (SPSS Inc, Chicago, IL, USA) was used for analysis. The mean fracture healing time in the first group (with bone graft in 3rd week) was 14.24±4.4 week and in the second group (with bone graft in 6th week) was 16.4±5.4 week and the difference was statistically meaningful. Differences in the rate of delayed union and none union in two groups were statistically insignificant. In addition to time of bone graft, the age, gender, injury mechanism, fixation method, cigarette smoking and drug abuse were studied in two groups. The difference as regards these factors in two groups was statically insignificant. Achievement of autogenus bone graft in open tibial fracture at the end of third week causes reduction of union time from 16.4 week to 14.4 week without increment of deep infection.
Ma, Ching-Hou; Wu, Chin-Hsien; Jiang, Jiun-Ru; Tu, Yuan-Kun; Lin, Ting-Sheng
This study aimed to evaluate the outcome of using a metaphyseal locking plate as a definitive external fixator for treating open tibial fractures based on biomechanical experiments and analysis of clinical results. A metaphyseal locking plate was used as an external fixator in 54 open tibial fractures in 52 patients. The mean follow-up was 38 months (range, 20-52 months). Moreover, static axial compression and torsional tests were performed to evaluate the strength of the fixation techniques. The average fracture healing time was 34.5 weeks (range, 12-78 weeks). At 4 weeks postoperatively and at the final follow-up, the average Hospital for Special Surgery knee score was 85 (range, 81-100) and 94 (range, 88-100), respectively, and the American Orthopaedic Foot and Ankle Society score was 88 (range, 80-100) and 96 (range, 90-100), respectively. Based on the static test result, the axial stiffness was significantly different among groups (p=0.002), whereas the torsional stiffness showed no significant difference (p=0.068). Clinical outcomes show that the use of locking plate as a definitive external fixator is an alternative choice for tibial fractures after obtaining appropriate fracture reduction. However, external locked plating constructs were not as strong as standard locked plating constructs. Therefore, the use of external locked plating constructs as a definitive treatment warrants further biomechanical study for construct strength improvement. Copyright © 2016 Elsevier Ltd. All rights reserved.
Chen, Xiaosong; Cheng, Xunsheng; Ma, Wuxiu; Chen, Congcong
To explore the effect and mechanism of hyperbaric oxygen (HBO₂) therapy of open tibial fractures in rabbits after transient seawater immersion. Forty-eight (48) New Zealand rabbits were randomly and averagely divided into an HBO₂ therapy group (Group A) and a control group (Group B). All rabbits were subjected to unilateral open tibial fractures, while immersed in artificial seawater (20-22 °C) for three hours prior to debridement and external fixation. Group A was treated with HBO₂ at 2 atmospheres absolute (ATA) for 50 minutes once daily for two weeks; Group B received postoperative routine treatments only. The fracture zone in each group was compared by radiological, histological and immunohistochemical examinations. In Group A, bony callus and mature osteocytes without infiltration of inflammatory cells were observed in the fracture zone. Vascular endothelial growth factor (VEGF) was expressed mainly in the cytoplasm of osteoblasts, chondrocytes and osteocytes, and exhibited significant changes at different time points. The gray value of bony callus in Group A was 190.58 ± 7.52; that of Group B was 144 ± 8.11. Difference between the groups was statistically significant (P ⟨ 0.01). The content of malondialdehyde (MDA) in Group A was significantly lower than Group B (P ⟨ 0.01), and the activity of superoxide dismutase (SOD) in Group A was higher than Group B (P ⟨ 0.01) at four weeks. There were no significant differences in MDA content and SOD activity between groups at eight and 12 weeks. HBO₂ treatment of open tibial fractures in seawater can reduce the inflammatory reaction and reperfusion injury, and promote osteocytic proliferation and fracture healing.
Olesen, Ulrik Kähler; Pedersen, Nicolas Jones; Eckardt, Henrik; Lykke-Meyer, Line; Bonde, Christian Thorsten; Singh, Upender Martin; McNally, Martin
Open tibial fractures needing soft tissue cover are challenging injuries. Infection risk is high, making treatment difficult and expensive. Delayed skin closure has been shown to increase the infection rate in several studies. We aimed at calculating the direct and indirect cost of treatment, and to determine the effect of delayed skin closure on this cost. We reviewed all records of patients treated with a free flap in our institution for an open tibial fracture from 2002 to 2013. We calculated direct costs based on length of stay (LOS) and orthopaedic and plastic surgical procedures performed, including medications and intensive care. We analysed indirect cost in terms of absenteeism and unemployment benefits. The primary goal was to establish the extra cost incurred by an infection. We analysed 46 injuries in 45 patients. Infection increased the LOS from 41 to 74 days and increased the cost of treatment from € 49,817 in uninfected fractures to € 81,155 for infected fractures. Employed patients spent 430 days more on unemployment benefits, than a matched cohort in the background population. Achieving skin cover within seven days of injury decreased the infection rate from 60 to 27 %. Severe open tibial fractures covered with free flaps, cause over a year of absenteeism. Infection increases direct cost of treatment over 60 % and roughly doubles LOS. Early soft-tissue cover and correct antibiotics have been shown to improve outcomes-underscoring the need for rapid referral to centres with an ortho-plastic set-up to handle such injuries.
Lin, Shishui; Mauffrey, Cyril; Hammerberg, E Mark; Stahel, Philip F; Hak, David J
The aim of this study was to identify risk factors for surgical site infections and to quantify the contribution of independent risk factors to the probability of developing infection after definitive fixation of tibial plateau fractures in adult patients. A retrospective analysis was performed at a level I trauma center between January 2004 and December 2010. Data were collected from a review of the patient's electronic medical records. A total of 251 consecutive patients (256 cases) were divided into two groups, those with surgical site infections and those without surgical site infections. Preoperative and perioperative variables were compared between these groups, and risk factors were determined by univariate analyses and multivariate logistic regression. Variables analyzed included age, gender, smoking history, diabetes, presence of an open fracture, presence of compartment syndrome, Schatzker classification, polytrauma status, ICU stay, time from injury to surgery, use of temporary external fixation, surgical approach, surgical fixation, operative time, and use of a drain. The overall rate of surgical site infection after ORIF of tibial plateau fractures during the 7 years of this study was 7.8% (20 of 256). The most common causative pathogens was Staphylococcus aureus (n=15, 75%). Independent predictors of surgical site infection identified by multivariate analyses were open tibial plateau fracture (odds ratio=3.9; 95% CI=1.3-11.6; p=0.015) and operative time (odds ratio=2.7; 95% CI=1.6-4.4; p<0.001). The presence of compartment syndrome (odds ratio=3.4; 95% CI=0.7-15.9; p=0.119), use of temporary external fixation (odds ratio=0.5; 95% CI=0.2-1.7; p=0.298), and ICU stay (odds ratio=1.0; 95% CI=1.0-1.1; p=0.074) were not determined to be independent predictors of surgical site infection. Both open fracture and operative time are independent risks factors for postoperative infection.
Ji, Jianfei; Zhao, Yinsong; He, Xueyu; Zhou, Yang
To determine the effect of interlocking intramedullary nail in treatment of open tibial and fibula fractures and analyze the method to promote the bone union. From December 2003 to June 2006, thirty-five patients with open tibial and fibula fracture were treated with emergency debridement, interlocked intramedullary fixation for tibia and fixed fibula at the same time. During operation, the bone marrow was collected and grafted into the fracture gaps. Among them, there were 27 males and 8 females, involving in 22 left legs and 13 right legs. Their ages ranged from 19 to 65 years, with an average of 34.7 years. The location of fracture was the middle of the tibia and fibula in 16 cases, the distal 1/3 of the tibia and fibula in 12 cases and the proximal 1/3 in 7 cases. According to the Gustilo classification of open injuries, there were 7 cases of type I, 19 cases of type II, 8 cases of type III a and 1 case of type III b. The mean range of knee motion was 48.3 degrees (45-70 degrees). The mean time from injury to operation was 4.3 hours (50 minutes to 7 hours). The mean operation time was 94 minutes (60-132 minutes) and the mean blood loss was 122 mL (100-350 mL). The wound healed by first intention in 32 patients. Incision was sutured in 2 cases of type III a fractures after operation 4 days, gastrocnemius flap graft was performed in 1 case of type III b fracture 1 week after operation. They all achieve good healing. No fractures split off, no iatrogenic nerve and vascular injury occurred, no osteofascial compartment syndromes or deep vein thrombus happened. Tension blisters appeared in 1 case of type II fracture after operation and subsided after 5 days. Patients were followed up for 14-43 months (mean 22 months). The X-ray films showed that fracture union was observe in 30 cases after 14 weeks of operation, in 3 cases after 18 weeks and in 1 case after 22 weeks of operation. The fractures union time was 15.2 weeks on average. About 2 cm nonunion in lateral
Villafan-Bernal, Jose Rafael; Franco-De La Torre, Lorenzo; Sandoval-Rodriguez, Ana Soledad; Armendariz-Borunda, Juan; Alcala-Zermeno, Juan Luis; Cruz-Ramos, Jose Alfonso; Lopez-Armas, Gabriela; Ramirez-Bastidas, Blanca Estela; González-Enríquez, Gracia Viviana; Collazo-Guzman, Emerson Armando; Martinez-Portilla, Raigam Jafet; Sánchez-Enríquez, Sergio
Bone fractures are a worldwide public health concern. Therefore, improving understanding of the bone healing process at a molecular level, which could lead to the discovery of potential therapeutic targets, is important. In the present study, a model of open tibial fractures with hematoma disruption, periosteal rupture and internal fixation in 6-month-old male Wistar rats was established, in order to identify expression patterns of key genes and their protein products throughout the bone healing process. A tibial shaft fracture was produced using the three-point bending technique, the hematoma was drained through a 4-mm incision on the medial aspect of the tibia and the fracture stabilized by inserting a needle into the medullary canal. Radiographs confirmed that the induced fractures were diaphyseal and this model was highly reproducible (kappa inter-rater reliability, 0.82). Rats were sacrificed 5, 14, 21, 28 and 35 days post-fracture to obtain samples for histological, immunohistochemical and molecular analysis. Expression of interleukin-1β (Il-1β), transforming growth factor-β2 (Tgf-β2), bone morphogenetic protein-6 (Bmp-6), bone morphogenetic protein-7 (Bmp-7) and bone γ-carboxyglutamic acid-containing protein (Bglap) genes was determined by reverse transcription quantitative polymerase chain reaction and protein expression was evaluated by immunohistochemistry, while histological examination allowed characterization of the bone repair process. Il-1β showed a biphasic expression, peaking 5 and 28 days post-fracture. Expression of Tgf-β2, Bmp-6 and Bmp-7 was restricted to the period 21 days post-fracture. Bglap expression increased gradually, peaking 21 days post-fracture, although it was expressed in all evaluated stages. Protein expression corresponded with the increased expression of their corresponding genes. In conclusion, a clear and well-defined expression pattern of the evaluated genes and proteins was observed, where their maximal expression
Tielinen, Laura; Lindahl, Jan E; Tukiainen, Erkki J
The treatment of open tibial shaft fractures remains controversial. Important considerations in surgical management include surgical timing, fixation technique and soft tissue coverage. This study was performed to evaluate the results of acute surgical debridement, unreamed nailing and soft tissue reconstruction in the treatment of severe open tibial shaft fractures. During a 10-year period between January 1993 and July 2002, 927 tibial shaft fractures were treated with interlocking intramedullary nails. Among them, there were 19 consecutive patients with Gustilo type IIIB to IIIC open tibial shaft fractures with extensive soft tissue injury needing a muscle flap coverage and being suitable for intramedullary nailing. All 19 patients were called for a late follow-up which was conducted with a physical examination and a radiographic and functional outcome assessment. The radiographs were reviewed to determine the fracture healing time and the final alignment. All 19 open fractures with severe soft tissue injury healed without any infection complications. The fractures united in a mean of 8 months. Nine patients had delayed fracture healing (union time over 24 weeks). One of these patients needed exchange nailing, one patient autogenous bone grafting and dynamisation on the nail and seven patients needed dynamisation of the nail before the final fracture healing. In all patients, the alignment was well maintained. However, seven patients had shortening of the tibia by 1-2 cm and two of them also external rotation of 10 degrees . The functional outcome was good in 18/19 patients. Acute surgical debridement, unreamed interlocking intramedullary nailing and soft tissue reconstruction with a muscle flap appear to be a safe and effective method of treatment for Gustilo type IIIB open tibial shaft fractures.
Hou, Zhiyong; Irgit, Kaan; Strohecker, Kent A; Matzko, Michelle E; Wingert, Nathaniel C; DeSantis, Joseph G; Smith, Wade R
Vacuum-assisted closure (VAC) therapy has been shown to be effective at reducing bacterial counts in wounds until definitive bony coverage. However, there is continued debate over timing and type of definitive wound coverage even with VAC therapy application. From 2004 to 2009, 32 patients with Gustilo type IIIB open tibia fractures were initially treated with VAC therapy were included. The number of debridements, length of treatment with VAC dressing, definitive wound coverage management, and length of hospital stay, flap-related complications, and time to radiographic fracture healing were recorded. The mean Injury Severity Score was 17.3 ± 2.0. All wounds closed after being treated with the primary VAC closure. The mean interval between the initial injury and definitive intervention was 10.9 days ± 0.3 days. Twenty of 27 patients (74%) underwent rotational muscle flaps; four received free muscle flaps and three only with split-thickness skin grafts for definitive wound coverage. Nine of 32 patients (28%) underwent below knee amputation, five without flap coverage after several VAC sessions and four after definitive flap coverage. The average time to union was 10.0 months ± 2.0 months. Eight patients developed nonunion and 11 patients developed infections. The average follow-up time is 2.4 years ± 0.2 years. Patients were divided into two groups for analysis according to the interval time. The rate of infection was significantly increased in patients who had an interval of more than 7 days from the time of injury to flap coverage. The VAC therapy may help to reduce the flap size and need for a flap transfer for type IIIB open tibial fractures. However, prolonged periods of VAC usage, greater than 7 days, should be avoided to reduce higher infection and amputation risks.
Ramasubbu, Rohan A; Ramasubbu, Benjamin M
Background: Management of open tibial fractures is well documented in adults, with existing protocols outlining detailed treatment strategies. No clear guidelines exist for children. Surgical stabilization of tibial fractures in the pediatric population requires implants that do not disrupt the open epiphyses (growth plate). Both elastic stable intramedullary nails and external fixation can be used. The objective of this study was to identify the optimal method of surgical stabilization in the treatment of open tibial fractures in children. Materials and Methods: MEDLINE and Embase were searched from their inception to March 2014 using the following advanced search terms (Key words): “open tibia fracture,” “fracture fixation,” “external fixation,” “intramedullary,” and “bone nail.” Only studies in English and pertaining to children with open fractures treated with elastic stable intramedullary nails or external fixation between 1994 and 2014 were included. Twelve clinical studies were critically appraised. Results: Due to a paucity in the literature coupled with a nonsystematic presentation of results, it proved to be very difficult in extracting relevant results from the studies. This was further added by a variation in outcome measures. Consequently, the results we obtained were difficult to draw conclusions from. Conclusion: There is no conclusive evidence or best practice guidelines for their management. Thus, as is highlighted in this study, more research is needed to determine the optimum treatment strategy for this common pediatric injury. The existing literature is of poor quality; consisting mainly of retrospective reviews of patients’ medical records, charts, and radiographs. Carefully designed, high-quality prospective cohort studies utilizing a nationalized multi-hospital approach are needed to improve understanding before protocols and guidelines can be developed and implemented. PMID:27746486
Ramasubbu, Rohan A; Ramasubbu, Benjamin M
Management of open tibial fractures is well documented in adults, with existing protocols outlining detailed treatment strategies. No clear guidelines exist for children. Surgical stabilization of tibial fractures in the pediatric population requires implants that do not disrupt the open epiphyses (growth plate). Both elastic stable intramedullary nails and external fixation can be used. The objective of this study was to identify the optimal method of surgical stabilization in the treatment of open tibial fractures in children. MEDLINE and Embase were searched from their inception to March 2014 using the following advanced search terms (Key words): "open tibia fracture," "fracture fixation," "external fixation," "intramedullary," and "bone nail." Only studies in English and pertaining to children with open fractures treated with elastic stable intramedullary nails or external fixation between 1994 and 2014 were included. Twelve clinical studies were critically appraised. Due to a paucity in the literature coupled with a nonsystematic presentation of results, it proved to be very difficult in extracting relevant results from the studies. This was further added by a variation in outcome measures. Consequently, the results we obtained were difficult to draw conclusions from. There is no conclusive evidence or best practice guidelines for their management. Thus, as is highlighted in this study, more research is needed to determine the optimum treatment strategy for this common pediatric injury. The existing literature is of poor quality; consisting mainly of retrospective reviews of patients' medical records, charts, and radiographs. Carefully designed, high-quality prospective cohort studies utilizing a nationalized multi-hospital approach are needed to improve understanding before protocols and guidelines can be developed and implemented.
Kojima, Kodi Edson; Ferreira, Ramon Venzon
The long-bone fractures occur most frequently in the tibial shaft. Adequate treatment of such fractures avoids consolidation failure, skewed consolidation and reoperation. To classify these fractures, the AO/OTA classification method is still used, but it is worthwhile getting to know the Ellis classification method, which also includes assessment of soft-tissue injuries. There is often an association with compartmental syndrome, and early diagnosis can be achieved through evaluating clinical parameters and constant clinical monitoring. Once the diagnosis has been made, fasciotomy should be performed. It is always difficult to assess consolidation, but the RUST method may help in this. Radiography is assessed in two projections, and points are scored for the presence of the fracture line and a visible bone callus. Today, the dogma of six hours for cleaning the exposed fracture is under discussion. It is considered that an early start to intravenous antibiotic therapy and the lesion severity are very important. The question of early or late closure of the lesion in an exposed fracture has gone through several phases: sometimes early closure has been indicated and sometimes late closure. Currently, whenever possible, early closure of the lesion is recommended, since this diminishes the risk of infection. Milling of the canal when the intramedullary nail is introduced is still a controversial subject. Despite strong personal positions in favor of milling, studies have shown that there may be some advantage in relation to closed fractures, but not in exposed fractures.
Kojima, Kodi Edson; Ferreira, Ramon Venzon
The long-bone fractures occur most frequently in the tibial shaft. Adequate treatment of such fractures avoids consolidation failure, skewed consolidation and reoperation. To classify these fractures, the AO/OTA classification method is still used, but it is worthwhile getting to know the Ellis classification method, which also includes assessment of soft-tissue injuries. There is often an association with compartmental syndrome, and early diagnosis can be achieved through evaluating clinical parameters and constant clinical monitoring. Once the diagnosis has been made, fasciotomy should be performed. It is always difficult to assess consolidation, but the RUST method may help in this. Radiography is assessed in two projections, and points are scored for the presence of the fracture line and a visible bone callus. Today, the dogma of six hours for cleaning the exposed fracture is under discussion. It is considered that an early start to intravenous antibiotic therapy and the lesion severity are very important. The question of early or late closure of the lesion in an exposed fracture has gone through several phases: sometimes early closure has been indicated and sometimes late closure. Currently, whenever possible, early closure of the lesion is recommended, since this diminishes the risk of infection. Milling of the canal when the intramedullary nail is introduced is still a controversial subject. Despite strong personal positions in favor of milling, studies have shown that there may be some advantage in relation to closed fractures, but not in exposed fractures. PMID:27026999
Frey, Steven; Hosalkar, Harish; Cameron, Danielle B; Heath, Aaron; David Horn, B; Ganley, Theodore J
Tibial tuberosity fractures in adolescents are uncommon. We retrospectively reviewed all tibial tuberosity fractures in adolescents (10-19) who presented to our level 1 pediatric trauma center over a 7-year period to review fracture morphology, mechanism of injury, fracture management including return to play, as well as complications. Additionally, we present a review of the literature and treatment algorithm. We reviewed the clinical charts and radiographs of consecutive patients with tibial tuberosity fractures between 01 January 2000 and 01 January 2007. Data parameters included the following: patients age and gender, involved side, injury classification, co-morbidities, mechanism of injury, treatment, return to activity and complications. Data were extracted and reviewed, and a treatment algorithm is proposed with some additional insights into the epidemiology of the injury. Nineteen patients met the inclusion criteria. There were 19 patients with 20 tibial tuberosity fractures. The mean age was 13.7 years. There were 18 males and 1 female patient. There were nine left-sided injuries and eleven right-sided including one patient with bilateral fractures. Mechanism of injuries included basketball injury (8), running injury (5), football injury (3), fall from a scooter (2), high jump (1) and fall (1). Co-morbidities included three patients with concurrent Osgood-Schlatter disease and one with osteogenesis imperfecta. All were treated with ORIF, including arthroscopic-assisted techniques in two cases. Complications included four patients with pre-operative presentation of compartment syndrome all requiring fasciotomy, one post-operative stiffness and one painful hardware requiring removal. Range of motion was started an average of 4.3 weeks post-operatively and return to play was an average of 3.9 months post-operatively. Although uncommon, tibial tuberosity fractures in adolescents are clinically important injuries. Early recognition and treatment (closed or open
Economic evaluation of reamed versus unreamed intramedullary nailing in patients with closed and open tibial fractures: results from the study to prospectively evaluate reamed intramedullary nails in patients with tibial fractures (SPRINT).
Briel, Matthias; Sprague, Sheila; Heels-Ansdell, Diane; Guyatt, Gordon; Bhandari, Mohit; Blackhouse, Gordon; Sanders, David; Schemitsch, Emil; Swiontkowski, Marc; Tornetta, Paul; Walter, Stephen D; Goeree, Ron
Recently, results from the large, randomized study to prospectively 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 resource use and effectiveness of reamed and unreamed intramedullary nailing using a cost-utility analysis. We calculated quality-adjusted life years (QALYs) for each patient from a self-administered health utility index 3 questionnaire for the first 12 months following the intramedullary nailing. A convenience sample of 235 SPRINT patients provided data on costs associated with health care resource utilization. All costs are reported in Canadian dollars for the 2008 financial year. We found incremental effects of -0.017 (95% confidence interval [CI] -0.021-0.058) and -0.002 (95% CI -0.060-0.062) QALYs for patients treated with reamed compared with unreamed intramedullary nails in closed and open fractures, respectively. The incremental costs for reamed compared with unreamed intramedullary nailing were $51 Canadian dollars (95% CI -$2298-$2400) in closed tibial fractures and $2546 Canadian dollars (95%CI -$1773-$6864) in open tibial fractures. Unreamed nailing dominated reamed nailing for both closed and open tibial fractures; however, the cost and the utility results had high variability. Our economic analysis from a governmental perspective suggests small differences in both cost and effectiveness with large uncertainty between reamed and unreamed intramedullary nailing. Copyright © 2011 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.
Tekin, Ali Çağrı; Saygılı, Mehmet Selçuk; Adaş, Müjdat; Çabuk, Haluk; Arslan, Samet Murat; Dedeoğlu, Süleyman Semih
Objective To evaluate functional and radiological results following treatment with the single-plane external fixator limb reconstruction system (LRS) for open tibial diaphyseal fractures resulting from high-energy trauma. Subjects and Methods From a total of 62 patients who were operated on between 2011 and 2014 for open tibial diaphyseal fractures resulting from high-energy trauma, 50 tibias from 49 patients (males: 32, females: 17) were classified as type 3 according to the Gustilo-Anderson open fracture classification, and definitive treatment was applied with the LRS. The patients ranged in age from 20 to 36 years. Time to union, time of external fixator usage, complications and functional results according to the Johner-Wruhs criteria were recorded. Results The mean follow-up period was 23 ± 12 months (range: 11–44). Of the 50 tibias, full union was achieved with the LRS in 48 (96s%). No shortness or deformity was observed in any patient. Knee and ankle range of movement were measured as full in all patients at the final follow-up examination after removal of the LRS. The mean time to union was 20.4 ± 4 weeks (range: 16–24). The mean time of external fixator use was 20 weeks (range: 16–24 weeks). Conclusion In this study, for the definitive treatment of open tibia diaphyseal fractures, the LRS was an optimal and safe choice that offered single-stage surgery. PMID:26655399
Golubović, Zoran; Vidić, Goran; Trenkić, Srbobran; Vukasinović, Zoran; Lesić, Aleksandar; Stojiljković, Predrag; Stevanović, Goran; Golubović, Ivan; Visnjić, Aleksandar; Najman, Stevo
Aircraft bombs can cause severe orthopaedic injuries. Tibia shaft fractures caused by aircraft bombs are mostly comminuted and followed by bone defects, which makes the healing process extremely difficult and prone to numerous complications. The goal of this paper is to present the method of treatment and the end results of treatment of a serious open tibial fracture with soft and bone tissue defects resulting from aircraft bomb shrapnel wounds. A 26-year-old patient presented with a tibial fracture as the result of a cluster bomb shrapnel wound. He was treated applying the method of external bone fixation done two days after wounding, as well as of early coverage of the lower leg soft tissue defects done on the tenth day after the external fixation of the fracture. The external fixator was removed after five months, whereas the treatment was continued by means of functional plaster cast for another two months. The final functional result was good. Radical wound debridement, external bone fixation of the fracture, and early reconstruction of any soft tissue and bone defects are the main elements of the treatment of serious fractures.
Sharma, H; Nunn, T
The closure of small-to-moderate-sized soft tissue defects in open tibial fractures can be successfully achieved with acute bony shortening. In some instances, it may be possible to close soft tissue envelope defects by preserving length and intentionally creating a deformity of the limb. As the soft tissue is now able to close, this manoeuvre converts an open IIIb to IIIa fracture. This obviates the need for soft tissue reconstructive procedures such as flaps and grafts, which have the potential to cause donor-site morbidity and may fail. In this article, the authors demonstrate the technique for treating anterior medial soft tissue defects by deforming the bone at the fracture site, permitting temporary malalignment and closure of the wound. After healing of the envelope, the malalignment is gradually corrected with the use of the Taylor Spatial Frame. We present two such cases and discuss the technical indications and challenges of managing such cases.
Sun, Yufu; Sun, Kai; Jiang, Wenxue
To conduct a meta-analysis with randomized controlled trials (RCTs) published in full text to demonstrate database to show the associations of perioperative, postoperative outcomes of arthroscopic reduction and percutaneous fixation(ARPF) and open reduction and internal fixation(ORIF) for tibial plateau fractures to provide the predictive diagnosis for clinic. Literature search was performed in PubMed, Embase, Web of Science and Cochrane Library for information from the earliest date of data collection to June 2017. RCTs comparing the benefits and risks of ARPF with those of ORIF in tibial plateau fractures were included. Statistical heterogeneity was quantitatively evaluated by X 2 test with the significance set P < 0.10 or I 2 > 50%. Seven RCTs consisting of 571 patients were included.(288 ARPF patients; 283 ORIF patients;). Pooled results showed that ORIF was related to a greater increase in operative time, incision length, hospital stay, perioperative complications, and full weight bearing compared with ARPF. The results showed that ARPF was related to a greater increase in ROM Rasmussen Scores compared with ORIF (WMD = 10.38; 95% CI, 8.31, 12.45; P < 0.10). This meta-analysis showed that arthroscopic reduction and percutaneous fixation for tibial plateau fractures, compared with open reduction and internal fixation, could demonstrate an decreased risk of perioperative and postoperative complications and improve clinical outcome in operative time, incision length, hospital stay, perioperative complications, full weight bearing and Rasmussen Scores. Copyright © 2018. Published by Elsevier Ltd.
Penn-Barwell, J G; Myatt, R W; Bennett, P M; Sargeant, I D
Extremity injuries define the surgical burden of recent conflicts. Current literature is inconclusive when assessing the merits of limb salvage over amputation. The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to equivalent outcomes for unilateral trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 and 2010, as described in a previously published series, were contacted. Consenting individuals conducted a brief telephone interview and were asked to complete a SF-36 questionnaire. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation between 2004 and 2010. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria. Telephone follow-up and SF-36 questionnaire data was available for 30 patients (61%). The median follow-up was 4 years (49 months, IQR 39-63). Ten of the 30 patients required revision surgery, three of which involved conversion from initial fixation to a circular frame for non- or mal-union. Twenty-two of the 30 patients (73%) recovered sufficiently to complete an age-standardised basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35-54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores between the limb salvage and amputation groups (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma
Shao, Jiashen; Chang, Hengrui; Zhu, Yanbin; Chen, Wei; Zheng, Zhanle; Zhang, Huixin; Zhang, Yingze
This study aimed to quantitatively summarize the risk factors associated with surgical site infection after open reduction and internal fixation of tibial plateau fracture. Medline, Embase, CNKI, Wanfang database and Cochrane central database were searched for relevant original studies from database inception to October 2016. Eligible studies had to meet quality assessment criteria according to the Newcastle-Ottawa Scale, and had to evaluate the risk factors for surgical site infection after open reduction and internal fixation of tibial plateau fracture. Stata 11.0 software was used for this meta-analysis. Eight studies involving 2214 cases of tibial plateau fracture treated by open reduction and internal fixation and 219 cases of surgical site infection were included in this meta-analysis. The following parameters were identified as significant risk factors for surgical site infection after open reduction and internal fixation of tibial plateau fracture (p < 0.05): open fracture (OR 3.78; 95% CI 2.71-5.27), compartment syndrome (OR 3.53; 95% CI 2.13-5.86), operative time (OR 2.15; 95% CI 1.53-3.02), tobacco use (OR 2.13; 95% CI 1.13-3.99), and external fixation (OR 2.07; 95% CI 1.05-4.09). Other factors, including male sex, were not identified as risk factors for surgical site infection. Patients with the abovementioned medical conditions are at risk of surgical site infection after open reduction and internal fixation of tibial plateau fracture. Surgeons should be cognizant of these risks and give relevant preoperative advice. Copyright © 2017. Published by Elsevier Ltd.
Yokoyama, Kazuhiko; Itoman, Moritoshi; Uchino, Masataka; Fukushima, Kensuke; Nitta, Hiroshi; Kojima, Yoshiaki
The purpose of this study was to evaluate contributing factors affecting deep infection and fracture healing of open tibia fractures treated with locked intramedullary nailing (IMN) by multivariate analysis. We examined 99 open tibial fractures (98 patients) treated with immediate or delayed locked IMN in static fashion from 1991 to 2002. Multivariate analyses following univariate analyses were derived to determine predictors of deep infection, nonunion, and healing time to union. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type, fracture grade by AO type, fracture location, timing or method of IMN, reamed or unreamed nailing, debridement time (< or =6 h or >6 h), method of soft-tissue management, skin closure time (< or =1 week or >1 week), existence of polytrauma (ISS< 18 or ISS> or =18), existence of floating knee injury, and existence of superficial/pin site infection. The predictive variables of nonunion selected for analysis was the same as those for deep infection, with the addition of deep infection for exchange of pin site infection. The predictive variables of union time selected for analysis was the same as those for nonunion, excluding of location, debridement time, and existence of floating knee and superficial infection. Six (6.1%; type II Gustilo n=1, type IIIB Gustilo n=5) of the 99 open tibial fractures developed deep infections. Multivariate analysis revealed that timing or method of IMN, debridement time, method of soft-tissue management, and existence of superficial or pin site infection significantly correlated with the occurrence of deep infection (P< 0.0001). In the immediate nailing group alone, the deep infection rate in type IIIB + IIIC was significantly higher than those in type I + II and IIIA (P = 0.016). Nonunion occurred in 17 fractures (20.3%, 17/84). Multivariate analysis revealed that Gustilo type, skin closure time, and existence of deep infection significantly correlated with
Zhao, Xing-Wen; Ma, Jian-Xiong; Ma, Xin-Long; Jiang, Xuan; Wang, Yin; Li, Fei; Lu, Bin
Both external fixation (ExFx) and open reduction and internal fixation(ORIF) were used to treat complex tibial plateau fractures, but it was not sure which one was better. So we did this meta-analysis to evaluate the outcomes of ExFx and ORIF in managing complex tibial plateau fractures. Articles published before August 5, 2016 were selected from PubMed, Cochrane library, and some other electronic database. Relevant journals were also searched manually with no language limited. Two independent reviewers searched and assessed the literature. A fixed effect model was initially used for meta-analyses with RevMan 5.3. When compared with ORIF, cases undergoing ExFx were more likely to return to the preinjury state at the early stage, but no difference in the later period of follow-up. However, ExFx group had higher infection rate (OR 1.98, 95% CI 1.08-3.63, P = 0.03), higher venous thromboembolism rate (OR 1.56, 95% CI 0.49-4.96, P = 0.45), higher re-operation rate (OR 0.87, 95% CI 0.47-1.62, P = 0.66) and lower compartment syndrome rate (OR 0.61, 95% CI 0.12-3.22, P = 0.56), lower TKA rate (OR 0.51, 95% CI 0.20-1.34, P = 0.17). There were no statistically significant differences in the rate of deep infection, venous thromboembolism, compartment syndrome and VTE between the two groups. Although external fixation may offer some advantages, both were acceptable strategies in managing complex tibial plateau fractures. According to our analysis results, we strongly recommend that selection of definitive fixators should base on the fracture patterns, soft-tissue condition as well as the injury stages in clinical practice. More important, further multicentered, randomized controlled studies should be implemented to get a more reliable and clear result. Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Zhen, Ping; Hu, Yun-Yu; Luo, Zhuo-Jing; Liu, Xing-Yan; Lu, Hao; Li, Xu-Sheng
This study evaluated the usefulness of a single-stage, free-fibular vascularized osteoseptocutaneous flap transfer for Type III open tibial shaft fractures with segmental bone loss for the reconstruction of combined bone and soft tissue defects. Nonrandomized retrospective study. University Level I trauma center. All Gustilo Type III open tibial shaft fractures with segmental bone loss that were treated at one institution between 2000 and 2007 were identified from a trauma registry. The study group consisted of 28 patients with Type III open tibial fractures: 27 were Gustilo-Anderson Type IIIB and one was Grade IIIC. The cause of tibial injury included eight industrial accidents, seven motor vehicle accidents, five crushing injuries caused by heavy objects, five falls from a height, and three motorcycle crashes. The lengths of the preoperative segmental tibial bone loss ranged from 9 to 17 cm and the size of the associated soft tissue defects ranged from 8 × 6 cm to 15 × 7 cm. The free fibular vascularized osteoseptocutaneous flap was used to graft and reconstruct combined bone and soft tissue defects. The radical wound débridement, soft tissue and bone revision, fracture stabilization, and early soft tissue coverage were achieved by this technique in a one-stage procedure. The average duration from injury to one-stage reconstruction was 15.8 hours (range, 5.3 hours to 6.5 days). Radiographic and functional evaluation of the lower extremity. All free fibular osteoseptocutaneous flaps survived completely. The average time to overall union for the entire group was 32 weeks after surgery (range, 26-41 weeks). None of the patients in this series had a nonunion. Acceptable radiographic alignment, defined as 5° of angulation in any plane, was obtained in 22 patients (78.6%). Malunion affected six (21.4%) fractures. According to the lower extremity functional assessment, excellent and good results were achieved for 82.1% (23 of 28), fair results were seen in 14
Page, Piers R J; Trickett, Ryan W; Rahman, Shakeel M; Walters, Angharad; Pinder, Leila M; Brooks, Caroline J; Hutchings, Hayley; Pallister, Ian
Severe open fractures of the lower limbs are complex injuries requiring expert multidisciplinary management in appropriate orthoplastic centres. This study aimed to assess the impact of open fractures on healthcare utilisation and test the null hypotheses that there is no difference in healthcare utilisation between the year before and year after injury, and that there is no difference in healthcare utilisation in the year post-injury between patients admitted directly to an orthoplastic centre in keeping with the joint BOA/BAPRAS standards and those having initial surgery elsewhere. This retrospective cohort study utilising secure anonymised information linkage (SAIL), a novel databank of anonymised nationally pooled health records, recruited patients over 18 years of age sustaining severe open lower limb fractures managed primarily or secondarily at our centre and who had data available in the SAIL databank. 101 patients met inclusion criteria and 90 of these had records in the SAIL databank. The number of days in hospital, number of primary care attendances, number of outpatient attendances and number of emergency department attendances in the years prior and subsequent to injury were recorded. Patients sustaining open fractures had significantly different healthcare utilisation in the year after injury when compared with the year before, in terms of days spent in hospital (23.42 vs. 1.70, p=0.000), outpatient attendances (11.98 vs. 1.05, p=0.000), primary care attendances (29.48 vs. 11.99, p=0.000) and emergency department presentations (0.2 vs. 0.01, p=0.025). Patients admitted directly to orthoplastic centres had significantly fewer operations (1.78 vs. 3.31) and GP attendances (23.6 vs. 33.52) than those transferred in subsequent to initial management in other units. There is a significant increase in healthcare utilisation after open tibial fracture. Adherence to national standards minimises the impact of this on both patients and health services. Copyright
Khoury, Amal; Liebergall, Meir; London, Eli; Mosheiff, Rami
This article presents our experience with 24 patients who had distal tibial fractures and were treated by percutaneous plate fixation. Distribution of the fractures according to the AO/OTA classification was as follows: five patients suffered from a 43 A type fracture, six from a 43 B type fracture, and 13 from a 43 C type fractures. Four of the fractures were open. Exclusion criteria included 43 C3 fractures and Gustilo III open fractures. All fractures showed radiographic signs of union enough to enable full weightbearing within an average time of 12.3 weeks. All patients showed a good range of motion (average dorsiflexion 12 degrees and average plantiflexion 18 degrees). Two fractures united with mal-union: one with an 8 degrees valgus deformity and another with a 7 degrees varus deformity. Both cases, which had a metaphyseal component, were treated by means of a "soft" (flexible and manually adjustable) AO 3.5 mm reconstruction plate. Except for one case of superficial infection, no infections were detected in any of the patients. The biological percutaneous plate fixation of distal tibial fractures with no extensive intra-articular involvement is a good soft tissue preserving technique. It provides a rigid and anatomical fixation in most cases. We conclude that type B fractures with one intact column can be fixed with either "soft" or "rigid" plates, and type A and C fractures with a metaphyseal component should be fixed with "rigid" plates (AO 4.5 mm Dynamic Compression Plate). In these fractures the reduction should be performed cautiously due to the tendency of sagittal plane mal-reduction.
Balaji, S Muthukumar; Chandra, P Madhu; Devadoss, Sathish; Devadoss, A
Isolated tibial shaft (ITS) fracture with intact fibula is a common injury but records often fail to mention it. Our primary aim was to study the effect of the intact fibula in ITS fractures in closed and open injuries and that these fractures can unite without a primary fibulectomy. 56 patients who sustained an ITS fracture with an intact fibula who underwent closed or open reduction and reamed intramedullary interlocking nailing (IM IL nail) for closed and open fractures between August 2008 and April 2014 were included in this study. Four patients were lost to followup. One patient died due to causes not related to the surgery. At the time of final followup, 51 patients with 51 ITS fractures were available for the analysis. There were 33 closed and 18 open fractures. Patients were followed up at 4 weekly intervals until radiological signs of union were noted. They were assessed for functional outcome using the IOWA knee and ankle score systems at the time of final followup. The average time to union was 19.7 weeks. Closed fractures united in 17.7 weeks as compared to 23.5 weeks for open fractures (P < 0.05). A delay in union occurred in 6 patients (4 open) and in 3 patients fractures failed to unite (2 open). The functional outcome as per the knee score and ankle score evaluation system was 93.13 and 92.54, respectively. The knee scores were 93.81 and 91.8 for closed and open ITS fractures, respectively (P > 0.05). Similarly, the ankle scores were 94.96 and 88.1 for closed and open ITS fractures, respectively (P < 0.05). ITS fracture with intact fibula is a common occurrence, and they can be treated safely with reamed IM nailing that provides good union rates and the excellent functional result even in open fractures.
recovered at nonunion. These included 1 patient who was treated with vancomycin for initial coagulase-negative staphylococcal wound infection who sub... staphylococcal infections is associated with exposure to these pathogens during the long rehabilitative phase of recovery or from the selection of...tend to be due to staphylococcal organisms, and these infections are Infection of Combat-Related Fractures • CID 2007:45 (15 August) • 415 typically
Ogden, J A; Tross, R B; Murphy, M J
The cases of fourteen adolescents with fifteen physeal fractures of the tibial tuberosity were reviewed to more accurately define specific fracture patterns, to establish treatment for the different types, and to determine the incidence of complications. A modified classification scheme with a greater emphasis on intra-articular extension of the fracture and communution of the tuberosity was devised. Closed or open reduction, as necessary, gave satisfactory results. The primary indications for surgery were: (1) displacement of one or more fragments of the tuberosity anterosuperiorly, and (2) extension of the fracture through the proximal tibial ossification center into the knee joint, with disruption of the joint surface. There appears to be an increased incidence of pre-existing Osgood-Schlatter disease (ipsilateral and contralateral) in patients who have an acute tuberosity injury. Complications are rare. The theoretical possibility of the subsequent development of genu recurvatum appears unlikely, since most of these injuries occur when the physis of the tuberosity is undergoing normal closure.
Zelle, Boris A; Boni, Guilherme
Statically locked, reamed intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point is a crucial part of the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Numerous reduction techiques are available to achieve an anatomic fracture alignment and the treating surgeon should be familiar with these maneuvers. Open reduction techniques should be considered if anatomic fracture alignment cannot be achieved by closed means. Favorable union rates above 90 % can be achieved by both reamed and unreamed intramedullary nailing. Despite favorable union rates, patients continue to have functional long-term impairments. In particular, anterior knee pain remains a common complaint following intramedullary tibial nailing. Malrotation remains a commonly reported complication after tibial nailing. The effect of postoperative tibial malalignment on the clinical and radiographic outcome requires further investigation.
Ankle TOTAL 52 Lateral ankle sprain 44 Medial ankle sprain 2 Ankle other 6 Foot TOTAL 84 Acute...sfrain 1 Tibial sfress fracture 3 Tibial sfress syndrome 6 Tibialis posterior sfrain 2 Lower leg other 6 Ankle TOTAL 20 Lateral ankle sprain 12...Medial ankle sprain 29 Ankle other 3 Foot TOTAL 21 Metatarsal stress syndrome 2 Metatarsal
Ankle TOTAL 82 Lateral ankle sprain 72 Medial ankle sprain 3 Ankle other 7 Foot TOTAL 124...strain 5 Acute fibular fracture 1 Lower leg other 25 31 Ankle TOTAL 59 Lateral ankle sprain 42 Medial ankle sprain 5 Ankle other 12 Foot TOTAL 96...tibial stress fracture. Therefore, we chose to investigate the individual knee and ankle stiffness in the sagittal plane. We evaluated this
Albuquerque, Rodrigo Pires e; Campos, André Siqueira; de Araújo, Gabriel Costa Serrão; Gameiro, Vinícius Schott
The fracture of tibial tuberosity is a rare lesion and still more unusual in adults. We describe a case in an adult who suffered a left knee injury due to a fall from height. No risk factors were identified. The lesion was treated with surgical reduction and internal fixation. The rehabilitation method was successful, resulting in excellent function and rage of motion of the knee. The aim of this study was to present an unusual case of direct trauma of the tibial tuberosity in an adult and the therapy performed. PMID:24293543
Polakoff, D R; Bucholz, R W; Ogden, J A
Twelve adolescent boys with avulsion fractures of the tibial tuberosity were treated with open reduction and tension band wire fixation. Fasciotomies were required in two cases for associated compartmental syndromes. All fractures healed in anatomic position. The tension band wire assisted both in neutralizing tensile (distracting) forces and compressing comminuted fragments. Early functional motion was started within four weeks. Osgood-Schlatter disease was diagnosed in five of the 12 patients. The apparent high incidence of this fracture pattern in the community prompted the recommendation to restrict jumping sports for adolescent boys with active Osgood-Schlatter disease.
Jones, Jeanine L; Losito, James M
A single case of a tibial sesamoid fracture in a softball player is reported here. A review of the literature confirms that this is an unusual and difficult problem to treat in the athletic population given the significant loads placed on the sesamoids during athletic activity. In the case presented, conservative care was not effective, and the athlete underwent surgical excision of the fractured sesamoid. With use of a postoperative orthosis and cleat modification, surgical management was successful and allowed the athlete to return to her athletic endeavors without restrictions in 8 weeks.
Francel, T J; Vander Kolk, C A; Hoopes, J E; Manson, P N; Yaremchuk, M J
Seventy-two patients with Gustilo grade IIIB open tibial fractures were treated with free-tissue transfers. If successful free-tissue transfer for soft-tissue reconstruction is performed within 15 days of injury, the risk of major complications is 3.6 percent. Long-term retrospective follow-up (mean 42 months) revealed successful limb salvage in 93 percent, good aesthetic results in 80 percent, and patient satisfaction in 96 percent. However, 66 percent of patients exhibited significantly decreased range of motion of the ankle, 44 percent experienced swelling and edema requiring elastic support and activity modification, and 50 percent occasionally required an assistance device for ambulation. The long-term employment rate was 28 percent, and no patient returned to work after 2 years of unemployment. In contrast, 68 percent of amputees after lower extremity trauma over the same period returned to work within 2 years. Patients need to realize the disruptive nature of this injury on their family, job, and future.
Colman, Matthew; Wright, Adam; Gruen, Gary; Siska, Peter; Pape, Hans-Christoph; Tarkin, Ivan
Fractures of the tibial plateau present a treatment challenge and are susceptible to both prolonged operative times and high postoperative infection rates. For those fractures treated with open plating, we sought to identify the relationship between surgical site infection and prolonged operative time as well as to identify other surgical risk factors. We performed a retrospective controlled analysis of 309 consecutive unicondylar and bicondylar tibial plateau fractures treated with open plate osteosynthesis at our institution's level I trauma centre during a recent 5-year period. We recorded operative times, injury characteristics, surgical treatment, and need for operative debridement due to infection. Operative times of infected cases were compared to uncomplicated surgical cases. Multivariable logistic regression analysis was performed to identify independent risk factors for postoperative infection. Mean operative time in the infection group was 2.8h vs. 2.2h in the non-infected group (p=0.005). 15 fractures (4.9%) underwent four compartment fasciotomies as part of their treatment, with a significantly higher infection rate than those not undergoing fasciotomy (26.7% vs. 6.8%, p=0.01). Open fracture grade was also significantly related to infection rate (closed fractures: 5.3%, grade 1: 14.3%, grade 2: 40%, grade 3: 50%, p<0.0001). In the bicolumnar fracture group, use of dual-incision medial and lateral plating as compared to single incision lateral locked plating had statistically similar infection rates (13.9% vs. 8.7%, p=0.36). Multivariable logistic regression analysis of the entire study group identified longer operative times (OR 1.78, p=0.013) and open fractures (OR 7.02, p<0.001) as independent predictors of surgical site infection. Operative times approaching 3h and open fractures are related to an increased overall risk for surgical site infection after open plating of the tibial plateau. Dual incision approaches with bicolumnar plating do not
Ma, Ju-Lei; Xu, Yun-Qin; Shen, Tu-Gang; Li, Qiang
To analyze the risk factor of infection for complex tibial plateau fractures after operation. Totally clinical data of 293 patients with complex tibial plateau fractures underwent open reduction and internal fixation were retrospectively analyzed from September 2010 to March 2015, including 199 males and 94 females, ranging in age from 17 to 80 years old with an average of 47.3 years old. The possible risk factors such as gender, age, smoking, diabetes, type of fracture(open/closed), classification of open fracture(Gustilo-Anderson classification), classification of soft tissue injury in closed fracture (Tscherne-Gotzen classification), fracture classification(Schatzker V/VI), osteofascial compartment syndrome, ASA score, anesthesia, timing of surgery, operative time(<=150 min/>150 min), surgical approach, combined approach or not, internal fixation site were studied. The multivariate Logistic regression model was used to analyze the risk factors. Twelve patients were infected of all 293 patients after operation, the infection rate was 4.10%. Univariate analysis showed that fracture type(χ ² =14.496, P =0.001), fracture classification(χ²=4.560, P =0.033), osteofascial compartment syndrome(χ²=15.631, P =0.001), operative time(χ²=11.233, P =0.001) were correlated with complex tibial plateau fractures postoperative infection. Multivariate analysis showed that open fractures(χ²=9.696, P =0.002) and osteofascial compartment syndrome(χ²=9.119, P =0.003) were complex tibial plateau fracture risk factors for infection after operation. Open fractures and osteofascial compartment syndrome are risk factor of complex tibial plateau fracture for infection after operation. While through debridement for open fracture patients, early diagnosis and promt treatment for osteofascial compartment syndrome could reduce incidence of infection.
e Albuquerque, Rodrigo Pires; Giordano, Vincenzo; Carvalho, Antônio Carlos Pires; Puell, Thiago; e Albuquerque, Maria Isabel Pires; do Amaral, Ney Pecegueiro
Simultaneous bilateral avulsion fracture of the tibial tuberosity in teenagers is a rare lesion. We describe the first case in the literature, in a teenage girl who sustained a fall while jumping during a volleyball match. No predisposing factors were iden tified. The lesions were treated with open surgical reduction and internal fixation. The aim of the present study was to present a case of simultaneous bilateral avulsion fracture of the tibial tuberosity in a teenage girl and the therapy used. PMID:27042651
E Albuquerque, Rodrigo Pires; Giordano, Vincenzo; Carvalho, Antônio Carlos Pires; Puell, Thiago; E Albuquerque, Maria Isabel Pires; do Amaral, Ney Pecegueiro
Simultaneous bilateral avulsion fracture of the tibial tuberosity in teenagers is a rare lesion. We describe the first case in the literature, in a teenage girl who sustained a fall while jumping during a volleyball match. No predisposing factors were iden tified. The lesions were treated with open surgical reduction and internal fixation. The aim of the present study was to present a case of simultaneous bilateral avulsion fracture of the tibial tuberosity in a teenage girl and the therapy used.
Nimityongskul, P; Montague, W L; Anderson, L D
Between January 1982 and May 1985, eight patients with avulsion fractures of tibial tuberosity were seen at the University of South Alabama Medical Center. All were boys, average age, 15 years 8 months. Six of eight had a positive history of Osgood-Schlatter disease. Seven patients underwent open reduction and internal fixation, one had closed reduction and cast. Followup ranged from 5 months to 3.5 years, averaging 19.5 months. All, except one who had lateral meniscectomy, regained practically full ROM and reported no pain or limitation of activities. No patient developed genu recurvatum deformity or leg length discrepancy due to the injury. Open reduction and internal fixation is the treatment of choice in displaced intra-articular fractures. Lateral parapatellar incision is a more direct approach to this fracture and is less likely to injure the infrapatellar branch of the saphenous nerve.
Gordon, J Eric; Gregush, Ronald V; Schoenecker, Perry L; Dobbs, Matthew B; Luhmann, Scott J
A retrospective review of 60 diaphyseal tibia fractures (31 closed and 29 open fractures) treated with flexible intramedullary fixation was conducted. All charts and radiographs were reviewed. Children ranged in age from 5.1 to 17 years. Fifty patients with 51 fractures were followed up until union and comprised the study group. The mean follow-up period for these 50 patients was 79 weeks. Forty-five fractures achieved bony union within 18 weeks (mean, 8 weeks). Five patients (11%) had delayed healing (3 had delayed unions that ultimately healed with casting or observation, and 2 had nonunions that required secondary procedures to achieve union [1 patient underwent a fibular osteotomy, and 1 underwent exchange nailing with a reamed tibial nail]). These 5 fractures ultimately healed, with a mean time to union of 41 weeks. Patients with delayed healing tended to be older (mean age, 14.1 years) versus the study population as a whole (mean age, 11.7 years). In addition to delayed union, other complications were observed in the study population. One patient healed with malunion (13-degree valgus), requiring corrective osteotomy. One patient with a grade II open fracture was diagnosed with osteomyelitis at the fracture site after attaining bony union. Two patients developed nail migration through the skin, requiring modification or nail removal. The fixation of pediatric diaphyseal tibia fractures with titanium elastic nails is effective but has a substantial rate of delayed healing, particularly in older patients.
Ellanti, Prasad; Hammad, Yassir; Kosutic, Damir; Grieve, Philip P
Fractures can be irreducible for several reasons, including soft tissue or bone fragment interposition. We report an unusual fracture configuration of a comminuted tibial pilon fracture in which the distal fibular shaft fragment was occupying the medullary canal of the proximal tibial shaft fragment and inhibiting reduction and fixation. To the best of our knowledge, this has not been previously reported in a published study. Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Robertson, Greg A J; Wong, Seng J; Wood, Alexander M
AIM To systemically review all studies reporting return to sport following tibial plateau fracture, in order to provide information on return rates and times to sport, and to assess variations in sporting outcome for different treatment methods. METHODS A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, MEDLINE, PEDro, Scopus, SPORTDiscus and Web of Science was performed in January 2017 using the keywords “tibial”, “plateau”, “fractures”, “knee”, “athletes”, “sports”, “non-operative”, “conservative”, “operative”, “return to sport”. All studies which recorded return rates and times to sport following tibial plateau fractures were included. RESULTS Twenty-seven studies were included: 1 was a randomised controlled trial, 7 were prospective cohort studies, 16 were retrospective cohort studies, 3 were case series. One study reported on the outcome of conservative management (n = 3); 27 reported on the outcome of surgical management (n = 917). Nine studies reported on Open Reduction Internal Fixation (ORIF) (n = 193), 11 on Arthroscopic-Assisted Reduction Internal Fixation (ARIF) (n = 253) and 7 on Frame-Assisted Fixation (FRAME) (n = 262). All studies recorded “return to sport” rates. Only one study recorded a “return to sport” time. The return rate to sport for the total cohort was 70%. For the conservatively-managed fractures, the return rate was 100%. For the surgically-managed fractures, the return rate was 70%. For fractures managed with ORIF, the return rate was 60%. For fractures managed with ARIF, the return rate was 83%. For fractures managed with FRAME was 52%. The return rate for ARIF was found to be significantly greater than that for ORIF (OR 3.22, 95%CI: 2.09-4.97, P < 0.001) and for FRAME (OR 4.33, 95%CI: 2.89-6.50, P < 0.001). No difference was found between the return rates for ORIF and FRAME (OR 1.35, 95%CI: 0.92-1.96, P = 0.122). The recorded return time was 6.9 mo (median), from a study
Gary, Joshua L; Sciadini, Marcus F
Minimally invasive osteosynthesis of proximal tibial fractures has grown in popularity in recent years. This article describes a patient with a Schatzker type VI proximal tibial fracture (AO/OTA type 41.C3) and previous compartment syndrome treated with definitive fixation 8 weeks after initial injury with a precontoured proximal tibial plate and a distal targeting device. Brisk bleeding occurred during percutaneous insertion of a cortical screw at the midshaft of the tibia. Surgical exploration revealed sidewall tearing of the anterior tibial artery and vein, which were clipped at the screw insertion site. After the bleeding was controlled, the patient had a strong palpable posterior tibial pulse with no palpable dorsalis pedis pulse, and the foot remained well perfused. Function of the deep peroneal nerve was normal postoperatively. Previous concerns regarding the percutaneous treatment of proximal tibial fractures have focused on the risks of damage to the superficial peroneal nerve from distal screws. Based on cadaveric studies, percutaneously and laterally based screw placement in the distal tibial metaphysis threatens injury to the anterior tibial system. However, with alterations to the normal anatomy caused by severe trauma, previously described safe zones may be changed and neurovascular structures may be exposed to risk in locations that were previously thought safe. Copyright 2012, SLACK Incorporated.
Rolvien, Tim; Barvencik, Florian; Klatte, Till Orla; Busse, Björn; Hahn, Michael; Rueger, Johannes Maria; Rupprecht, Martin
The use of beta-tricalciumphospate (ß-TCP, Cerasorb®) ceramics as an alternative for autologous bone-grafting has been outlined previously, however with no study focusing on both clinical and histological outcomes of ß-TCP application in patients with multi-fragment tibial plateau fractures. The aim of this study was to analyze the long-term results of ß-TCP in patients with tibial plateau fractures. 52 patients were included in this study. All patients underwent open surgery with ß-TCP block or granulate application. After a mean follow-up of 36months (14-64months), the patients were reviewed. Radiography and computed-tomography were performed, while the Rasmussen score was obtained for clinical outcome. Furthermore, seven patients underwent biopsy during hardware removal, which was subsequently analyzed by histology and backscattered electron microscopy (BSEM). An excellent reduction with two millimeters or less of residual incongruity was achieved in 83% of the patients. At follow-up, no further changes occurred and no nonunions were observed. Functional outcome was good to excellent in 82%. Four patients underwent revision surgery due to reasons unrelated to the bone substitute material. Histologic analyses indicated that new bone was built around the ß-TCP-grafts, however a complete resorption of ß-TCP was not observed. ß-TCP combined with internal fixation represents an effective and safe treatment of tibial plateau depression fractures with good functional recovery. While its osteoconductivity seems to be successful, the biological degradation and replacement of ß-TCP is less pronounced in humans than previous animal studies have indicated. Copyright © 2017 Elsevier B.V. All rights reserved.
Houben, I B; Raaben, M; Van Basten Batenburg, M; Blokhuis, T J
The relation between timing of weight bearing after a fracture and the healing outcome is yet to be established, thereby limiting the implementation of a possibly beneficial effect for our patients. The current study was undertaken to determine the effect of timing of weight bearing after a surgically treated tibial shaft fracture. Surgically treated diaphyseal tibial fractures were retrospectively studied between 2007 and 2015. The timing of initial weight bearing (IWB) was analysed as a predictor for impaired healing in a multivariate regression. Totally, 166 diaphyseal tibial fractures were included, 86 cases with impaired healing and 80 with normal healing. The mean age was 38.7 years (range 16-89). The mean time until IWB was significantly shorter in the normal fracture healing group (2.6 vs 7.4 weeks, p < 0.001). Correlation analysis yielded four possible confounders: infection requiring surgical intervention, fracture type, fasciotomy and open fractures. Logistic regression identified IWB as an independent predictor for impaired healing with an odds ratio of 1.13 per week delay (95% CI 1.03-1.25). Delay in initial weight bearing is independently associated with impaired fracture healing in surgically treated tibial shaft fractures. Unlike other factors such as fracture type or soft tissue condition, early resumption of weight bearing can be influenced by the treating physician and this factor therefore has a direct clinical relevance. This study indicates that early resumption of weight bearing should be the treatment goal in fracture fixation. 3b.
Al-Ashhab, Mohamed E
Management of severely comminuted, complete articular tibial pilon fractures (Rüedi and Allgöwer type III) remains a challenge, with few treatment options providing good clinical outcomes. Twenty patients with severely comminuted tibial pilon fractures underwent primary ankle arthrodesis with a retrograde calcaneal nail and autogenous fibular bone graft. The fusion rate was 100% and the varus malunion rate was 10%. Fracture union occurred at a mean of 16 weeks (range, 13-18 weeks) postoperatively. Primary ankle arthrodesis is a successful method for treating highly comminuted tibial pilon fractures, having a low complication rate and a high satisfaction score. [Orthopedics. 2017; 40(2):e378-e381.]. Copyright 2016, SLACK Incorporated.
Beaman, Douglas N; Gellman, Richard
Posttraumatic arthritis and prolonged recovery are typical after a severely comminuted tibial pilon fracture, and ankle arthrodesis is a common salvage procedure. However, few reports discuss the option of immediate arthrodesis, which may be a potentially viable approach to accelerate overall recovery in patients with severe fracture patterns. (1) How long does it take the fracture to heal and the arthrodesis to fuse when primary ankle arthrodesis is a component of initial fracture management? (2) How do these patients fare clinically in terms of modified American Orthopaedic Foot and Ankle Society (AOFAS) scores and activity levels after this treatment? (3) Does primary ankle arthrodesis heal in an acceptable position when anterior ankle arthrodesis plates are used? During a 2-year period, we performed open fracture reduction and internal fixation in 63 patients. Eleven patients (12 ankles) with severely comminuted high-energy tibial pilon fractures were retrospectively reviewed after surgical treatment with primary ankle arthrodesis and fracture reduction. Average patient age was 58 years, and minimum followup was 6 months (average, 14 months; range, 6-22 months). Anatomically designed anterior ankle arthrodesis plates were used in 10 ankles. Ring external fixation was used in nine ankles with concomitant tibia fracture or in instances requiring additional fixation. Clinical evaluation included chart review, interview, the AOFAS ankle-hindfoot score, and radiographic evaluation. All of the ankle arthrodeses healed at an average of 4.4 months (range, 3-5 months). One patient had a nonunion at the metaphyseal fracture, which healed with revision surgery. The average AOFAS ankle-hindfoot score was 83 with 88% having an excellent or good result. Radiographic and clinical analysis confirmed a plantigrade foot without malalignment. No patients required revision surgery for malunion. Primary ankle arthrodesis combined with fracture reduction for the severely comminuted
Milgrom, Charles; Burr, David B; Finestone, Aharon S; Voloshin, Arkady
Previous human in vivo tibial strain measurements from surface strain gauges during vigorous activities were found to be below the threshold value of repetitive cyclical loading at 2500 microstrain in tension necessary to reduce the fatigue life of bone, based on ex vivo studies. Therefore it has been hypothesized that an intermediate bone remodeling response might play a role in the development of tibial stress fractures. In young adults tibial stress fractures are usually oblique, suggesting that they are the result of failure under shear strain. Strains were measured using surface mounted unstacked 45° rosette strain gauges on the posterior aspect of the flat medial cortex just below the tibial midshaft, in a 48year old male subject while performing vertical jumps, staircase jumps and running up and down stadium stairs. Shear strains approaching 5000 microstrain were recorded during stair jumping and vertical standing jumps. Shear strains above 1250 microstrain were recorded during runs up and down stadium steps. Based on predictions from ex vivo studies, stair and vertical jumping tibial shear strain in the test subject was high enough to potentially produce tibial stress fracture subsequent to repetitive cyclic loading without necessarily requiring an intermediate remodeling response to microdamage. Copyright © 2015 Elsevier Inc. All rights reserved.
Meardon, Stacey A; Willson, John D; Gries, Samantha R; Kernozek, Thomas W; Derrick, Timothy R
Combinations of smaller bone geometry and greater applied loads may contribute to tibial stress fracture. We examined tibial bone stress, accounting for geometry and applied loads, in runners with stress fracture. 23 runners with a history of tibial stress fracture & 23 matched controls ran over a force platform while 3-D kinematic and kinetic data were collected. An elliptical model of the distal 1/3 tibia cross section was used to estimate stress at 4 locations (anterior, posterior, medial and lateral). Inner and outer radii for the model were obtained from 2 planar x-ray images. Bone stress differences were assessed using two-factor ANOVA (α=0.05). Key contributors to observed stress differences between groups were examined using stepwise regression. Runners with tibial stress fracture experienced greater anterior tension and posterior compression at the distal tibia. Location, but not group, differences in shear stress were observed. Stepwise regression revealed that anterior-posterior outer diameter of the tibia and the sagittal plane bending moment explained >80% of the variance in anterior and posterior bone stress. Runners with tibial stress fracture displayed greater stress anteriorly and posteriorly at the distal tibia. Elevated tibial stress was associated with smaller bone geometry and greater bending moments about the medial-lateral axis of the tibia. Future research needs to identify key running mechanics associated with the sagittal plane bending moment at the distal tibia as well as to identify ways to improve bone geometry in runners in order to better guide preventative and rehabilitative efforts. Copyright © 2015 Elsevier Ltd. All rights reserved.
Kayali, Cemil; Oztürk, Hasan; Altay, Taskin; Reisoglu, Ali; Agus, Haluk
The aim of our study was to evaluate the results of lateral tibial plateau fractures treated with arthroscopically assisted percutaneous osteosynthesis (AAPO). Twenty-one patients (14 men and 7 women) with a mean age of 41 years underwent AAPO to repair low-energy Schatzker I-III tibial plateau fractures. Under pneumatic tourniquet, we reduced and fixed the fracture with 1 or 2 subchondral cannulated screws. Accompanying lesions included 10 meniscus tears, which we partially excised in 9 patients and repaired in 1 patient. On the second postoperative day, patients began range-of-motion exercises. We encouraged partial and full weight-bearing by the sixth and tenth weeks, respectively. The mean follow-up period was 38 (range 12-96) months, and we evaluated the patients using Rasmussen's clinical and radiologic criteria. We used a t test for statistical analysis. There were 13 excellent (62%), 6 good (28%) and 2 fair (10%) clinical results, and 11 excellent (52%), 7 good (33%) and 3 fair (14%) radiologic results. We observed mild or moderate arthritic changes in 5 patients (24%). There were no infection or wound problems, but we removed hardware in 4 patients. Arthroscopically assisted treatment of lateral tibial plateau fractures yields satisfactory results and can be accepted as an alternative and effective method for the treatment of low-energy tibial plateau fractures.
Tibial plateau fractures overall and especially in winter sports are rare. However, the incidence in recent years is increasing. In a retrospective study from 2009-2012, we found 52 injuries affiliated with winter sports. Noticeable was the high rate of severe injury patterns. In 20 of the 52 cases, there were complete articular or bicondylar fractures (38 %). In 25 cases (48 %), fragment dislocation corresponding to the Moore classification was observed. The operative algorithm was based on the initial soft tissue damage and the type of fracture. A two or more stage procedure with first line soft tissue management and temporary external fixation stabilization was performed 12 times. The final internal osteosynthesis was based on the morphology of the fracture, i.e., direct exposition and stabilization of relevant fracture patterns. In 24 cases (46 %), there was a need for two (or more) approaches. In the anterior aspect of the tibial head, customary implants were used; posterior pathologies were stabilized with low-dimension implants. Summarizing with regard to the literature, there is a more discriminating view of tibial plateau fractures, regarding all relevant fracture patterns. Thus, different options in operative access and choice of implants can be made.
Perez Carro, L
Arthroscopic assessment and treatment of tibial plateau fractures has gained popularity in recent years. This article describes some maneuvers to facilitate the management of these fractures with the arthroscope. We use a 14-mm rounded curved periosteal elevator to manipulate fragments within the joint instead of using a probe. To facilitate visualization of fractures, we describe the use of loop sutures around the meniscus to retract the meniscus when there is a tear in the meniscus. We suggest the use of the arthroscope for directly viewing the interosseous space to be sure that any internal fixation devices remain outside the articular space. The use of these tactics will allow a faster, more accurate reduction with less radiation exposure in patients with displaced tibial plateau fractures.
St-Jean, G; Clem, M F; DeBowes, R M
Medical records of 5 calves with tibial fractures that were reduced and stabilized by transfixation pinning and casting were reviewed. Multiple Steinmann pins were placed transversely through proximal and distal fracture fragments, and the pin ends were incorporated in fiberglass cast material after fracture reduction. Cast material serves as an external frame to maintain pin position and fracture reduction. Calves were between 2 weeks and 6 months old and weighed between 40 and 180 kg. Three fractures were spiral in configuration and 2 were comminuted. One tibial fracture was open. After surgery, all calves were ambulatory within 24 hours. To improve tarsal flexion and achieve normal stance in 3 calves, cast revision was required on the caudal aspect of the limb. Good radiographic and clinical evidence of stability was observed in 5 to 10 weeks (mean 8 weeks), at which time the pis and cast were removed. Return to normal function was rapid and judged to be excellent at follow-up evaluation 3 to 12 months later. Advantages of transfixation pinning and casting in management of tibial fractures include flexibility in pin positioning, adequate maintenance of reduction, early return to weight-bearing status, joint mobility, and ease of ambulation. The inability to adjust fixation and alignment after cast application is a disadvantage of this technique compared with other external fixators.
Rotter, R; Gierer, P
The anatomical reconstruction of tibial pilon fractures is a major challenge with respect to preoperative planning, time management and the intraoperative procedure. Presentation of the various surgical procedures available and the clinical outcome. The established open reduction and internal plate fixation procedures form the basis for new minimally invasive treatment concepts. The current results of comparative studies and basic literature are discussed. The treatment result depends on the severity of the initial fracture and accompanying soft tissue damage. Essential is an anatomical reduction with an articular displacement of less than 2 mm. Overall, only approximately half of all patients return to work within 1 year. The fixation procedure used is not relevant for this purpose. Both plate fixation and the combination of external fixator plus minimally invasive articular reconstruction with and without arthroscopy achieve equivalent results. Good clinical results can be achieved by an accurate preoperative planning with respect to the surgical procedure, time of surgery and the surgical steps. In cases of disregarding these points and inadequate surgical expertise, loss of function and reduced quality of life are impending.
Stannard, James P; Lopez, Robert; Volgas, David
The purpose of this study was to document the pattern of ligament and meniscal injuries that occur during high-energy tibial plateau fractures. One hundred three patients with fractures due to high-energy mechanisms were evaluated with knee magnetic resonance imaging (MRI). All studies were read by a single musculoskeletal radiologist who was blinded to surgical and physical exam findings. Pertinent demographic information was obtained. There were 66 patients with AO/OTA type 41C fractures and 37 patients with AO/OTA type 41B fractures. Seventy-three (71%) patients tore at least one major ligament group, and 55 (53%) patients tore multiple ligaments. There were 53 torn ligaments in AO/OTA type 41C fractures (80%) compared with 20 torn ligaments in AO/OTA type 41B fractures (54%) (p < 0.001, Fisher's exact test). Using Schatzker's classification, we found the following correlation: type I, 13 fractures with 6 ligaments (46%); type II, 11 fractures with 5 ligaments (45%); type IV, 13 fractures with 9 ligaments (69%); type V, 13 fractures with 11 ligaments (85%); and type VI, 53 fractures with 42 ligaments (79%). A significant difference exists between the groups regarding the incidence of ligament injuries (p < 0.05) and also regarding high-energy (type IV, V, VI) versus low-energy (type I, II, III) fracture patterns. The incidence of knee dislocation was 32% for AO/OTA type 41B fractures and 23% for AO/OTA type 41C fractures. Knee dislocations (dislocated on presentation, bicruciate injury, or at least three ligament groups torn with a dislocatable knee) were most common in Schatzker type IV fractures (46%). Fifty patients sustained meniscus tears (49%), with 25 medial menisci and 35 lateral menisci injuries. Tibial plateau fractures frequently have important soft tissue injuries that are difficult to diagnose on physical examination. High-energy fracture patterns (AO/OTA type 41C or Schatzker type IV, V, VI) clearly have a significantly higher incidence of ligament
Ankle TOTAL 79 Lateral ankle sprain 69 Medial ankle ... sprain 3 Ankle other 7 Foot TOTAL 129 Acute metatarsal fracture 3 Metatarsal stress fracture 23 Metatarsal stress syndrome 3 Neuroma 6 Painful 1st MTP... ankle sprain 26 Medial ankle sprain 8 Ankle other 12 Foot TOTAL 86 Metatarsal stress syndrome 5 Metatarsal stress fracture 6 Painful 1 st MTP joint
Encinas-Ullán, C A; Fernandez-Fernandez, R; Rubio-Suárez, J C; Gil-Garay, E
Tibial plafond fractures are one of the most challenging injuries in orthopaedic surgery. Their results could be improved by following the new guidelines for the management, and modern plating techniques. The results and complication rate between anteromedial and anterolateral approach for open reduction and internal fixation of these fractures were compared. A study was conducted on 40 patients treated by open reduction an internal fixation between 2007 and 2008. The surgical approach was selected by the surgeon in charge, depending on fracture pattern and skin situation. Patients were evaluated clinically and radiographically by an independent orthopaedic surgeon, not involved in the surgical procedure, using clinical (American Orthopaedic Foot and Ankle Society score) and radiological criteria at a minimum of two years. The appearance of complications after both approaches was recorded. Forty patients were included. The mean age was 53 years, with 24 males and 16 females. Seventeen of the injuries were of high energy, and there were 8 open fractures (3 of type i, 4 type ii and one type iii), and 12 of the closed injuries were grade ii or iii in the Tscherne classification. Six patients (15%) had associated injuries. At final follow-up there were 33 (82%) excellent or good results. No statistical differences were found between either surgical approach regarding time to bone union, rate of delayed union and infection rate. Three plates of the anteromedial group and none of the anterolateral group needed to be removed. Open reduction and internal fixation of distal tibia fractures produced reliable results, with no statistical differences found between anteromedial and anterolateral surgical approaches. Clinical and radiological results and complication rate were mainly related to the fracture type. Copyright © 2012 SECOT. Published by Elsevier Espana. All rights reserved.
Steinberg, Ely L; Geller, David S; Yacoubian, Shahan V; Shasha, Nadav; Dekel, Shmuel; Lorich, Dean G
To evaluate and present our experience using the expandable nail system for the treatment of acute tibial shaft fractures. Retrospective study. Two level-1 trauma centers-University teaching hospitals. Fifty-four consecutive patients were treated by this nail system for acute tibial shaft fracture. Two nail diameters were used, 8.5 mm and 10 mm. Operation, hospitalization and healing times, reaming versus nonreaming, isolated versus multiple injuries, and reoperations were recorded and analyzed statistically. Follow-up was obtained either until fracture healing or for a minimum of 1 year with an average of 14 months (12 to 24). All fractures healed in an average time of 72 days (21 to 204). The average healing times for patients treated with 8.5-mm and 10-mm nails were 77.2 days (27 to 204) and 63.4 days (21 to 121), respectively. Average operative time was 103 minutes (40 to 185) if reamed and 56 minutes (30 to 80) if unreamed. Average healing times were 65.4 days (21 to 190) if reamed and 79.5 days (42 to 204) if unreamed. There were 11 complications (20.4%) related to the nailing: 3 deep infections, 2 superficial infections, 2 bone shortenings of 1 cm secondary to nail protrusion in the knee, 1 compartment syndrome, 1 fracture propagation, 1 distal malalignment, and 1 delayed union. Hardware was removed in 6 patients (3 infections, 2 patients' request and 1 protrusion into the knee), and 1 additional patient underwent exchange nailing due to a delayed union. The expandable nail offers the theoretical advantages of improved load sharing and rotational control without the need for interlocking screws. This study demonstrates satisfactory healing and alignment for the treatment of tibial shaft fractures using this device. However, caution must be exercised when using this nail in cases of significant comminution and in cases where the fracture pattern involves the more proximal or distal aspect of the tibial shaft.
Sinigaglia, Riccardo; Gigante, Cosimo; Basso, Giampaolo; Turra, Sisto
Our purpose is to report a very rare case of proximal tibia triplane fracture, focusing the particular pattern of fracture and the long-term follow-up result. The triplane fracture is an exceptional fracture that occurs in the 3 planes (coronal, sagittal and transverse) close to the end of the growth period. A 15-year-old boy was admitted to our Center for a left femoral diaphyseal fracture and an ipsilateral lateral proximal tibia triplane fracture following a road accident. The femur was fixed with an intramedullary nail, the triplane fracture was anatomically reduced and percutaneously fixed. After 4 years follow-up, the knee was stable and with no complaints. Its range of motion was complete. Radiographs and MRI did not show any abnormality on the left leg and knee. In order to stabilize a proximal tibia triplane fracture a surgical internal fixation is usually required, with the possibility of a good long-term outcome also due to the growth potential remaining, if physeal arrest does not occur.
Beltsios, Michail; Mavrogenis, Andreas F; Savvidou, Olga D; Karamanis, Eirineos; Kokkalis, Zinon T; Papagelopoulos, Panayiotis J
To compare modular monolateral external fixators with single monolateral external fixators for the treatment of open and complex tibial shaft fractures, to determine the optimal construct for fracture union. A total of 223 tibial shaft fractures in 212 patients were treated with a monolateral external fixator from 2005 to 2011; 112 fractures were treated with a modular external fixator with ball-joints (group A), and 111 fractures were treated with a single external fixator without ball-joints (group B). The mean follow-up was 2.9 years. We retrospectively evaluated the operative time for fracture reduction with the external fixator, pain and range of motion of the knee and ankle joints, time to union, rate of malunion, reoperations and revisions of the external fixators, and complications. The time for fracture reduction was statistically higher in group B; the rate of union was statistically higher in group B; the rate of nonunion was statistically higher in group A; the mean time to union was statistically higher in group A; the rate of reoperations was statistically higher in group A; and the rate of revision of the external fixator was statistically higher in group A. Pain, range of motion of the knee and ankle joints, rates of delayed union, malunion and complications were similar. Although modular external fixators are associated with faster intraoperative fracture reduction with the external fixator, single external fixators are associated with significantly better rates of union and reoperations; the rates of delayed union, malunion and complications are similar.
Muzaffar, Nasir; Bhat, Rafiq; Yasin, Mohammad
Background The management of distal tibia fractures continues to remain a source of controversy and debate. Objectives The aim of this study was to evaluate the various complications of minimally invasive percutaneous plate osteosynthesis (MIPPO) using a locking plate for closed fractures of distal tibia in a retrospective study. Patients and Methods Twenty-five patients with distal tibial fractures, treated by minimally invasive percutaneous plate osteosynthesis, were evaluated in a retrospective study. We studied the rate, probable etiological factors and preventive and corrective measures of various complications associated with minimally invasive plating of distal tibia. Results Mean age of the patients was 41.16 years (range 22 - 65). There were 13 male and 12 female patients. All fractures united at an average duration of 16.8 weeks. There were two cases of superficial and two cases of deep infection, and deep infections required removal of hardware for cure. There were four cases of ankle stiffness, most of them occurring in intra-articular fractures, three cases of palpable implant, three cases of malunion, one case of loss of reduction and one patient required reoperation. The average AO foot and ankle score was 83.6. Conclusions We found MIPPO using locking plate to be a safe and effective method for the treatment of distal tibial fractures in properly selected patients yet can result in a variety of complications if proper precautions before, during and after surgery are not taken care of. PMID:28182170
Muzaffar, Nasir; Bhat, Rafiq; Yasin, Mohammad
The management of distal tibia fractures continues to remain a source of controversy and debate. The aim of this study was to evaluate the various complications of minimally invasive percutaneous plate osteosynthesis (MIPPO) using a locking plate for closed fractures of distal tibia in a retrospective study. Twenty-five patients with distal tibial fractures, treated by minimally invasive percutaneous plate osteosynthesis, were evaluated in a retrospective study. We studied the rate, probable etiological factors and preventive and corrective measures of various complications associated with minimally invasive plating of distal tibia. Mean age of the patients was 41.16 years (range 22 - 65). There were 13 male and 12 female patients. All fractures united at an average duration of 16.8 weeks. There were two cases of superficial and two cases of deep infection, and deep infections required removal of hardware for cure. There were four cases of ankle stiffness, most of them occurring in intra-articular fractures, three cases of palpable implant, three cases of malunion, one case of loss of reduction and one patient required reoperation. The average AO foot and ankle score was 83.6. We found MIPPO using locking plate to be a safe and effective method for the treatment of distal tibial fractures in properly selected patients yet can result in a variety of complications if proper precautions before, during and after surgery are not taken care of.
Sankar, Wudbhav N; Jones, Kristofer J; David Horn, B; Wells, Lawrence
The purpose of our study was to investigate the safety and efficacy of elastic stable intramedullary nailing for unstable pediatric tibial shaft fractures using titanium elastic nails (TENs). To our knowledge, this is the largest series reported in the literature of this specific fixation technique. We reviewed all children with tibial shaft fractures treated operatively at our tertiary care children's hospital to find those patients who underwent fixation with TENs. Between 1998 and 2005, we identified 19 consecutive patients who satisfied inclusion criteria. The average age of the patients in our series was 12.2 years (range 7.2-16 years), and mean follow-up was 15.7 months (range 6-28 months). Patient charts and radiographs were retrospectively reviewed to gather the clinical data. Outcomes were classified as excellent, satisfactory, or poor according to the Flynn classification for flexible nail fixation. All patients achieved complete healing at a mean of 11.0 weeks (range 6-18 weeks). At final follow-up, mean angulation was 2 degrees (range 0 degrees -6 degrees ) in the sagittal plane and 3 degrees in the coronal plane (range 0 degrees -9 degrees ). Five patients (26%) complained of irritation at the nail entry site; there were no leg length discrepancies or physeal arrests as a result of treatment. Two patients required remanipulation after the index procedure to maintain adequate alignment. According to the Flynn classification, we had 12 excellent, six satisfactory, and one poor result. Although the indications for operative fixation of pediatric tibial shaft fractures are rare, occasionally surgical treatment is warranted. Based on our results, elastic stable intramedullary nailing with titanium elastic nails is an effective surgical technique which allows rapid healing of tibial shaft fractures with an acceptable rate of complications.
Zamboni, Caio; Campos, Felipe Augusto Garcez de; Foni, Noel Oizerovici; Souza, Rafael Carboni; Christian, Ralph Walter; Mercadante, Marcelo Tomanik
The authors report on a case of tibial shaft fracture associated with ankle injury. The clinical, radiological and surgical characteristics are discussed. Assessment of associated injuries is often overlooked and these injuries are hard to diagnose. When torque occurs in the lower limb, the ankle becomes susceptible to simultaneous injury. It is essential to make careful assessment based on clinical, radiographic, intraoperative and postoperative characteristics in order to attain functional recovery.
Metcalfe, David; Hickson, Craig J; McKee, Lesley; Griffin, Xavier L
It is uncertain whether external fixation or open reduction internal fixation (ORIF) is optimal for patients with bicondylar tibial plateau fractures. A systematic review using Ovid MEDLINE, Embase Classic, Embase, AMED, the Cochrane Library, Open Grey, Orthopaedic Proceedings, WHO International Clinical Trials Registry Platform, Current Controlled Trials, US National Institute for Health Trials Registry, and the Cochrane Central Register of Controlled Trials. The search was conducted on 3rd October 2014 and no language limits were applied. Inclusion criteria were all clinical study designs comparing external fixation with open reduction internal fixation of bicondylar tibial plateau fractures. Studies of only one treatment modality were excluded, as were those that included unicondylar tibial plateau fractures. Treatment effects from studies reporting dichotomous outcomes were summarised using odds ratios. Continuous outcomes were converted to standardized mean differences to assess the treatment effect, and inverse variance methods used to combine data. A fixed effect model was used for meta-analyses. Patients undergoing external fixation were more likely to have returned to preinjury activities by six and twelve months (P = 0.030) but not at 24 months follow-up. However, external fixation was complicated by a greater number of infections (OR 2.59, 95 % CI 1.25-5.36, P = 0.01). There were no statistically significant differences in the rates of deep infection, venous thromboembolism, compartment syndrome, or need for re-operation between the two groups. Although external fixation and ORIF are associated with different complication profiles, both are acceptable strategies for managing bicondylar tibial plateau fractures.
Gui, Jing-xiong; Ou, Ju-lun; Wang, Xiao-ping; Zhu, Xiao-hua; Guo, Sheng; Xu, Guo-tai; Deng, Zhi-cheng
To explore the effect of a self-made guiding needle of steel wire in guiding the wire through the tibial tunnel for the treatment of avulsion fractures of tibial posterior cruciate ligament with open reduction and wire fixation. From February 2011 to June 2014, a total of 22 patients with avulsion fractures of tibial posterior cruciate ligament underwent surgical treatments were analyzed, including 14 males and 8 females with an average age of 35.6 years old (ranged, 17 to 63 years old). According to Meyers classification, 9 patients were classified as type II, 13 patients were classified as type III. All the patients underwent open reduction and wire fixation with medial knee "L" shape approach. A wire guiding needle was used to guide the wire through the tibial tunnel during operation. With the assistance of wire guidance needles, wires passed through the tibial tunnel rapidly during the operation in all the 22 patients. All the patients were followed up, X-ray imagings 6 months after operation showed the fractures healed well. The average follow-up time in all patients was 6 months (ranged, 6 to 12 months). The averaged Lysholm knee score in 22 knee was 92.7 +/- 3.4. All patients' posterior drawer test were negative. Self-made wire guiding needle can simplify the operation procedures in which the wires pass through the tibial tunnel, shorten the operation time, reduce the surgical trauma and complications, and be worthy of clinical application.
Kreb, Dieuwertje L; Blokhuis, Taco J; van Wessem, Karlijn J P; Bemelman, Mike; Lansink, Koen W W; Leenen, Luke P H
Intramedullary fixation is the treatment of choice for diaphyseal fractures of the femur and tibia. Locking the implant can sometimes be cumbersome and time consuming. In our institution, fractures with axial and rotational stability are treated with intramedullary nailing without interlocking. All consecutive patients presented in the University Medical Center Utrecht from October 2003 to August 2009 with acute traumatic diaphyseal fractures of the tibia or femur that were considered axial and rotational stable were included. They underwent internal fixation using intramedullary nails without interlocking. Patient records were evaluated for duration of surgery, perioperative complications, consolidation time and re-operations. Twenty-nine long bone fractures were treated in 27 patients: 20 men and 7 women, with an average age of 28.9 years (range 15.6-54.4). There were 12 femoral fractures and 17 tibial fractures. Sixteen fractures were closed and 13 were open (10 Gustilo 1, 3 Gustilo 2). The mean operating time was 43 min (range 18-68 min) for tibial fractures and 55 min (range 47-150 min) for femoral fractures. Postoperative complications occurred in six patients. Two patients (three fractures) were lost to follow-up. Healing occurred in 25 of the 26 remaining fractures (96 %) without additional interventions. One tibia was secondarily converted to a standard locked nail because of axial and rotational instability. All patients returned to their pre-injury level of activity. The use of intramedullary nailing without interlocking is associated with minimal complications in selected fractures. The advantages include a short operating time and the simplicity of its application.
Little, Z; Smith, T O; McMahon, S E; Cooper, C; Trompeter, A; Pearse, M; Britten, S; Rogers, B; Sharma, H; Narayan, B; Costa, M; Beard, D J; Hing, C B
Segmental tibial fractures are complex injuries with a prolonged recovery time. Current definitive treatment options include intramedullary fixation or a circular external fixator. However, there is uncertainty as to which surgical option is preferable and there are no sufficiently rigorous multi-centre trials that have answered this question. The objective of this study was to determine whether patient and surgeon opinion was permissive for a randomised controlled trial (RCT) comparing intramedullary nailing to the application of a circular external fixator. A convenience questionnaire survey of attending surgeons was conducted during the United Kingdom's Orthopaedic Trauma Society annual meeting 2017 to determine the treatment modalities used for a segmental tibial fracture (n=63). Patient opinion was obtained from clinical patients who had been treated for a segmental tibial fracture as part of a patient and public involvement focus group with questions covering the domains of surgical preference, treatment expectations, outcome, the consent process and follow-up regime (n=5). Based on the surgeon survey, 39% routinely use circular frame fixation following segmental tibial fracture compared to 61% who use nail fixation. Nail fixation was reported as the treatment of choice for a closed injury in a healthy patient in 81% of surgeons, and by 86% for a patient with a closed fracture who was obese. Twenty-one percent reported that they would use a nail for an open segmental tibia fracture in diabetics who smoked, whilst 57% would opt for a nail for a closed injury with compartment syndrome, and only 27% would use a nail for an open segmental injury in a young fit sports person. The patient and public preference exercise identified that sleep, early functional outcomes and psychosocial measures of outcomes are important. We concluded that a RCT comparing definitive fixation with an intramedullary nail and a circular external fixator is justified as there remains
Krause, Matthias; Preiss, Achim; Meenen, Norbert M; Madert, Jürgen; Frosch, Karl-Heinz
To analyze the anatomic accuracy of fracture reduction controlled by fluoroscopy as compared with arthroscopically assisted reduction ("fracturoscopy") in patients with complex tibial plateau fractures (AO/OTA 41-C). Quality of fracturoscopy-guided reduction was checked with postoperative computed tomography. Prospective observational study. Urban level 1 trauma center. Seventeen consecutive patients, with a complex, bicondylar tibial plateau fracture. The intraoperative, open insertion of an arthroscope (2.4-mm or 2.8-mm optics), to visualize the articular surface and fracture reduction. Ability to detect residual fracture depression or gap after previous open reduction under fluoroscopic guidance. An open fracture reduction with fluoroscopic guidance was performed in all cases. In 7 cases, open reduction and fluoroscopy resulted in satisfactory fracture reduction (fluoroscopy group). In 10 of 17 cases, subsequent "fracturoscopy" showed persistent fracture depression (≥2 mm, fracturoscopy group) with the need for intraoperative correction. Patients in the fracturoscopy group demonstrated significantly greater preoperative fragment depression (12.55 ± 6.56 mm) and a larger preoperative fracture gap (7.83 ± 5.49 mm) compared with patients with a satisfactory reduction under fluoroscopy (depression 4.97 ± 4.02 mm, P = 0.016; gap 2.47 ± 1.07 mm, P = 0.023). Fluoroscopy was not successful in achieving satisfactory reduction in cases in which the postero-latero-central region was affected (P = 0.004, χ test). Postoperative computed tomography demonstrated satisfactory articular reconstruction in all cases. Intraoperative fracturoscopy permitted a significantly improved visualization of fracture fragment displacement, specifically in the postero-latero-central region of the tibial plateau, as compared with fluoroscopy. Fracturoscopy is recommended for fractures involving the postero-latero-central region of the tibial plateau. Therapeutic Level IV. See
Busse, Jason W; Bhandari, Mohit; Guyatt, Gordon H; Heels-Ansdell, Diane; Mandel, Scott; Sanders, David; Schemitsch, Emil; Swiontkowski, Marc; Tornetta, Paul; Wai, Eugene; Walter, Stephen D
To compare the Short Musculoskeletal Function Assessment Dysfunction Index (SMFA DI) and the Short Form-36 Physical Component Summary (SF-36 PCS) scores among patients undergoing operative management of tibial fractures. Between July 2000 and September 2005, we enrolled 1,319 skeletally mature patients with open or closed fractures of the tibial shaft that were managed with intramedullary nailing. Patients were asked to complete the SMFA Questionnaire and SF-36 at discharge and 3, 6, and 12 months post-surgical fixation. The SMFA DI and SF-36 PCS scores were highly correlated at 3, 6, and 12 months post-surgical fixation. The difference in the mean standardized change scores for SMFA DI and SF-36 PCS, from 3 to 12 months post-surgical fixation, was not statistically significant. Both the SMFA DI and SF-36 PCS scores were able to discriminate between healed and nonhealed tibial fractures at 3, 6, and 12 months postsurgery. In patients with tibial-shaft fractures, the SMFA DI offered no significant advantages over the SF-36 PCS score. These results, along with the usefulness of SF-36 for comparing populations, recommend the SF-36 for assessing physical function in studies of patients with tibial fractures.
Objective To compare the Short Musculoskeletal Function Assessment Dysfunction Index and the Short Form-36 Physical Component Summary scores among patients undergoing operative management of tibial fractures. Study Design and Setting Between July 2000 and September 2005, we enrolled 1319 skeletally mature patients with open or closed fractures of the tibial shaft that were managed with intramedullary nailing. Patients were asked to complete the Short Musculoskeletal Function Assessment and Short Form-36 at discharge and 3, 6, and 12 months post surgical fixation. Results Short Musculoskeletal Function Assessment Dysfunction Index and Short Form-36 Physical Component Summary scores were highly correlated at 3, 6, and 12 months post surgical fixation. The difference in mean standardized change scores for the Short Musculoskeletal Function Assessment Dysfunction Index and the Short Form-36 Physical Component Summary, from 3 to 12 months post-surgical fixation, was not statistically significant. Both the Short Musculoskeletal Function Assessment Dysfunction Index and Short Form-36 Physical Component Summary scores were able to discriminate between healed and non-healed tibial fractures at 3, 6, and 12 months post surgery. Conclusion In patients with tibial shaft fractures, the Short Musculoskeletal Function Assessment Dysfunction Index offered no important advantages over the Short Form-36 Physical Component Summary score. These results, along with the usefulness of the Short Form-36 for comparing populations, recommends the Short Form-36 for assessing physical function in studies of patients with tibial fractures. PMID:19364637
Kim, Joon-Woo; Oh, Chang-Wug; Oh, Jong-Keon; Kyung, Hee-Soo; Park, Kyeong-Hyeon; Kim, Hee-June; Jung, Jae-Wook; Jung, Young-Soo
High-energy proximal tibial fractures often accompany compartment syndrome and are usually treated by fasciotomy with external fixation followed by secondary plating. However, the initial soft tissue injury may affect bony union, the fasciotomy incision or external fixator pin sites may lead to postoperative wound infections, and the staged procedure itself may adversely affect lower limb function. We assess the results of staged minimally invasive plate osteosynthesis (MIPO) for proximal tibial fractures with acute compartment syndrome. Twenty-eight patients with proximal tibial fractures accompanied by acute compartment syndrome who underwent staged MIPO and had a minimum of 12 months follow-up were enrolled. According to the AO/OTA classification, 6 were 41-A, 15 were 41-C, 2 were 42-A and 5 were 42-C fractures; this included 6 cases of open fractures. Immediate fasciotomy was performed once compartment syndrome was diagnosed and stabilization of the fracture followed using external fixation. After the soft tissue condition normalized, internal conversion with MIPO was done on an average of 37 days (range, 9-158) after index trauma. At the time of internal conversion, the external fixator pin site grades were 0 in 3 cases, 1 in 12 cases, 2 in 10 cases and 3 in 3 cases, as described by Dahl. Radiographic assessment of bony union and alignment and a functional assessment using the Knee Society Score and American Orthopedic Foot and Ankle Society (AOFAS) score were carried out. Twenty-six cases achieved primary bony union at an average of 18.5 weeks. Two cases of nonunion healed after autogenous bone grafting. The mean Knee Society Score and the AOFAS score were 95 and 95.3 respectively, at last follow-up. Complications included 1 case of osteomyelitis in a patient with a grade IIIC open fracture and 1 case of malunion caused by delayed MIPO due to poor wound conditions. Duration of external fixation and the external fixator pin site grade were not related to the
Busel, Gennadiy A; Watson, J Tracy; Israel, Heidi
Comminuted fibular fractures can occur with pilon fractures as a result of valgus stress. Transverse fibular fractures can occur with varus deformation. No definitive guide for determining the proper location of tibial fixation exists. The purpose of this study was to identify optimal plate location for fixation of pilon fractures based on the orientation of the fibular fracture. One hundred two patients with 103 pilon fractures were identified who were definitively treated at our institution from 2004 to 2013. Pilon fractures were classified using the AO/OTA classification and included 43-A through 43-C fractures. Inclusion criteria were age of at least 18 years, associated fibular fracture, and definitive tibial plating. Patients were grouped based on the fibular component fracture type (comminuted vs transverse), and the location of plate fixation (medial vs lateral) was noted. Radiographic outcomes were assessed for mechanical failures. Forty fractures were a result of varus force as evidenced by transverse fracture of the fibula and 63 were due to valgus force with a comminuted fibula. For the transverse fibula group, 14.3% mechanical complications were noted for medially placed plate vs 80% for lateral plating ( P = .006). For the comminuted fibular group, 36.4% of medially placed plates demonstrated mechanical complications vs 16.7% for laterally based plates ( P = .156). Time to weight bearing as tolerated was also noted to be significant between groups plated medially and laterally for the comminuted group ( P = .013). Correctly assessing the fibular component for pilon fractures provides valuable information regarding deforming forces. To limit mechanical complications, tibial plates should be applied in such a way as to resist the original deforming forces. Level of Evidence Level III, comparative study.
Dong, Quanyu; Hong, Do Yeong; Park, Yong Wook; Kim, Hyong Nyun
In the present technique report, we describe a useful noninvasive traction technique that uses a 6-inch elastic bandage that can be obtained in every operating room and can be easily applied around the patient's ankle and the surgeon's waist to offer a stable traction force during minimally invasive plate fixation of distal tibial fractures. This technique frees the surgeon's hands to focus on applying other forces, such as rotational, varus, or valgus forces, to reduce the fracture and stabilize the reduction and alignment during percutaneous insertion and fixation of the plate. This technique, although simplistic and old-fashioned, is also useful for the closed reduction of distal tibial physeal injuries in children, because it can provide a significant amount of traction force while allowing the surgeon to apply other forces for fracture reduction. This technique can be used in the emergency room, where an ankle distractor is not usually present, and in some cases could be useful during ankle arthroscopy. Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Sawyer, Gregory A; Anderson, Brett C; Paller, David; Schiller, Jonathan; Eberson, Craig P; Hulstyn, Michael
To perform a biomechanical analysis of suture bridge fixation for tibial eminence fractures using PushLock anchors (Arthrex, Naples, FL) and compare it with traditional suture fixation and screw fixation. This study used 24 porcine knees, divided into 3 comparison fixation groups: PushLock suture bridge fixation, screw fixation, and suture fixation. Each knee was dissected of all soft tissue, leaving only the anterior cruciate ligament. A tibial eminence fracture was created with disruption of the posterior hinge, and each knee was fixed with a randomly assigned fixation technique. After fixation, each knee underwent 2 phases of biomechanical testing. The initial cyclic dynamic phase assessed the displacement change after 200 cycles (in millimeters) and initial stiffness (in Newtons per millimeter) of the fixation construct. After completion of dynamic testing, each specimen underwent a single tensile failure test load to assess ultimate failure load (in Newtons) and displacement (in millimeters) to ultimate failure. There was a significant difference for the load-to-failure outcome variable among treatment groups (P = .004 by analysis of variance, 1 - β = 0.851). Mean ultimate failure load borne by the PushLock fixation group was statistically significantly higher in comparison with the screw (P = .007) and suture (P = .017) fixation groups. For the cyclical testing, the primary outcome variable of displacement change after 200 loading cycles failed to show a significant difference among the 3 groups (P = .412). Suture bridge fixation with PushLock anchors is a new and effective surgical technique for the treatment of displaced tibial eminence fractures. By use of a high-bone density animal model, our results suggest that this suture bridge construct provides superior fixation with regard to ultimate failure load compared with standard screw fixation and suture fixation. The suture bridge technique provides another fixation option for displaced tibial eminence
von Pfeil, Dirsko J F; Glassman, Mathieu; Ropski, Meaghan
To retrospectively describe cases treated via percutaneous tibial physeal fracture repair (PTPFR), using intra-operative fluoroscopy (IFL) or digital radiography (DR). To describe a technique ("spiking"), used to treat tibial tuberosity avulsion fractures. Clinical data of 14 dogs and three cats were included. The "spiking" technique was described. Intra-operative fluoroscopy (n = 11) and DR (n = 6) were successfully used in 11 tibial tuberosity avulsion fractures, one combined proximal physeal and tibial tuberosity avulsion fracture, and five distal tibial/fibular physeal fractures. Surgery times ranged from eight to 54 minutes. The "spiking" technique was successfully applied in six tibial tuberosity avulsion fracture cases. Return to function was at a mean (± standard deviation) of 1.9 (± 1.6) weeks. Long-term (>12 months; n = 17) follow-up was available at a mean of 40.6 (± 13.4) months. Major complications consisted of skin irritation from a pin (distal tibia / fibula physeal fracture case; 8 weeks post-PTPFR), and a bilateral grade II medial patella luxation (tibial tuberosity avulsion fracture case; 1.5 years post-PTPFR). One case developed a mild tibial tuberosity avulsion fracture re-avulsion. All conditions in these three cases were not of clinical concern at follow-up and final outcome was graded as good in these and excellent in the other 14 cases. Percutaneous tibial physeal fracture repair can be considered as a technique to treat tibial physeal fractures. The "spiking" technique was successfully applied in six dogs. A larger, prospective case series is indicated to provide additional clinical information.
Squyer, Emily R; Dikos, Gregory D; Kaehr, David M; Maar, Dean C; Crichlow, Renn J
To evaluate the ability of orthopaedic trauma subspecialists to predict early bony union in femoral and tibia shaft fractures. Eight orthopaedic trauma subspecialists prospectively predicted the probability of bony union at 6 and 12 weeks post-operatively for an aggregate of 48 femoral and tibial shaft fractures treated at a Level 1 trauma centre. An additional orthopaedic trauma subspecialist was blinded to treating surgeon and adjudicated healing at 18 weeks. The Squared-Error Skill Score (SESS) determined the likelihood of accurate forecasting for bony union. Nine patients were lost follow-up, resulting in 39 fractures (81.25% retention) including 20 femoral and 19 tibial fractures. Fourteen fractures were open, 15 were not-yet united at final follow-up. SESS values were 0.25-0.77. The ability to predict union (sensitivity) was 1.000. The ability to predict nonunions (specificity) was 0.330-0.500. The probability of a correct predicted union was 0.727 and correct predicted nonunion at final follow-up was 1.000. AO/OTA type A fractures pattern predictions were highly accurate. As body mass index increased, predictions trended toward decreased accuracy (p=0.06). Tobacco use, age, gender, associated injuries, open fractures, and surgeons' years in clinical practice were not associated with accuracy of predictions. At 12-weeks post-operatively orthopaedic trauma subspecialists can confidently predict the union state in this patient population. This data is most useful in the nonunion patient, directing early intervention, thereby decreasing patient disability and discomfort. Copyright Â© 2016 Elsevier Ltd. All rights reserved.
Honkonen, S E; Kannus, P; Natri, A; Latvala, K; Järvinen, M J
The isokinetic performance of thigh muscles was evaluated in 37 patients at an average of 7 years after sustaining a fracture of the tibial plateau. The mean torque deficit in the quadriceps of the injured limb was an average of 15% at a speed of 60 degrees/s and 16% at 180 degrees/s, while the corresponding deficits in the hamstrings were 3% and 8%. The radiological appearance of the injured knee correlated significantly to the quadriceps deficit at both speeds. Limited knee movement and thigh atrophy also correlated with the deficit at the lower speed. The strength deficit tended to decrease during follow-up. A multiple step-wise regression analysis showed that the radiological result, length of follow-up and thigh atrophy accounted for 47% of the variation in loss of quadriceps strength. At the higher speed, the functional result was associated with the deficit in quadriceps strength, and older patients had greater deficits than younger. Regression analysis indicated that the radiological and functional result accounted for 31% of the variation in quadriceps strength. Anatomical restoration of the tibial plateau and good muscle rehabilitation are important in obtaining good long term results after this fracture.
Collinge, Cory A; Beltran, Michael J; Dollahite, Henry A; Huber, Florian G
The reduction of tibial shaft fractures during intramedullary nailing is important if limb alignment is to be restored and successful clinical outcomes are expected. We have used a percutaneously applied (or open) clamp or clamps to achieve and maintain reduction during nailing of all amendable tibial shaft fractures. In this article, we describe the technique and preliminary results comparing closed, simple spiral and oblique tibial shaft fractures (OTA 42-A1 and A2) managed with percutaneous clamp-assisted nailing (CAN) versus nailing using manual reduction (MRN) held by the surgical team. In the MRN group, there were an increased fracture gap (P = 0.04) and trends toward malalignment (P = 0.07) and healing time (P = 0.06) compared with the CAN group. There were also trends in clinical; no wound complications occurred in either group. We have found that percutaneous CAN of closed, simple spiral and oblique tibial shaft fractures seems safe and allows for early predictable union with reproducible alignment compared with nailing using MRN.
Yoo, Jae Ho; Hahn, Sung Ho; Yang, Bo Kyu; Yi, Seung Rim; Ahn, Young Joon; Yoon, Dong Jin; Kim, Jin Hong
We report a case of en bloc avulsion fracture of tibial tuberosity and Gerdy's tubercle, which has never been reported. A 14-year-old boy suffered from an acute pain in his left knee during running just before a jump. Simple radiographs showed an avulsion of the tibial tuberosity. On CT scans, the fractured fragment was attached not only to patellar tendon but also to iliotibial band (ITB) via Gerdy's tubercle. MRI evaluation revealed no intra-articular associated pathology. Open reduction and internal fixation with three cannulated screws were performed under lateral parapatellar approach to expose both the tibial tuberosity with patellar tendon and Gerdy's tubercle with ITB. At postoperative 1 year, he could walk, run, squat, and complained of no difficulty in activities on daily living with full range-of-motion of the knee. Radiographs showed well-healed fracture in situ. Gradually, he returned to sports activity. We believe that the injury was caused by the dynamic pull of quadriceps muscle via patellar tendon onto tibial tuberosity and the mostly static pull of ITB onto Gerdy's tubercle, both of which took a part in the fracture of the anterolateral portion of the unfused epiphysis of proximal tibia. The pes anserinus attaching on the anteromedial metaphysis of proximal tibia might exert the opposing deforming force. Preoperative planning including the determination of the extent of fracture and recognition of concomitant injury is a prerequisite for appropriate treatment.
Kuo, Liang Tseng; Chi, Ching-Chi; Chuang, Ching-Hui
The distal tibial metaphysis is located in the lower (distal) part of the tibia (shin bone). Fractures of this part of the tibia are most commonly due to a high energy injury in young men and to osteoporosis in older women. The optimal methods of surgical intervention for a distal tibial metaphyseal fracture remain uncertain. To assess the effects (benefits and harms) of surgical interventions for distal tibial metaphyseal fractures in adults. We planned to compare surgical versus non-surgical (conservative) treatment, and different methods of surgical intervention. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (9 December 2014), the Cochrane Central Register of Controlled Trials (2014, Issue 12), MEDLINE (1946 to November Week 3 2014), EMBASE (1980 to 2014 Week 48), the Airiti Library (1967 to 2014 Week 8), China Knowledge Resource Integrated Database (1915 to 2014 Week 8), ClinicalTrials.gov (February 2014) and reference lists of included studies. We included randomised and quasi-randomised controlled clinical studies comparing surgical versus non-surgical (conservative) treatment or different surgical interventions for treating distal tibial metaphyseal fractures in adults. Our primary outcomes were patient-reported function and the need for secondary or revision surgery or substantive physiotherapy because of adverse outcomes. Two authors independently selected studies, assessed the risk of bias in each study and extracted data. We resolved disagreement by discussion and, where necessary, in consultation with a third author. Where appropriate we pooled data using the fixed-effect model. We included three randomised trials that evaluated intramedullary nailing versus plating in 213 participants, with useable data from 173 participants of whom 112 were male. The mean age of participants in individual studies ranged from 41 to 44 years. There were no trials comparing surgery with non-surgical treatment. The three included trials
Oladeji, Lasun O; Dreger, Tina K; Pratte, Eli L; Baumann, Charles A; Stannard, James P; Volgas, David A; Rocca, Gregory J Della; Crist, Brett D
Orthopaedic surgeons commonly have the misconception that patients with tibial plateau fractures will likely go on to posttraumatic knee arthritis requiring total knee arthroplasty (TKA). In younger patients, osteochondral allograft (OCA) transplantation is an alternative method to address posttraumatic knee arthritis. The purpose of this study was (1) to identify our institutional failure rate following tibial plateau open reduction and internal fixation (ORIF) (failure was defined as conversion to TKA or OCA); (2) to determine if there are patient- or injury-related risk factors predictive of failure; and (3) to characterize differences between patients treated with TKA versus those treated with OCA transplantation. A 10-year retrospective review was conducted to identify patients treated at our institution with a tibial plateau fracture. Patients included in the final analysis were at least 18 years of age with an articular fracture (AO/OTA 41 B/C). The primary outcome was subsequent ipsilateral OCA or TKA. There were 350 patients (359 tibial plateau fractures) with a mean follow-up of 22.3 months (range, 6-133 months) who met inclusion criteria. Twenty-seven fractures (7.5%) were subsequently converted to a TKA or OCA at an average of 3.75 ± 3.1 years following their initial surgery. Patients who consumed tobacco were 2.3 times more likely to require a joint replacement (confidence interval [CI], 1.0-5.2; p = 0.04). Those patients who received an OCAs were significantly younger as compared with their TKA peers, both at time of initial injury (37 vs. 51 years, p = 0.02) and at time of surgery (41 vs. 55 years, p = 0.009). The joint replacement rate in this study is similar to those studies in the published literature that focused solely on the prevalence of conventional TKA. Tobacco is a risk factor for failure following tibial plateau ORIF. Patients who were treated with an OCA were younger at time of injury and failure. Thieme Medical
van den Berg, Juriaan; Reul, Maike; Nunes Cardozo, Menno; Starovoyt, Anastasiya; Geusens, Eric; Nijs, Stefaan; Hoekstra, Harm
INTRODUCTION: Although regularly ignored, there is growing evidence that posterior tibial plateau fractures affect the functional outcome. The goal of this study was to assess the incidence of posterior column fractures and its impact on functional outcome and general health status. We aimed to identify all clinical variables that influence the outcome and improve insights in the treatment strategies. A retrospective cohort study including 218 intra-articular tibial plateau fractures was conducted. All fractures were reclassified and applied treatment was assessed according to the updated three-column concept. Relevant demographic and clinical variables were studied. The patient reported outcome was assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS). Median follow-up was 45.5 (IQR 24.9-66.2) months. Significant outcome differences between operatively and non-operatively treated patients were found for all KOOS subscales. The incidence of posterior column fractures was 61.9%. Posterior column fractures, sagittal malalignment and an increased complication rate were associated with poor outcome. Patients treated according to the updated three-column concept, showed significantly better outcome scores than those patients who were not. We could not demonstrate the advantage of posterior column fracture fixation, due to a limited patient size. Our data indicates that implementation of the updated three-column classification concept may improve the surgical outcome of tibial plateau fractures. Failure to recognize posterior column fractures may lead to inappropriate utilization of treatment techniques. The current concept allows us to further substantiate the importance of reduction and fixation of posterior column fractures with restoration of the sagittal alignment. 3.
Bumči, Igor; Vlahović, Tomislav; Jurić, Filip; Žganjer, Mirko; Miličić, Gordana; Wolf, Hinko; Antabak, Anko
Paediatric ankle fractures comprise approximately 4% of all paediatric fractures and 30% of all epiphyseal fractures. Integrity of the ankle "mortise", which consists of tibial and fibular malleoli, is significant for stability and function of the ankle joint. Tibial malleolar fractures are classified as SH III or SH IV intra-articular fractures and, in cases where the fragments are displaced, anatomic reposition and fixation is mandatory. Type SH III-IV fractures of the tibial malleolus are usually treated with open reduction and fixation with cannulated screws that are parallel to the physis. Two K-wires are used for temporary stabilisation of fragments during reduction. A third "guide wire" for the screw is then placed parallel with the physis. Considering the rules of mechanics, it is assumed that the two temporary pins with the additional third pin placed parallel to the physis create a strong triangle and thus provide strong fracture fixation. To prove this hypothesis, an experiment was conducted on the artificial models of the lower end of the tibia from the company "Sawbones". Each model had been sawn in a way that imitates the fracture of medial malleoli and then reattached with 1.8mm pins in various combinations. Prepared models were then tested for tensile and pressure forces. The least stable model was that in which the fractured pieces were attached with only two parallel pins. The most stable model comprised three pins, where two crossed pins were inserted in the opposite compact bone and the third pin was inserted through the epiphysis parallel with and below the growth plate. A potential method of choice for fixation of tibial malleolar fractures comprises three K-wires, where two crossed pins are placed in the opposite compact bone and one is parallel with the growth plate. The benefits associated with this method include shorter operating times and avoidance of a second operation for screw removal. Copyright © 2015 Elsevier Ltd. All rights
Kempton, Laurence B; Dibbern, Kevin; Anderson, Donald D; Morshed, Saam; Higgins, Thomas F; Marsh, J Lawrence; McKinley, Todd O
Determine the agreement between subjective assessments of fracture severity and an objective computed tomography (CT)-based metric of fracture energy in tibial plateau fractures. Six fellowship-trained orthopaedic trauma surgeons independently rank-ordered 20 tibial plateau fractures in terms of severity based on anteroposterior and lateral knee radiographs. A CT-based image analysis methodology was used to quantify the fracture energy, and agreement between the surgeons' severity rankings and the fracture energy metric was tested by computing their concordance, a statistical measure that estimates the probability that any 2 cases would be ranked with the same ordering by 2 different raters or methods. Concordance between the 6 orthopaedic surgeons ranged from 82% to 93%, and concordance between surgeon severity rankings and the computed fracture energy ranged from 73% to 78%. There is a high level of agreement between experienced surgeons in their assessments of tibial plateau fracture severity, and a slightly lower agreement between the surgeon assessments and an objective CT-based metric of fracture energy. Taken together, these results suggest that experienced surgeons share a similar understanding of what makes a tibial plateau fracture more or less severe, and an objective CT-based metric of fracture energy captures much but not all of that information. Further research is ongoing to characterize the relationship between surgeon assessments of severity, fracture energy, and the eventual clinical outcomes for patients with fractures of the tibial plateau.
Kempton, Laurence B.; Dibbern, Kevin; Anderson, Donald D.; Morshed, Saam; Higgins, Thomas F.; Marsh, J. Lawrence; McKinley, Todd O.
Objectives Determine the agreement between subjective assessments of fracture severity and an objective CT-based metric of fracture energy in tibial plateau fractures. Methods Six fellowship-trained orthopaedic trauma surgeons independently rank-ordered 20 tibial plateau fractures in terms of severity based upon AP and lateral knee radiographs. A CT-based image analysis methodology was used to quantify the fracture energy, and agreement between the surgeons’ severity rankings and the fracture energy metric was tested by computing their concordance, a statistical measure that estimates the probability that any two cases would be ranked with the same ordering by two different raters or methods. Results Concordance between the six orthopaedic surgeons ranged from 82% to 93%, and concordance between surgeon severity rankings and the computed fracture energy ranged from 73% to 78%. Conclusions There is a high level of agreement between experienced surgeons in their assessments of tibial plateau fracture severity, and a slightly lower agreement between the surgeon assessments and an objective CT-based metric of fracture energy. Taken together, these results suggest that experienced surgeons share a similar understanding of what makes a tibial plateau fracture more or less severe, and an objective CT-based metric of fracture energy captures much but not all of that information. Further research is ongoing to characterize the relationship between surgeon assessments of severity, fracture energy, and the eventual clinical outcomes for patients with fractures of the tibial plateau. PMID:27243347
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 randomized trial of 1319 adults in whom a tibial shaft fracture was treated with either reamed or unreamed intramedullary nailing. Perioperative care was standardized, 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 thousand two hundred and twenty-six participants (93%) completed one year of follow-up. Of these, 622 patients were randomized to reamed nailing and 604 patients were randomized 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
Jöstl, Julian; Tiefenböck, Thomas Manfred; Hofbauer, Marcus; Winnisch, Markus; Lang, Nikolaus; Hajdu, Stefan; Sarahrudi, Kambiz
The purpose of this study was the comparison of the most commonly used surgical techniques (external fixation, intramedullary nailing, and plate fixation) for the treatment of distal tibial fractures (AO/OTA classification 42-A, B, C or 43-A, B1). A retrospective cohort study of patients who underwent surgical treatment for distal tibial fractures between 1992 and 2011 was performed. A total of 93 patients (52 male/41 female) met inclusion criteria. Statistically significant differences were found regarding the consolidation time of the intramedullary-nailing (147.32 ± 91.16 days) and the plate-fixation group (135.75 ± 110.75 days) versus the external-fixation group (163.12 ± 96.79 days; P = 0.001; P = 0.01). Significant differences were also observed in the range of motion (ROM) of the ankle joint in the intramedullary-nailing and plate-fixation group versus the ROM in the external-fixation group (P = 0.044; P = 0.025). The overall complication rate was 13/93 (14 %). Out of 66 patients treated with intramedullary nailing, 8 (12 %) suffered from complications. Out of the 15 patients treated with plate and 12 patients with external fixation, 2 (13 %) and 3 (25 %) showed complications, respectively. Our results demonstrate advantages in terms of shorter mobilization time and a better ROM of the ankle joint for intramedullary nailing and plate fixation compared with external fixation. Due to our results, we suggest internal fixation (intramedullary nailing or plate fixation) whenever patient's condition and the local fracture situation allow it.
Pretell-Mazzini, Juan; Kelly, Derek M; Sawyer, Jeffrey R; Esteban, Eva M A; Spence, David D; Warner, William C; Beaty, James H
Systematic review of the literature was done to determine (1) the frequency and type of associated injuries, (2) frequency of concomitant Osgood-Schlatter disease, (3) methods of treatment, (4) functional and radiologic outcomes according to fracture type, and (5) complications of tibial tubercle fractures in pediatric patients. A systematic review of the English literature from 1970 to 2013 included 23 eligible articles reporting 336 fractures with a mean follow-up of 33.56 months (range, 5.7 to 115 mo). Fractures were classified by a comprehensive system that included characteristics of previous systems. Clinical outcomes were assessed by a qualitative scale (excellent/fair/poor), the rate of return to preinjury activity, and knee range of motion. Rate of fracture healing, associated injuries (patellar/quadriceps tendon avulsion and meniscal tears), compartment syndrome, and complications were also recorded. Mean age at surgery was 14.6 years and the most common fracture reported was type III (50.6%). The overall associated injury rate was 4.1%, most common in type III fractures (4.7%). Compartment syndrome was present in 3.57% of cases. Open reduction and internal fixation were done in 98% of surgical cases. Rates of return to preinjury activity and knee range of motion were 98%, regardless of the type of fracture. Fracture consolidation was achieved in 99.4% of cases. Overall complication rate was 28.3%; removal of an implant because of bursitis (55.8%) was most common. Tenderness/prominence (17.9%) and refracture (6.3%) were also common. Treatment of tibial tubercle fractures in adolescents produced good clinical and radiologic results regardless of fracture type, which was more related to potential complications. Fractures with intra-articular involvement tended to present with more associated injuries and to have fair functional outcomes, suggesting that advanced imaging may be justified with these fractures. Complications could be more common than expected
Narayana Gowda, B S; Mohan Kumar, J
Osgood-Schlatter disease (OSD) is a well known condition, characterized by pain over the tibial tubercle with subsequent tubercle prominence. Avulsion fracture following OSD is a rare complication. We report an unusual case of simultaneous bilateral tibial tubercle avulsion fracture in a 16 year old boy who was a known case of OSD. A 16 year old boy a known case of OSD presented to the outpatient department with history of jumping from the school compound wall (two feet height) while playing, followed by severe pain around anterior aspect of both knees and difficulty in walking. Radiographs showed bilateral tibial tubercle avulsion fracture. He was treated successfully with open reduction and internal fixation with tension band wiring. At the end of 22 months the patient was symptomatically relieved and both the tuberosities were united with the main bone. Even though bilateral Osgood-Schlatter disease (OSD) is a well known condition, one should always keep in mind the risk of tibial tubercle avulsion fractures while treating a case of OSD. Patient should be advised not to involve in strenuous activities till the disease subsides radiologically or till skeletal maturity.
Narayana Gowda, BS; Mohan Kumar, J
Introduction: Osgood-Schlatter disease (OSD) is a well known condition, characterized by pain over the tibial tubercle with subsequent tubercle prominence. Avulsion fracture following OSD is a rare complication. We report an unusual case of simultaneous bilateral tibial tubercle avulsion fracture in a 16 year old boy who was a known case of OSD. Case presentation: A 16 year old boy a known case of OSD presented to the outpatient department with history of jumping from the school compound wall (two feet height) while playing, followed by severe pain around anterior aspect of both knees and difficulty in walking. Radiographs showed bilateral tibial tubercle avulsion fracture. He was treated successfully with open reduction and internal fixation with tension band wiring. At the end of 22 months the patient was symptomatically relieved and both the tuberosities were united with the main bone. Conclusion: Even though bilateral Osgood-Schlatter disease (OSD) is a well known condition, one should always keep in mind the risk of tibial tubercle avulsion fractures while treating a case of OSD. Patient should be advised not to involve in strenuous activities till the disease subsides radiologically or till skeletal maturity. PMID:27298849
Kinney, Matthew C; Nagle, David; Bastrom, Tracey; Linn, Michael S; Schwartz, Alexandra K; Pennock, Andrew T
Displaced tibial shaft fractures are common in adolescent patients, yet there is no standardized management strategy. We compared surgical fixation and closed reduction and casting (CRC) of these fractures to assess treatment outcomes and determine predictors of failure. We retrospectively reviewed all patients aged 12 to 18 who presented with a displaced tibial shaft fracture that required reduction over an 8-year period. Exclusion criteria included open fractures and lack of follow-up to radiographic union or to 6 months from the index procedure. Fractures were initially treated based on surgeon preference either with CRC or with immediate intramedullary nailing. Seventy-four patients met inclusion criteria: 57 were initially managed with CRC and 17 with operative fixation. Radiographic healing was defined as bridging of 3 cortices and adequacy of final alignment was defined as <5 degrees of angular deformity in both planes and <1.0 cm of shortening. Outcomes were analyzed both on intent-to-treat principles and by definitive treatment method. Although all fractures in both groups achieved bony healing, 23 of the 57 patients who underwent CRC failed closed treatment and ultimately required surgery (40.3%). Multivariate analysis of patient and fracture characteristics revealed fracture displacement of >20% (odds ratio=7.8, P<0.05) and the presence of a fibula fracture (odds ratio=5.06, P=0.05) as predictors of closed treatment failure. Patients ultimately managed with intramedullary nailing trended toward increased adequacy of final alignment (92.5% vs. 72.4%, P=0.10) but required longer hospitalization (5.4 vs. 1.9 d, P<0.001) and had a higher incidence of anterior knee pain (20% vs. 0%, P<0.01). There was no significant difference between groups with respect to time to healing. Treatment outcomes between initial operative fixation and closed reduction of displaced tibia fractures in adolescents are similar, but patients must be counseled about the high failure
Cefalu, Charles A; Royals, Thomas P; Krause, Peter C
Pseudoaneurysms are uncommon in patients with trauma, but can cause diagnostic difficulty and result in significant morbidity. Etiologies range from penetrating and nonpenetrating trauma to operative injury during fracture fixation, arthroscopy, total joint arthroplasty, and hardware loosening and removal. Pseudoaneurysms can conspicuously present as a pulsatile mass with an audible bruit, or as a subtly expanding hematoma. In either case, the complications can be serious if diagnosed late. The authors report a case of a pseudoaneurysm arising from the descending geniculate artery following a tibial plateau fracture. This was suspected following a slowly expanding hematoma and persistent anemia refractory to transfusion. Computed tomography angiography was used for confirmation. Successful treatment was accomplished with embolization, surgical evacuation of the hematoma, delayed skin grafting, and fracture fixation. The postoperative outcome was satisfactory, with complete wound healing, functional but decreased range of motion, normal perfusion distal to the injury, and the sole report of mild intermittent knee pain. [Orthopedics. 2017; 40(1):e188-e191.]. Copyright 2016, SLACK Incorporated.
Stenroos, A; Pakarinen, H; Jalkanen, J; Mälkiä, T; Handolin, L
Alpine skiing and snowboarding share the hazards of accidents accounting for tibial fractures. The aim of this study was to evaluate the fracture patterns and mechanisms of injury of tibial fractures taking place in downhill skiing and snowboarding. All patients with tibial fracture due to alpine skiing or snowboarding accident treated in four trauma centers next to the largest ski resorts in Finland were analyzed between 2006 and 2012. The hospital records were retrospectively reviewed for data collection: equipment used (skis or snowboard), age, gender, and mechanism of injury. Fractures were classified according to AO-classification. There were 342 skiing and 30 snowboarding related tibial fractures in 363 patients. Tibial shaft fracture was the most common fracture among skiers (n = 215, 63%), followed by proximal tibial fractures (n = 92, 27%). Snowboarders were most likely to suffer from proximal tibial fracture (13, 43%) or tibial shaft fracture (11, 37%). Snowboarders were also more likely than skiers to suffer complex AO type C fractures (23% vs 9%, p < 0.05). Adult skiers had both wider variety of fractures and higher prevalence of proximal tibial fractures compared to children (49% vs 16%, p < 0.05). Skiers typically got injured due to falling down on the same level (70%) and snowboarders due to loss of control while jumping (46%). The most important finding was the relatively high number of the tibial plateau fractures among adult skiers. The fracture patterns between snowboarding and skiing were different; the most common fracture type in skiers was spiral tibial shaft fracture compared to proximal tibial fractures in snowboarders. Children had more simple fractures than adults. © The Finnish Surgical Society 2016.
Kabukçuoğlu, Yavuz; Sökücü, Sami; Özcan, Çağrı; Beng, Kubilay; Lapçin, Osman; Demir, Bilal
The aim of this study was to compare solitary tibial diaphysis fractures and tibial diaphysis fractures associated with fibula fracture treated with the intramedullary nailing method. Records of 254 patients diagnosed with tibial diaphysis fracture and treated with intramedullary nailing between 2010 and 2013 were examined and 30 patients were included in the study. Group 1 comprised patients with solitary tibial diaphysis fracture, and Group 2 was made up of patients with tibial diaphysis fractures associated with fibula fracture. Patients in both groups were compared in terms of time to surgery, duration of surgical tourniquet, time to union, and varus, valgus, recurvatum, and antecurvatum deformities of the tibia at final follow-up. No statistically significant difference was found between the 2 groups in time to surgery, duration of surgical tourniquet, time to union, or varus, valgus, recurvatum, and antecurvatum deformities. Results indicated that intact fibula in tibial diaphysis fracture treated with intramedullary nailing was not a disadvantage; it did not affect rate of union or lead to loss of reduction, non-union, or malunion.
Chaudhry, Zaira S; Raikin, Steven M; Harwood, Marc I; Bishop, Meghan E; Ciccotti, Michael G; Hammoud, Sommer
Although most anterior tibial stress fractures heal with nonoperative treatment, some may require surgical management. To our knowledge, no systematic review has been conducted regarding surgical treatment strategies for the management of chronic anterior tibial stress fractures from which general conclusions can be drawn regarding optimal treatment in high-performance athletes. This systematic review was conducted to evaluate the surgical outcomes of anterior tibial stress fractures in high-performance athletes. Systematic review; Level of evidence, 4. In February 2017, a systematic review of the PubMed, MEDLINE, Cochrane, SPORTDiscus, and CINAHL databases was performed to identify studies that reported surgical outcomes for anterior tibial stress fractures. Articles meeting the inclusion criteria were screened, and reported outcome measures were documented. A total of 12 studies, published between 1984 and 2015, reporting outcomes for the surgical treatment of anterior tibial stress fractures were included in this review. All studies were retrospective case series. Collectively, surgical outcomes for 115 patients (74 males; 41 females) with 123 fractures were evaluated in this review. The overall mean follow-up was 23.3 months. The most common surgical treatment method reported in the literature was compression plating (n = 52) followed by drilling (n = 33). Symptom resolution was achieved in 108 of 123 surgically treated fractures (87.8%). There were 32 reports of complications, resulting in an overall complication rate of 27.8%. Subsequent tibial fractures were reported in 8 patients (7.0%). Moreover, a total of 17 patients (14.8%) underwent a subsequent procedure after their initial surgery. Following surgical treatment for anterior tibial stress fracture, 94.7% of patients were able to return to sports. The available literature indicates that surgical treatment of anterior tibial stress fractures is associated with a high rate of symptom resolution and return
Shen, Kaiying; Cai, Haiqing; Wang, Zhigang; Xu, Yunlan
Abstract Elastic stable intramedullary nailing (ESIN) has became a well-accepted method of osteosynthesis of diaphyseal fractures in the skeletally immature patient for many advantages, the purpose of this study is to evaluate the preliminary results of this minimally invasive treatment for severely displaced distal tibial diaphyseal metaphyseal junction (DTDMJ) fractures. This study was carried out over a 6-year period. Twenty-one severely displaced DTDMJ fractures treated using ESIN were evaluated clinically and radiographically. Complications were assessed: the patients were evaluated with regard to nonunion, malunion, infection, growth arrest, leg length discrepancy, implant irritation, and joint function. Mean age at the time of surgery was 7.8 years (range between 5.3 and 14.8 years), mean body weight 34.1 kg, all fractures were transverse or mild oblique type, including 3 open fractures, 5 multifragmented fractures, and 4 fractures associated with polytrauma; 6 cases were treated with antegrade ESIN of tibia while 15 cases need combined retrograde fibula and antegrade tibia fixation treatments. Follow-ups were ranging from 11 to 36 months, 19 fractures showed both clinical and radiographic evidence of healing within 5 months; all cases had full range motion of knee and ankle with symmetrical foot progress angle. Nail removal was at a mean 7.1 months, at final follow-up, no growth arrest or disturbances occurred. Five patients had complications; leg length discrepancy had decreased yet affected 2 patients, 2 cases showed delayed union, and 1 case developed restricted dorsal extension at the metatarsophalangeal joint of the hallux. ESIN is the treatment of choice for pediatric severely displaced DTDMJ fractures that cannot be reduced by closed reduction or ones that cannot be casted. The advantages include faster fracture healing, excellent functional and cosmetic results, safe and reliable surgical technique, and lower severe complication rate. PMID
Morin, Vincent; Pailhé, Régis; Sharma, Akash; Rouchy, René-Christopher; Cognault, Jérémy; Rubens-Duval, Brice; Saragaglia, Dominique
Over the past 10 years, like many authors, we observed an increasing number of Moore I tibial plateau fractures related to alpine skiing for which the surgeon may face difficult choices regarding surgical approach and fixation means. Some authors have recently been suggesting a posterior approach associated to open reduction and osteosynthesis by a buttress plate. But in our knowledge there is no specific study on sports activity recovery after Moore I tibial fractures. The aim of this work was to assess sports activities and clinical outcomes after surgically treated Moore I tibial plateau fractures in an athletic population of skiers. We conducted a prospective case series between 2012 and 2014. This included fifteen patients aged 39.6±7 years whom presented with a Moore I tibial plateau fracture during a skiing accident. 12 cases (80%) presented with an associated tibial spine fracture. Treatment consisted of a standard antero-medial approach, with a medial para patellar arthrotomy to allow direct visualisation of articular reduction and spinal fixation. Two or three 6.5mm long cancellous bone screws were placed antero-posteriorly so as to ensure perfect compression of the fracture site. Radiological and functional results were assessed by an independent observer (Lysholm-Tegner, UCLA, KOOS scores) at the longest follow-up. Mean follow-up was 18.2±6 months (12-28). An immediate postoperative anatomical reduction was achieved in all cases and remained stable in time. At last follow-up Lysholm mean score was 85±14 points (59-100), UCLA score was 7.3±1.6 (4-10) and Tegner score was 4.6±1.3 (3-6). Mean KOOS score was 77±15 (54-97). 87% of patients had resumed their skiing activity and 93% were satisfied or very satisfied from their post-operative surgical outcome. We observed no pseudarthrosis or secondary varus displacement. In our series 87% of patients had resumed back to their sporting activities. Surgical management of Moore I tibial plateau fractures by
Hasenboehler, Erik; Smith, Wade R; Laudicina, Laurence; Philips, Giby C; Stahel, Philip F; Morgan, Steven J
Treatment options for comminuted tibial shaft fractures include plating, intramedullary nailing, and external fixation. No biomechanical comparison between an interlocking tibia nail with external fixation by an Ilizarov frame has been reported to date. In the present study, we compared the fatigue behaviour of Ilizarov frames to interlocking intramedullary nails in a comminuted tibial fracture model under a combined loading of axial compression, bending and torsion. Our goal was to determine the biomechanical characteristics, stability and durability for each device over a clinically relevant three month testing period. The study hypothesis was that differences in the mechanical properties may account for differing clinical results and provide information applicable to clinical decision making for comminuted tibia shaft fractures. In this biomechanical study, 12 composite tibial bone models with a comminuted fracture and a 25 mm diaphyseal gap were investigated. Of these, six models were stabilized with a 180-mm four-ring Ilizarov frame, and six models were minimally reamed and stabilized with a 10 mm statically locked Russell-Taylor Delta tibial nail. After measuring the pre-fatigue axial compression bending and torsion stiffness, each model was loaded under a sinusoidal cyclic combined loading of axial compression (2.8/28 lbf; 12.46/124.6 N) and torque (1.7/17 lbf-in; 0.19/1.92 Nm) at a frequency of 3 Hz. The test was performed until failure (implant breakage or >or= 5 degrees angulations and/or 2 cm shortening) occurred or until 252,000 cycles were completed, which corresponds to approximately three months testing period. In all 12 models, both the Ilizarov frame and the interlocking tibia nail were able to maintain fracture stability of the tibial defect and to complete the full 252,000 cycles during the entire study period of three months. A significantly higher stiffness to axial compression and torsion was demonstrated by the tibial interlocking nail model
Belangero, William Dias; Santos Pires, Robinson Esteves; Livani, Bruno; Rossi, Felipe Lins; de Andrade, Andre Luis Lugnani
Treatment of proximal tibial shaft fractures is always challenging. Despite the development of modern techniques, the literature still shows high complication rates, especially regarding proximal fragment malalignment. It is well known that knee position in flexion during tibial nailing is responsible for extension and valgus deformities of the proximal fragment. Unlike in tibial shaft fractures, nails do not reduce proximal tibial fractures due to the medullary canal width. This study aims to describe a simple, useful, and inexpensive technique to prevent valgus and extension deformities when treating proximal tibial fractures using conventional nails: the so-called clothesline technique.
Wiss, D A; Schilz, J L; Zionts, L
Fifteen patients with Type III avulsion fractures of the tibial tubercle treated surgically were reviewed at an average of 9.6 years after injury. Six patients had a history of Osgood-Schlatter disease, and two patients had Type I osteogenesis imperfecta. Associated injuries to the meniscus were found and repaired in three patients. Two of these patients had also avulsed the origin of the tibialis anterior muscle, leading to a compartment syndrome in one. All but one fracture healed. There was one refracture. Five patients developed bursitis over prominent screw heads, which required screw removal. All but two patients were asymptomatic and participated in sports. A full range of knee motion without instability was present in all patients. Thigh and calf circumferences were equal to the opposite side. Radiographs showed normal knee joints in all but one asymptomatic patient, who showed signs of an early arthrosis. No patient developed angular or recurvatum deformities. However, a leg-length discrepancy of 1.0-1.8 cm was noted in four patients (two overgrowth, two undergrowth).
Tay, Wei-Han; de Steiger, Richard; Richardson, Martin; Gruen, Russell; Balogh, Zsolt J
Knowledge about the functional consequences of lower limb long bone fractures is helpful to inform patients, clinicians and employers about their recovery process and prognosis. This study aims to describe the epidemiology and health outcomes of femoral and tibial shaft fractures treated at two level I trauma centres, by comparing the differences between patients with delayed union or nonunion and patients with union. An analysis of registry data over two years, supplemented with medical record review, was conducted. Fracture healing was retrospectively assessed by clinical and radiological evidence of union, and the need for surgical intervention. SF-12 scores, and work and pain status were prospectively recorded at six and twelve months post injury. 285 fractures progressed to union and 138 fractures developed delayed union or nonunion. There was a significant difference between the two cohorts with regards to the mechanism of injury, association with multi-trauma, open fractures, grade of Gustilo classification, patient fund source, smoking status and presence of comorbidities. The SF-12 physical component score was less than 50 at both six and twelve months with improvement in the union group, but not in the delayed union or nonunion group. 72% of patients with union had returned to work at one year, but 54% continued to have pain. The difference compared to patients with delayed union or nonunion was significant. Even patients whose fractures unite in the expectant time-frame will have residual physical disability. Patients with delayed union or nonunion have still poorer outcomes, including ongoing problems with returning to work and pain. It is important to educate patients about their injury so that they have realistic expectations. This is particularly relevant given that the patients most likely to sustain femoral or tibial shaft fractures are working-age healthy adults, and up to a third of fractures may develop delayed union or nonunion. Despite modern
Schottel, Patrick C; Berkes, Marschall B; Little, Milton T M; Lazaro, Lionel E; Nguyen, Joseph T; Helfet, David L; Lorich, Dean G
To quantify the radiographic tibia and fibula shaft fracture characteristics that are associated with a concomitant ipsilateral ankle injury. Retrospective case-control study. Academic level I trauma center. Seventy-one adult patients with an operatively treated tibial shaft fracture met the inclusion/exclusion criteria. Preoperative radiographs were categorized according to tibia and fibula fracture pattern, location and spatial relationship to each other. Preoperative computed tomographic scans were then evaluated to assess for the presence of an articular ankle injury. (1) incidence of concomitant tibial shaft fracture and ipsilateral ankle injury; and (2) statistical association between tibia and fibula fracture characteristics in patients with and without an ipsilateral ankle fracture. Thirty-five of 71 (49.3%) tibial shaft fracture patients had a concomitant ipsilateral ankle injury. Of these, 31 (88.6%) ankle injuries occurred in patients with a spiral pattern tibia fracture of the distal third diaphysis (P < 0.001). A spiral pattern tibia fracture, a distal one-third tibial shaft fracture location, or a spiral pattern fibula fracture all were significantly associated with the presence of an ipsilateral ankle injury (P ≤ 0.001; P = 0.001; and P = 0.002, respectively). Patients with either a transverse pattern or absent fibula fracture, a nonspiral pattern tibia fracture, or a midshaft diaphyseal tibia fracture location were significantly less likely to have an associated ankle injury (P ≤ 0.001; P ≤ 0.001; and P = 0.012, respectively). Ipsilateral ankle fractures are commonly associated with tibial shaft fractures, specifically distal one-third spiral type injuries. Recognition of an associated ankle injury is important as it can alter operative and postoperative management. Clinical studies are needed to examine patient outcomes with or without ipsilateral ankle injury to determine the clinical significance of this entity. Prognostic level IV. See
Schottel, Patrick C.; Berkes, Marschall B.; Little, Milton T. M.; Lazaro, Lionel E.; Nguyen, Joseph T.; Helfet, David L.; Lorich, Dean G.
STRUCTURED ABSTRACT Objectives To quantify the radiographic tibia and fibula shaft fracture characteristics that are associated with a concomitant ipsilateral ankle injury. Design Retrospective case-control study. Setting Academic level I trauma center. Patients Seventy-one adult patients with an operatively treated tibial shaft fracture met the inclusion/exclusion criteria. Intervention Preoperative radiographs were categorized according to tibia and fibula fracture pattern, location and spatial relationship to each other. Preoperative CT scans were then evaluated to assess for the presence of an articular ankle injury. Main Outcome Measurements 1) incidence of concomitant tibial shaft fracture and ipsilateral ankle injury; and 2) statistical association between tibia and fibula fracture characteristics in patients with and without an ipsilateral ankle fracture. Results Thirty-five of 71 (49.3%) tibial shaft fracture patients had a concomitant ipsilateral ankle injury. Of these, 31 (88.6%) ankle injuries occurred in patients with a spiral pattern tibia fracture of the distal third diaphysis (p<0.001). A spiral pattern tibia fracture, a distal one-third tibial shaft fracture location or a spiral pattern fibula fracture all were significantly associated with the presence of an ipsilateral ankle injury (p=<0.001; p=0.001; and p=0.002). Patients with either a transverse pattern or absent fibula fracture, a non-spiral pattern tibia fracture or a midshaft diaphyseal tibia fracture location were significantly less likely to have an associated ankle injury (p=<0.001; p=<0.001; and p=0.012) Conclusions Ipsilateral ankle fractures are commonly associated with tibial shaft fractures, specifically distal one-third spiral type injuries. Recognition of an associated ankle injury is important as it can alter operative and postoperative management. Clinical studies are needed to examine patient outcomes with or without ipsilateral ankle injury to determine the clinical
Wang, Peng-cheng; Ren, Dong; Zhou, Bing
A 66-year-old woman had sustained crush injury 3 hours prior to her presentation to our hospital. The diagnosis was defined as lateral tibial plateau fracture of the right knee (Schatzker III). Supine position was set up and a pad was put under the affected hip. After sterilization of the surgical field the sterilized sheets were placed beneath the leg in order to be higher than the other side. A rolled sheet was put under the knee joint so that the knee joint was flexed around 30° to 40°. After the surgical field was draped the skin was incised. Iliotibial band was incised by blade (not by electrotomy) and sharp dissection was performed in the Gerdy's tubercle. Capsulotomy was made by cutting the tibial meniscal ligament. Then the meniscus was tagged superiorly and the articular surface was clearly visualized. A window was made in the lateral cortex beneath the plateau, so the impacted fragment was elevated through the window. The metaphyseal void was filled by bone allograft. The placement of the raft-screw plate must be ensured that the raft screws passing the plate could purchase the subchondral bone. After perfect placement of the plate was defined, the femoral distractor was removed and the knee joint was relaxed. It was ensured that the alignment of the lower leg was normal, and then the other screws were inserted. Following placing drainage in the wound the iliotibial band was closed and the subcutaneous soft tissue and skin were closed in layer. © 2015 Chinese Orthopaedic Association and Wiley Publishing Asia Pty Ltd.
Ocegueda-Sosa, Miguel Ángel; Valenzuela-Flores, Adriana Abigail; Aldaco-García, Víctor Daniel; Flores-Aguilar, Sergio; Manilla-Lezama, Nicolás; Pérez-Hernández, Jorge
Closed tibiae plateau fractures are common injuries in the emergency room. The optimal treatment is not well defined or established. For this reason, there are several surgical management options: open reduction and internal fixation, closed reduction and percutaneous synthesis, external fixation, and even conservative treatment for this kind of fracture. The mechanism of production of this fracture is through large varus or valgus deformation to which is added a factor of axial load. The trauma may be direct or indirect. The degree of displacement, fragmentation and involvement of soft tissues like ligaments, menisci, vascular and nerve structures are determined by the magnitude of the force exerted. Any intra-articular fracture treatment can lead to an erroneous instability, deformity and limitation of motion with subsequent arthritic changes, leading to joint incongruity, limiting activity and significantly altering the quality of life. Open reduction and internal fixation with anatomic restitution is the method used in this type of fracture. However, the results of numerous publications can be questioned due to the inclusion in the same study of fractures treated with very different methods.
Uzun, Metin; Kara, Adnan; Adaş, Müjdat; Karslioğlu, Bülent; Bülbül, Murat; Beksaç, Burak
Purpose. We evaluated whether intramedullary nail fixation for tibial diaphysis fractures with concomitant fibula fractures (except at the distal one-third level) managed conservatively with an associated fibula fracture resulted in ankle deformity and assessed the impact of the ankle deformity on lower extremity function. Methods. Sixty middle one-third tibial shaft fractures with associated fibular fractures, except the distal one-third level, were included in this study. All tibial shaft fractures were anatomically reduced and fixed with interlocking intramedullary nails. Fibular fractures were managed conservatively. Hindfoot alignment was assessed clinically. Tibia and fibular lengths were compared to contralateral measurements using radiographs. Functional results were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Foot and Ankle Disability Index Score (FADI). Results. Anatomic union, defined as equal length in operative and contralateral tibias, was achieved in 60 fractures (100%). Fibular shortening was identified in 42 fractures (68%). Mean fibular shortening was 1.2 cm (range, 0.5–2 cm). Clinical exams showed increased hindfoot valgus in 42 fractures (68%). The mean KOOS was 88.4, and the mean FADI score was 90. Conclusion. Fibular fractures in the middle or proximal one-third may need to be stabilized at the time of tibial intramedullary nail fixation to prevent development of hindfoot valgus due to fibular shortening. PMID:25544899
Haffner, Nicolas; Antonic, Vlado; Smolen, Daniel; Slezak, Paul; Schaden, Wolfgang; Mittermayr, Rainer; Stojadinovic, Alexander
Tibial non-unions are common cause of demanding revision surgeries and are associated with a significant impact on patients' quality of life and health care costs. Extracorporeal shockwave therapy (ESWT) has been shown to improve osseous healing in vitro and in vivo. The main objective of present study was to evaluate the efficacy of ESWT in healing of tibial non-unions unresponsive to previous surgical and non-surgical measures. A retrospective multivariant analysis of a prospective open, single-centre, clinical trial of tibia non-union was conducted. 56 patients with 58 eligible fractures who met the FDA criteria were included. All patients received 3000-4000 impulses of electrohydraulic shockwaves at an energy flux density of 0.4mJ/mm(2) (-6dB). On average patients underwent 1.9 times (±1.3SD) surgical interventions prior to ESWT displaying the rather negatively selected cohort and its limited therapy responsiveness. In 88.5% of patients receiving ESWT complete bone healing was observed after six months irrespective of underlying pathology. The multivariant analysis showed that time of application is important for therapy success. Patients achieving healing received ESWT earlier: mean number of days between last surgical intervention and ESWT (healed - 355.1 days±167.4SD vs. not healed - 836.7 days±383.0SD; p<0.0001). ESWT proved to be a safe, effective and non-invasive treatment modality in tibial non-unions recalcitrant to standard therapies. The procedure is well tolerated, time-saving, lacking side effects, with potential to significantly decrease health care costs. Thus, in our view, ESWT should be considered the treatment of first choice in established tibial non-unions. Copyright © 2016 Elsevier Ltd. All rights reserved.
Thewlis, Dominic; Fraysse, Francois; Callary, Stuart A; Verghese, Viju Daniel; Jones, Claire F; Findlay, David M; Atkins, Gerald J; Rickman, Mark; Solomon, Lucian B
Tibial plateau fractures are complex and the current evidence for postoperative rehabilitation is weak, especially related to the recommended postoperative weight bearing. The primary aim of this study was to investigate if loading in the first 12 weeks of recovery is associated with patient reported outcome measures at 26 and 52 weeks postoperative. We hypothesized that there would be no association between loading and patient reported outcome measures. Seventeen patients, with a minimum of 52-week follow-up following fragment-specific open reduction and internal fixation for tibial plateau fracture, were selected for this retrospective analysis. Postoperatively, patients were advised to load their limb to a maximum of 20kg during the first 6 weeks. Loading data were collected during walking using force platforms. A ratio of limb loading (affected to unaffected) was calculated at 2, 6 and 12 weeks postoperative. Knee Injury and Osteoarthritis Scores were collected at 6, 12, 26 and 52 weeks postoperative. The association between loading ratios and patient reported outcomes were investigated. Compliance with weight bearing recommendations and changes in the patient reported outcome measures are described. Fracture reduction and migration were assessed on plain radiographs. No fractures demonstrated any measurable postoperative migration at 52 weeks. Significant improvements were seen in all patient reported outcome measures over the first 52 weeks, despite poor adherence to postoperative weight bearing restrictions. There were no associations between weight bearing ratio and patient reported outcomes at 52 weeks postoperative. Significant associations were identified between the loading ratio at 2 weeks and knee-related quality of life at six months (R 2 =0.392), and between the loading ratio at 6 weeks combined with injury severity and knee-related quality of life at 26 weeks (R 2 =0.441). In summary, weight bearing as tolerated does not negatively affect the
Muñoz Vives, Josep; Bel, Jean-Christophe; Capel Agundez, Arantxa; Chana Rodríguez, Francisco; Palomo Traver, José; Schultz-Larsen, Morten; Tosounidis, Theodoros
In 1975, Blake and McBryde established the concept of ‘floating knee’ to describe ipsilateral fractures of the femur and tibia.1 This combination is much more than a bone lesion; the mechanism is usually a high-energy trauma in a patient with multiple injuries and a myriad of other lesions. After initial evaluation patients should be categorised, and only stable patients should undergo immediate reduction and internal fixation with the rest receiving external fixation. Definitive internal fixation of both bones yields the best results in almost all series. Nailing of both bones is the optimal fixation when both fractures (femoral and tibial) are extra-articular. Plates are the ‘standard of care’ in cases with articular fractures. A combination of implants are required by 40% of floating knees. Associated ligamentous and meniscal lesions are common, but may be irrelevant in the case of an intra-articular fracture which gives the worst prognosis for this type of lesion. Cite this article: Muñoz Vives K, Bel J-C, Capel Agundez A, Chana Rodríguez F, Palomo Traver J, Schultz-Larsen M, Tosounidis, T. The floating knee. EFORT Open Rev 2016;1:375-382. DOI: 10.1302/2058-5241.1.000042. PMID:28461916
Nicolini, Alexandre P; Carvalho, Rogerio T; Ferretti, Mario; Cohen, Moises
Tibial tuberosity avulsion fractures are injuries accounting for less than 3% of all epiphyseal and 1% of all physeal injuries in adolescents. Bilateral injuries are very rare, with only 19 cases described in the literature. These types of fractures occur commonly in male teenagers during sport activities and are often associated with other orthopaedic disorders. We report the case of a male teenager with simultaneous bilateral tibial tubercle fractures, describe the evolution and treatment of this injury and review the literature on this subject. Case report.
Zhang, Yu; Song, Lijun; Li, Xiang; Fang, Jiahu
The authors have identified a subset of unicondylar tibial plateau depression fracture patterns caused by a flexion-valgus force. The purpose of this study was to describe this fracture pattern and suggest a modified lateral approach that may allow for improved reduction and stabilization. The preoperative radiographs and CT scans of 102 patients who sustained unicondylar tibial plateau fractures (OTA 41B) were reviewed. Twenty-six fracture patients had posterolateral (PL) tibial plateau depression fractures. By medical record review and telephone follow-up, the injury mechanism of the 22 unicondylar tibial plateau fractures was confirmed as a flexion-valgus force. The radiographic features of those cases were analyzed and measured. To address this specific fracture pattern, a modified approach combined with a novel intra-articular osteotomy was applied. According to the morphological characteristics, this tibial plateau fracture pattern could be divided into two subtypes: type A was a confined, basin-like articular surface depression fracture located in the PL quadrant, and type B was a cancellous fracture involving the PL tibial plateau resulting in a decrease in the posterior slope. One radiographic hallmark of this fracture pattern is an anatomically or a mechanically intact posterior column wall. The novel approach was applied to both types. The postoperative radiographic measurements revealed excellent reduction quality. On axial scans, the distance between the most posterior rafting screw and the tangent line of the tibial plateau rim was 3.0 ± 2.07 mm (from -1.9 to 4.3), and the angulation between them was 8.9 ± 3.02° (from -7.3 to 15.6). These results indicated excellent PL quadrant coverage from the rafting screws. Flexion-valgus force-induced unicondylar tibial plateau depression fracture is a unique injury pattern. We suggest a novel surgical approach to address this injury's key features, which may facilitate exposure and enhance fixation
Baltaci, G; Ozer, H; Tunay, V B
A sixteen-year-old boy suffered from sharp pain in the knee during a jump while playing basketball. He had a positive history of Osgood Schlatter disease. Radiographic evaluation demonstrated an avulsion fracture of the tibial tuberosity Type III according to the classification of Watson-Jones. Rehabilitation after avulsion fracture of the tibial tuberosity is an important consideration for this relatively uncommon adolescent injury. In such avulsion fractures, landing on the ground with the knee fully extended after a jump is the most likely cause. This case report reviews the rehabilitation program, and selected functional outcome measures after rehabilitation are reported. The patient returned to sporting activity after 12 months.
Ahrens, Philipp; Sandmann, Gunther; Bauer, Jan; König, Benjamin; Martetschläger, Frank; Müller, Dirk; Siebenlist, Sebastian; Kirchhoff, Chlodwig; Neumaier, Markus; Biberthaler, Peter; Stöckle, Ulrich; Freude, Thomas
Fractures of the tibial plateau are among the most severe injuries of the knee joint and lead to advanced gonarthrosis if the reduction does not restore perfect joint congruency. Many different reduction techniques focusing on open surgical procedures have been described in the past. In this context we would like to introduce a novel technique which was first tested in a cadaver setup and has undergone its successful first clinical application. Since kyphoplasty demonstrated effective ways of anatomical correction in spine fractures, we adapted the inflatable instruments and used the balloon technique to reduce depressed fragments of the tibial plateau. The technique enabled us to restore a congruent cartilage surface and bone reduction. In this technique we see a useful new method to reduce depressed fractures of the tibial plateau with the advantages of low collateral damage as it is known from minimally invasive procedures.
Pascarella, Fabio; Ziranu, Antonio; Maccauro, Giulio
We present a case of tibial tubercle fracture in a young male athlete with both bilateral bipartite patella at the lower pole (Saupe type I) and Osgood-Schlatter disease. Open reduction and internal fixation were performed to restore the extensor mechanism of the knee. PMID:25785215
Pascarella, Fabio; Ziranu, Antonio; Maccauro, Giulio
We present a case of tibial tubercle fracture in a young male athlete with both bilateral bipartite patella at the lower pole (Saupe type I) and Osgood-Schlatter disease. Open reduction and internal fixation were performed to restore the extensor mechanism of the knee.
Valdés-Martínez, Alejandro; Seiler, Gabriela; Mai, Wilfried; Bolt, David M; Mudge, Margaret; Dukti, Sarah A; Hubert, Jeremy D
To develop a quantitative method of interpreting tibial scintigrams of Thoroughbred racehorses with tibial stress fractures that may facilitate diagnosis of fractures and to provide prognostic information regarding future performance of affected horses. 35 Thoroughbred racehorses. Static bone-phase scintigrams of tibial stress fractures were quantitatively analyzed by use of ratios of the mean radionuclide counts per pixel in a region of interest (ROI) drawn around the area of increased uptake of radiopharmaceutical to mean counts per pixel in a second ROI drawn around an apparently normal area of the tibial diaphysis. In horses with unilateral fractures, ratios for the contralateral tibia were determined by use of 2 ROIs drawn at the same positions as the ROIs in the fractured tibia. Ratios were compared between fractured versus apparently normal tibias, between horses that returned to racing versus those that did not, and among horses with various grades of lameness. The association between ratios for fractured tibias and intervals between diagnosis and return to racing was also assessed. Mean ratio of ROIs in apparently normal tibias was 1.35 (95% confidence interval [CI], 1.21 to 1.50); that in tibias with stress fractures was 3.55 (95% CI, 2.50 to 4.60). These ratios were significantly different. None of the associations between ratios for fractured tibias and grades of lameness or performance outcomes were significant. Tibial stress fracture scintigrams can be quantitatively analyzed. A prospective study with a controlled rehabilitation period is necessary to evaluate the possible applications of this method.
Vetter, Sven Yves; Euler, Finn; von Recum, Jan; Wendl, Klaus; Grützner, Paul Alfred; Franke, Jochen
The intraoperative assessment of the articular surface in displaced intra-articular distal tibia fractures can be challenging using conventional fluoroscopy. The aim of the study was to determine the frequency and the method of intraoperative corrections of fracture reductions or implant placements during open reduction, internal fixation by using cone beam computed tomography (CT) after conventional fluoroscopy. Displaced intra-articular distal tibia fractures were retrospectively analyzed from August 2001 until December 2011. The fractures were classified according to the standards of the AO/OTA as type B or C and treated with open reduction and internal plate fixation. After primary reduction using conventional fluoroscopy, an additional cone beam CT scan was used to determine the alignment of the joint line and the implant position. The number of intraoperative revisions of the primary reduction due to the use of cone beam CT was analyzed. A total of 143 patients with an intra-articular tibial plafond fracture were included in the analysis. In 43 patients (30%), an intraoperative correction was performed after the cone beam CT scan. In 34 (24%) of these cases, intraoperative correction was required because of inadequate joint line reduction. Nine (6%) corrections were required as a result of a malposition of the implant. The revision rate did not differ by fracture classification. Despite its acceptance as the standard method of imaging, intraoperative conventional fluoroscopy for the assessment of implant positioning and fracture reduction of tibial plafond fractures is limited. The intraoperative utilization of cone beam CT provided additional information for the surgeon to detect insufficient reduction or implant malposition. Level III, retrospective comparative series. © The Author(s) 2016.
Merloz, P; de Cheveigne, C; Butel, J; Robb, J E
We present a case of bilateral Salter-Harris type II epiphyseal injury to the proximal tibial epiphysis that occurred during gentle exercise. The mechanism and the likely contribution of preexisting Osgood-Schlatter disease are discussed.
Lakhotia, Devendra; Sharma, Gaurav; Khatri, Kavin; Kumar, G-N; Sharma, Vijay; Farooque, Kamran
Soft tissue healing is of paramount importance in distal tibial fractures for a successful outcome. There is an increasing trend of using anterolateral plate due to an adequate soft tissue cover on ante- rolateral distal tibia. The aim of this study was to evaluate the results and complications of minimally invasive anterolateral locking plate in distal tibial fractures. This is a retrospective study of 42 patients with distal tibial fractures treated with minimally invasive anterolateral tibial plating. This study evaluates the bone and soft tissue healing along with emphasis on complications related to bone and soft tissue healing. Full weight bearing was allowed in mean time period of 4.95 months (3-12 months). A major local complication of a wound which required revision surgery was seen in one case. Minor complications were identified in 9 cases which comprised 4 cases of marginal necrosis of the surgical wound, 1 case of superficial infection, 1 case of sensory disturbance over the anterolateral foot, 1 case of muscle hernia and 2 cases of delayed union. Mean distance between the posterolateral and anterolateral incision was 5.7 cm (4.5-8 cm). The minimally invasive distal tibial fixation with anterolateral plating is a safe method of stabilization. Distance between anterolateral and posterolateral incision can be placed less than 7 cm apart depending on fracture pattern with proper surgical timing and technique.
Guler, Ferhat; Kose, Ozkan; Erol, Bekir; Turan, Adil; Koroglu, Mert; Akalin, Serdar
The purpose of this prospective study was to examine the prevalence of occult knee injuries in patients with ipsilateral tibial shaft fractures and determine their impact on clinical outcome. Preoperative knee MRI examination was performed in 41 patients (42 knees) with isolated tibial shaft fractures. Menisci, cruciate ligaments, collateral ligaments, extensor mechanism, osteochondral lesions, bone contusions and knee effusion were evaluated. All patients were treated with reamed and locked intra-medullary tibial nailing without an additional surgical procedure for knee injuries. All patients were followed to at least fracture union and were evaluated with knee examination and Lysholm knee score. Of the 42 knees, 41 (97.6 %) showed at least one defined injury around the knee. There was only one patient who had totally normal knee MRI findings. One or more ligamentous injuries of the knee were identified in 35 (83.3 %) of the knees. Five patents (11.9 %) had medial meniscal tear in posterior horn. Extensor mechanism injuries were seen in two patients. Mild to marked joint effusion was observed in 35 (81 %) knees. Twenty-two knees demonstrated bone bruise; femoral condyle (n = 7), tibial plateau (n = 12), patella (n = 2) and fibular head (n = 1). No patients had osteochondral lesion. Patients were followed with a mean of 13.2 ± 3.6 (range 8-22) months. Clinical knee examination revealed Grade II (+) anterior drawer test in two patients. The mean Lysholm knee score was 99.1 ± 2.14 (range 91-100) at the final follow-up. Ipsilateral intra-articular, extra-articular or combined knee injuries may occur at the time of injury with tibial shaft fractures. However, most of these injuries are not clinically relevant and heal without any sequel or remain asymptomatic late after fracture union. Routine use of preoperative knee MRI examination in patients with tibial shaft fractures is not necessary.
Vicenti, G; Pesce, V; Tartaglia, N; Abate, A; Mori, C M; Moretti, B
The dynamic locking screw (DLS) in association with minimally invasive plate osteosynthesis (MIPO) in a bridging construct for simple metadiaphyseal long bone fractures enables modulation of the rigidity of the system and facilitates the development of early and triplanar bone callus. Twenty patients affected by distal tibial fracture were treated with MIPO bridging technique and DLS at the proximal side of the fracture. Time of consolidation, quality of the reduction, complications and American Orthopaedic Foot and Ankle Society (AOFAS) score were monitored and the results compared with those from a control group treated with only standard screws on both fracture sides. Student t-test for independent samples was used for the comparison of means between the two groups. Chi-square test was used for the comparison of proportions. A multiple logistic regression model was constructed to assess the possible confounding effects. Performance was considered significant for p<0.05. The mean healing time was 17.6 ± 2.8 weeks in the group treated with standard screws and 13.5 ± 1.8 weeks in the group treated with DLS (t=5.5, p<0.0001). The DLS was associated with early healing and triplanar bone callus. Copyright © 2014 Elsevier Ltd. All rights reserved.
Carrera, Ion; Gelber, Pablo Eduardo; Chary, Gaetan; Gomez Masdeu, Mireia; González Ballester, Miguel A; Monllau, Juan Carlos; Noailly, Jerome
The role of the proximal tibiofibular joint (PTFJ) in tibial plateau fractures is unknown. The purpose of this study was to assess, with finite-element (FE) calculations, differences in interfragmentary movement (IFM) in a split fracture of lateral tibial plateau, with and without intact fibula. It was hypothesized that an intact fibula could positively contribute to the mechanical stabilization of surgically reduced lateral tibial plateau fractures. A split fracture of the lateral tibial plateau was recreated in an FE model of a human tibia. A three-dimensional FE model geometry of a human femur-tibia system was obtained from the VAKHUM project database, and was built from CT images from a subject with normal bone morphologies and normal alignment. The mesh of the tibia was reconverted into a geometry of NURBS surfaces. The fracture was reproduced using geometrical data from patient radiographs, and two models were created: one with intact fibula and other without fibula. A locking screw plate and cannulated screw systems were modelled to virtually reduce the fracture, and 80 kg static body weight was simulated. Under mechanical loads, the maximum interfragmentary movement achieved with the fibula was about 30% lower than without fibula, with both the cannulated screws and the locking plate. When the locking plate model was loaded, intact fibula contributed to lateromedial forces on the fractured fragments, which would be clinically translated into increased normal compression forces in the fractured plane. The intact fibula also reduced the mediolateral forces with the cannulated screws, contributing to stability of the construct. This FE model showed that an intact fibula contributes to the mechanical stability of the lateral tibial plateau. In combination with a locking plate fixation, early weight bearing may be allowed without significant IFM, contributing to an early clinical and functional recovery of the patient.
Warschawski, Yaniv; Elbaz, Avi; Segal, Ganit; Norman, Doron; Haim, Amir; Jacov, Elis; Grundshtein, Alon; Steinberg, Ely
The purpose of the current study was to evaluate the long-term functional outcome as measured by gait patterns and quality of life assessment of patients with high-energy tibial plateau fracture compared to matched controls. Thirty-eight patients were evaluated in a case-controlled comparison. Twenty-two patients with tibial plateau fracture were evaluated after 3.1 (1.63) years (sd) from injury. Patients underwent a computerized spatiotemporal gait test and completed the SF-12 health survey. 16 healthy subjects, matched for age and gender served as a control group. The main outcome measures for this study were spatiotemporal gait characteristics, physical quality of life and mental quality of life. Significant differences were found in all gait parameters between patients with tibial plateau fracture and healthy controls. Patients with tibial plateau fracture walked slower by 18% compared to the control group (p < 0.001), had slower cadence by 8% compared (p = 0.002) to the control group and had shorter step length in the involved leg by 11% and in the uninvolved leg by 12% compared to the control group (p = 0.006 and p = 0.003, respectively). Patients with tibial plateau fracture also showed shorter single limb support (SLS) in the involved leg by 12% compared to the uninvolved leg and 5% in the uninvolved leg compared to the control group (p < 0.001 and p = 0.017, respectively). Significant differences were found in the Short Form (SF)-12 scores. Physical Health Score of patients with tibial plateau fracture was 65% lower compared to healthy controls (p < 0.001), and Mental Health Score of the patients was 40% lower compared to healthy controls (p < 0.001). Finally, significant correlations were found between SF-12 and gait patterns. Long-term deviations in gait and quality of life exist in patients following tibial plateau fracture. Patients following tibial plateau fracture present altered spatiotemporal gait patterns compared to healthy controls, as well as
Leung, Kwok-Sui; Lee, Wing-Sze; Tsui, Hon-For; Liu, Paul Po-Lung; Cheung, Wing-Hoi
A clinical study was conducted to investigate the effect of low-intensity pulsed ultrasound (US) stimulation (LIPUS) on the healing of complex tibial fractures. Thirty complex tibial fractures were randomly assigned to the treatment with LIPUS (n = 16) or by a dummy machine (sham-exposed: n = 14). The fractures were immobilized by either internal or external fixations according to the clinical indications. LIPUS was given 20 min/day for 90 days. Fracture healing was monitored by clinical, radiological, densitometric and biochemical assessments. The LIPUS-treated group showed statistically significantly better healing, as demonstrated by all assessments. Complications were minimal in the LIPUS group. There were two cases of delayed union, with one in each group. There were two cases of infection in the control group. The delayed-union cases were subsequently treated by LIPUS and the infection cases were treated with standard protocol. Fracture healing in these patients was again treated by LIPUS.
Hoekstra, H; Rosseels, W; Luo, C-F; Nijs, S
Open reduction and internal fixation of two column posterior and lateral tibial plateau fractures through a combined posterior reversed L-shaped and anterolateral approach in floating position in Caucasians. Two column posterior and lateral tibial plateau fractures. Tibial plateau fractures that do not involve the posterior and lateral column. The patient is positioned in floating position, a reversed L-shaped skin incision is made, the posterior column after lateral retraction of the medial head of the gastrocnemius muscle is exposed, and the posterior fragments are reduced and fixed. Subsequently, flexion and varus stress on the knee is applied, an anterolateral skin incision is made, the lateral column is exposed, and the lateral fragments are reduced and fixed. Despite a different physique as Asians, a combined posterior reversed L-shaped and anterolateral approach in a floating position for the surgical treatment of two column posterior and lateral tibial plateau fractures is technically possible in Caucasians. In our experience, this combined approach is an excellent strategy in most patients for surgical treatment of two column posterior and lateral column fractures. Copyright © 2015 Elsevier Ltd. All rights reserved.
Galbraith, John G; Daly, Charles J; Harty, James A; Dailey, Hannah L
For tibial fractures, the decision to fix a concomitant fibular fracture is undertaken on a case-by-case basis. To aid in this clinical decision-making process, we investigated whether loss of integrity of the fibula significantly destabilises midshaft tibial fractures, whether fixation of the fibula restores stability to the tibia, and whether removal of the fibula and interosseous membrane for expediency in biomechanical testing significantly influences tibial interfragmentary mechanics. Tibia/fibula pairs were harvested from six cadaveric donors with the interosseous membrane intact. A tibial osteotomy fracture was fixed by reamed intramedullary (IM) nailing. Axial, torsion, bending, and shear tests were completed for four models of fibular involvement: intact fibula, osteotomy fracture, fibular plating, and resected fibula and interosseous membrane. Overall construct stiffness decreased slightly with fibular osteotomy compared to intact bone, but this change was not statistically significant. Under low loads, the influence of the fibula on construct stability was only statistically significant in torsion (large effect size). Fibular plating stiffened the construct slightly, but this change was not statistically significant compared to the fibular osteotomy case. Complete resection of the fibula and interosseous membrane significantly decreased construct torsional stiffness only (large effect size). These results suggest that fixation of the fibula may not contribute significantly to the stability of diaphyseal tibial fractures and should not be undertaken unless otherwise clinically indicated. For testing purposes, load-sharing through the interosseous membrane contributes significantly to overall construct mechanics, especially in torsion, and we recommend preservation of these structures when possible. Copyright © 2016 Elsevier Ltd. All rights reserved.
Abdelhamid, Mohamed M; Bayoumy, Maysara Abdelhalim; Elkady, Hesham A; Abdelkawi, Ayman Farouk
Several techniques of arthroscopic treatment of tibial spine avulsion fractures have been described in the literature. These techniques include the use of various fixation devices such as screws, K-wires, wiring, sutures, and suture anchors. In this study, we evaluate a new wiring technique for the treatment of these injuries. This technique involves fixation by stainless steel tension wires passed over the fractured spine and tied over a bone bridge. The advantages of this technique are that it aids in reduction, allows for compression of the tibial spine fragment anatomically in its fracture bed, provides stable fixation in difficult comminuted fractures, and allows for early mobilization and weight bearing because of the solid fixation.
Liu, Yong-gang; Zuo, Li-xin; Pei, Guo-xian; Dai, Ke; Sang, Jing-wei
To explore the establishment of Schatzker classification digital model of tibial plateau fractures and its application in virtual surgery. Proximal tibial of one healthy male volunteer was examined with 64-slice spiral computed tomography (CT). The data were processed by software Mimics 10.01 and a model of proximal tibia was reconstructed. According to the Schatzker classification criteria of tibial plateau fractures, each type of fracture model was simulated.Screen-captures of fracture model were saved from different directions.Each type of fracture model was exported as video mode.Fracture model was imported into FreeForm modeling system.With a force feedback device, a surgeon could conduct virtual fracture operation simulation.Utilizing the GHOST of FreeForm modeling system, the software of virtual cutting, fracture reduction and fixation was developed.With a force feedback device PHANTOM, a surgeon could manipulate virtual surgical instruments and fracture classification model and simulate surgical actions such as assembly of surgical instruments, drilling, implantation of screw, reduction of fracture, bone grafting and fracture fixation, etc. The digital fracture model was intuitive, three-dimensional and realistic and it had excellent visual effect.Fracture could be observed and charted from optional direction and angle.Fracture model could rotate 360 ° in the corresponding video mode. The virtual surgical environment had a strong sense of reality, immersion and telepresence as well as good interaction and force feedback function in the FreeForm modeling system. The user could make the corresponding decisions about surgical method and choice of internal fixation according to the specific type of tibial plateau fracture as well as repeated operational practice in virtual surgery system. The digital fracture model of Schatzker classification is intuitive, three-dimensional, realistic and dynamic. The virtual surgery systems of Schatzker classifications make
Bhan, S; Mehara, A K
Percutaneous bone grafting with a specially devised milling cutter was used in 21 patients with nonunion or delayed union of fractures of the tibial shaft. Union was obtained in 18. The technique is safe, simple and can be done under local anaesthesia.
Bhandari, Mohit; Guyatt, Gordon; Tornetta, Paul; Schemitsch, Emil; Swiontkowski, Marc; Sanders, David; Walter, Stephen D
Surgeons agree on the benefits of operative treatment of tibial fractures - the most common of long bone fractures - with an intramedullary rod or nail. Rates of re-operation remain high - between 23% and 60% in prior trials - and the two alternative nailing approaches, reamed or non-reamed, each have a compelling biological rationale and strong proponents, resulting in ongoing controversy regarding which is better. The objective of this trial was to assess the impact of reamed versus non-reamed intramedullary nailing on rates of re-operation in patients with open and closed fractures of the tibial shaft. The study to prospectively evaluate reamed intramedullary nails in tibial fractures (S.P.R.I.N.T) was a multi-center, randomized trial including 29 clinical sites in Canada, the United States and the Netherlands which enrolled 1200 skeletally mature patients with open (Gustilo Types I-IIIB) or closed (Tscherne Types 0-3) fractures of the tibial shaft amenable to surgical treatment with an intramedullary nail. Patients received a statically locked intramedullary nail with either reamed or non-reamed insertion. The first strategy involved fixation of the fracture with an intramedullary nail following reaming to enlarge the intramedullary canal (Reamed Group). The second treatment strategy involved fixation of the fracture with an intramedullary nail without prior reaming of the intramedullary canal (Non-Reamed Group). Patients, outcome assessors, and data analysts were blinded to treatment allocation. Peri-operative care was standardized, and re-operations before 6 months were proscribed. Patients were followed at discharge, 2 weeks post-discharge, and at 6 weeks, 3, 6, 9, and 12 months post surgery. A committee, blinded to allocation, adjudicated all outcomes. The primary outcome was re-operation to promote healing, treat infection, or preserve the limb (fasciotomy for compartment syndrome after nailing). The primary outcome was a composite comprising the following
Introduction: Tibial plateau injury involves the articular surface of the proximal tibia with diverse group of fractures that represent a wide spectrum of severity that challenge even the most experienced surgeons, but with the invent of modern diagnostic technology and the advent of locking plates, results appear to be improving over time. Method: The study was conducted on thirty patients admitted in the department of orthopaedics with diagnoses of tibial plateau fractures treated with Locking Condylar Plate. The patients were followed up for a minimum period of six months and clinico-radiological progression of fracture union with the functional outcome was studied using 100 point rating system devised by Delamarter et al . Result: Twenty-two patients showed excellent results while eight patients had good to fair and none with poor result. The average time for radiological union was 17.5 weeks. Conclusion: The results of the study concluded that while locking condylar plate seems to show excellent results in low energy tibial plateau fractures, it can probably be used to successfully treat patients with high energy fracture patterns without the need for additional medial stabilization.
Sivasubramanian, H; Kini, S G; Ang, K Y; Sathappan, S S
Metaphyseal tantalum cones in primary total knee arthroplasty and their functional outcome is described using 3 case reports over 6 years. 3 knees in 3 elderly individuals (mean age of 70.4 years), with pre-existing osteoarthritis and complex proximal tibial fractures, were operated on. Ambulation with walking frame was achieved from post-operation day 1, with weight-bearing as tolerated. Mean range of motion was 122° and Mean Knee Society Score was 88. All showed improvement in pre-operative limb alignment. Radiological fracture union was achieved on an average of 3 months. All were independent ambulators and pain-free at the latest follow-up. Our case series shows that tantalum cones are associated with significant improvements in clinical scores, patient symptoms, range of movement, early weight-bearing and low rates of complications in complex proximal tibial fractures with poor bone stock.
Petfield, Joseph L; Hayeck, Garry T; Kopperdahl, David L; Nesti, Leon J; Keaveny, Tony M; Hsu, Joseph R
Virtual stress testing (VST) provides a non-invasive estimate of the strength of a healing bone through a biomechanical analysis of a patient's computed tomography (CT) scan. We asked whether VST could improve management of patients who had a tibia fracture treated with external fixation. In a retrospective case-control study of 65 soldier-patients who had tibia fractures treated with an external fixator, we performed VST utilizing CT scans acquired prior to fixator removal. The strength of the healing bone and the amount of tissue damage after application of an overload were computed for various virtual loading cases. Logistic regression identified computed outcomes with the strongest association to clinical events related to nonunion within 2 months after fixator removal. Clinical events (n = 9) were associated with a low tibial strength for compression loading (p < 0.05, AUC = 0.74) or a low proportion of failed cortical bone tissue for torsional loading (p < 0.005, AUC = 0.84). Using post-hoc thresholds of a compressive strength of four times body-weight and a proportional of failed cortical bone tissue of 5%, the test identified all nine patients who failed clinically (100% sensitivity; 40.9% positive predictive value) and over three fourths of those (43 of 56) who progressed to successful healing (76.8% specificity; 100% negative predictive value). In this study, VST identified all patients who progressed to full, uneventful union after fixator removal; thus, we conclude that this new test has the potential to provide a quantitative, objective means of identifying tibia-fracture patients who can safely resume weight bearing. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:805-811, 2017. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Say, Ferhat; Bülbül, Murat
Rotational malalignment following closed intramedullary nailing of tibial fractures does not attract attention but is a complication which may lead to serious results. This study aimed to present findings related to rotational malalignment from rotational alignment measurements made clinically and with computerised tomography (CT) in patients who had undergone locked intramedullary nailing for tibial fracture. A total of 26 patients (male/female: 23/3) were evaluated after application of reamed locking intramedullary nailing to a diagnosed tibial shaft fracture. The mean age was determined as 37.5 ± 15.6 years. Rotational alignment was measured in both lower extremities clinically as thigh-foot angle (TFA) and radiologically with CT. Rotational malalignment was accepted as a more than 10º difference between the two lower extremities. Malrotation was determined at more than 10º from TFA in two (7 %) of 26 patients and from CT in five (19 %) of 26 patients. In three of them, the malrotation was >15º. Of the patients determined with malrotation with CT, it was determined from clinical measurements in 40 %. The mean rotational difference was determined as greater with CT measurement (4.7° ± 9.5) compared to the TFA (1.1° ± 5.6) (p < 0.001). No statistically significant relationship was determined between a rotational difference over 10º and the AO fracture type, fracture location and fibula fixation. A significant number of patients treated with intramedullary nailing for a tibial fracture may result in rotational malalignment. To determine rotational malalignment, a thorough clinical evaluation must be made and different kinds of clinical measurements taken and, when suspicions remain, determination should be made by CT.
Zheng, Wenhao; Chen, Chunhui; Tao, Zhenyu; Zhang, Chuanxu; Zhang, Hui; Li, Hang; Feng, Zhenhua; Cheng, Liang; Chen, Hua
The objective of this study was to compare the outcomes of pediatric tibial shaft fractures treated with titanium elastic nail (TEN) by pediatric orthopedists and non-pediatric orthopedists. We conducted a prospective cohort study of 90 children of tibial shaft fractures, who were randomized to operative stabilization either by pediatric orthopedists (Group A, 45 cases) or by non-pediatric orthopedists (Group B, 45 cases) from April 2010 to May 2015. Demographic data and clinical characteristics (age, sex, weight, fracture side and type, cause of injury, number of fibula fracture and time from injury to operation) were comparable between the two groups before surgery. Clinical data, complications and functional outcomes between the two groups were recorded. A total of 10 patients were lost to follow-up for various reasons and each group remained 40 cases. The mean follow-up period was 14.9 ± 1.9 months for Group A and 15.3 ± 2.2 months for Group B (P = 0.451). There was no significant difference in length of hospitalization, full weight-bearing time, fracture union time and TEN outcome scores between the two groups (P = 0.917, P = 0.352, P = 0.404, P = 506, respectively). However, Group A exhibited significantly shorter operation duration and less fluoroscopy times than Group B (P < 0.001 and P < 0.001, respectively). Also, there was a trend for patients of Group A to have lower rate of open reduction than Group B (P = 0.019). When comparing the total complications, no significant difference existed between the groups (P = 0.764). Our results indicated that pediatric tibial shaft fractures treated surgically by pediatric orthopedists offered potential advantages including a shorter operating time, less times of fluoroscopy and a lower rate of open reduction. However, both pediatric and non-pediatric orthopedists could achieve satisfactory clinical results in treatment of these injuries. Copyright © 2018 IJS Publishing
Behera, Prateek; Aggarwal, Sameer; Kumar, Vishal; Kumar Meena, Umesh; Saibaba, Balaji
Fractures of the tibia are one of the most commonly seen orthopedic injuries. Most of them result from a high velocity trauma. While intramedullary nailing of tibial diaphyseal fractures is considered as the golden standard form of treatment for such cases, many metaphyseal and metaphyseal-diaphyseal junction fractures can also be managed by nailing. Maintenance of alignment of such fractures during surgical procedure is often challenging as the pull of patellar tendon tends to extend the proximal fragment as soon as one flexes the knee for the surgical procedure. Numerous technical modifications have been described in the literature for successfully nailing such fractures including semi extended nailing, use of medial plates and external fixators among others. In this study, it was aimed to report two cases in which we used our ingenious method of applying external fixator for maintaining alignment of the fracture and aiding in the entire process of closed intramedullary nailing of metaphyseal tibial fractures by the conventional method. We were able to get good alignment during and after the closed surgery as observed on post-operative radiographs and believe that further evaluation of this technique may be of help to surgeons who want to avoid other techniques.
Eichhubl, P.; Alzayer, Y.; Laubach, S.; Fall, A.
Fracture aperture is a primary control on flow in fractured reservoirs of low matrix permeability including unconventional oil and gas reservoirs and most geothermal systems. Guided by principles of linear elastic fracture mechanics, fracture aperture is generally assumed to be a linear function of fracture length and elastic material properties. Natural opening-mode fractures with significant preserved aperture are observed in core and outcrop indicative of fracture opening strain accommodated by permanent solution-precipitation creep. Fracture opening may thus be decoupled from length growth if the material effectively weakens after initial elastic fracture growth by either non-elastic deformation processes or changes in elastic properties. To investigate the kinematics of fracture length and aperture growth, we reconstructed the opening history of three opening-mode fractures that are bridged by crack-seal quartz cement in Travis Peak Sandstone of the SFOT-1 well, East Texas. Similar crack-seal cement bridges had been interpreted to form by repeated incremental fracture opening and subsequent precipitation of quartz cement. We imaged crack-seal cement textures for bridges sampled at varying distance from the tips using scanning electron microscope cathodoluminescence, and determined the number and thickness of crack-seal cement increments as a function of position along the fracture length and height. Observed trends in increment number and thickness are consistent with an initial stage of fast fracture propagation relative to aperture growth, followed by a stage of slow propagation and pronounced aperture growth. Consistent with fluid inclusion observations indicative of fracture opening and propagation occurring over 30-40 m.y., we interpret the second phase of pronounced aperture growth to result from fracture opening strain accommodated by solution-precipitation creep and concurrent slow, possibly subcritical, fracture propagation. Similar deformation
Märdian, Sven; Landmann, Felix; Wichlas, Florian; Haas, Norbert P; Schaser, Klaus-Dieter; Schwabe, Philipp
Background: Articular reconstruction and stable fixation of tibial plateau fractures and its various subtypes continue to represent a surgical challenge. Only few trials have studied results following angular stable plate fixation. The present study aimed to investigate the clinical, radiological, functional and quality of life results following tibial plateau fractures using angular stable plate fixation. Materials and Methods: 101 patients were retrospectively studied using functional (ROM; KSS; VAS), radiographic (osteoarthritis score, loss of reduction) and quality of life (WOMAC; Lysholm) scores. There were 46 males and 55 females. The average of patients was 51 years (range 22-77 years). Study groups were assigned according to the AO fracture classification. Results: Mean followup was 57 ± 30 months. Fracture type distribution revealed a significantly (P < 0.001) increased number of type B- (62.4%) compared to C-fractures. Functional assessment showed a significantly better total KSS (84.1 ± 15.6 vs. 74.7 ± 18.0; P = 0.01) as well as ROM (active: 124°±17° vs. 116°±15°, P = 0.014; passive: 126°±18° vs. 118 ± 14°, P = 0.017) in the B-fracture group. VAS was found to be markedly higher (P = 0.0039) following type C-fractures. Rating osteoarthritis secondary to a tibial plateau fracture as a function of injury severity (r = 0.485; P < 0.001) and relating the loss of reduction to the grade of evolving osteoarthritis (r = 0.643; P < 0.001) a positive correlation was found. Quality of life showed significantly improved results for Lysholm score (P = 0.004) following B-fractures with low overall values for the WOMAC score. Conclusion: Presented data provide sufficient evidence that anatomic restoration of tibial plateau fractures with angular stable plate fixation result in decreased loss of reduction and declined incidence of posttraumatic osteoarthritis, thereby providing acceptable mid to long term outcome. PMID:26806969
Cuéllar, Vanessa G; Martinez, Danny; Immerman, Igor; Oh, Cheongeun; Walker, Peter S; Egol, Kenneth A
Although the posteromedial fragment in tibial plateau fractures is often considered unstable, biomechanical evidence supporting this view is lacking. We aimed to evaluate the stability of the fragment in a cadaver model. Our hypothesis was that under the expected small axial force during rehabilitation and the combined effects of this force with shear force, internal rotation torque, and varus moment, the most common posteromedial tibial fragment morphology could maintain stability in early flexion. Axial compression force alone or combined with posterior shear, internal rotation torque, or varus moment was applied to the femurs of 5 fresh cadaveric knees. A Tekscan pressure mapping system was used to measure pressure and contact area between the femoral condyles, meniscus, and tibial plateau. A Microscribe 3D digitizer was used to define the 3-dimensional positions of the femur and tibia. A 10-mm and then a 20-mm osteotomy was created with a saw at an angle of 30 degrees in the axial plane with respect to the tangent of the posterior tibial plateau and 75 degrees in the sagittal plane, representing a typical posteromedial fracture fragment. At each flexion angle (15, 30, 60, 90, and 120 degrees) and loading condition (axial compression only, compression with shear force, torque, and varus moment), distal displacement of the medial femoral condyle and the tibial fracture fragments was determined. For the 10-mm fragment, medial femoral condyle displacement was little affected up to approximately 30-degree flexion, after which it increased. For the 20-mm fragment, there was progressive medial femoral condyle displacement with increasing flexion from baseline. However, for the 10- and 20-mm fragments themselves, displacements were noted at every flexion angle, starting at 1.7 mm inferior displacement with 15 degrees of flexion and internal rotation torque and up to 10.2 mm displacement with 90 degrees of flexion and varus bending moment. In this cadaveric model of a
Frosch, K-H; Krause, M; Frings, J; Drenck, T; Akoto, R; Müller, G; Madert, J
Malreduction of tibial head fractures often leads to malalignment of the lower extremity, pain, limited range of motion and instability. The extent of the complaints and the degree of deformity requires an exact analysis and a standardized approach. True ligamentous instability should be distinguished from pseudoinstability of the joint. Also extra- and intra-articular deformities have to be differentiated. In intra-articular deformities the extent of articular surface displacement, defects and clefts must be accurately evaluated. A specific surgical approach is necessary, which allows adequate visualization, correct osteotomy and refixation of the fractured area of the tibial head. In the long-term course good clinical results are described for intra-articular osteotomies. If the joint is damaged to such an extent that it cannot be reconstructed or in cases of advanced posttraumatic osteoarthritis, total knee arthroplasty may be necessary; however, whenever possible and reasonable, anatomical reconstruction and preservation of the joint should be attempted.
Nicetto, Tommaso; Longo, Federico
Radiographs revealed a slightly displaced long oblique diaphyseal tibial fracture with bone fissures running distally in a 2-year-old, 4.5 kg cat that had been hit by a car. An angle stable implant was applied in a supracutaneous fashion. The patient tolerated the external implant and had a satisfactory functional recovery. Radiographic follow-up after 60 days revealed sign of osseous union; therefore, the plate was removed. PMID:28588330
May, Jonathan David; Paavana, Thumri; McGregor-Riley, Jonathan; Royston, Simon
To review the outcomes of patients treated with the Ilizarov method for an isolated, closed, simple diaphyseal, Tibial fracture at our institution over the last decade. The Ilizarov frame database was used to identify 76 skeletally mature patients who sustained an isolated, closed, extra-articular, simple, diaphyseal Tibial fracture; the injury also known as a "nail-able Tibial fracture." The average age of the patient was 38 (17-70). All 76 patients progressed to union. The average time until union was 148 (55-398) days. The coronal and sagittal alignment was 3° (0-17°) and 4° (0-14°) respectively. No patient suffered from compartment syndrome. No patient developed septic arthritis. No patient had documented anterior knee pain or secondary knee specialist input post frame removal. On average, there were 9(4-29) follow up appointments and 10(5-26) radiographs post frame application. There is a 59% chance of a patient having a difficulty post frame application. The malunion rate was 5%. Persisting pinsite infection post frame removal occurred in 5 patients (6.5%). Drilling of the pinsite sequestrum resolved the infection in four of these patients, giving a deep infection rate of 1.3%. The Ilizarov method has a role to play in the treatment of simple closed Tibial shaft fractures in patients who need to kneel. Patient education is a priority however; the patient must be made aware of the difficulty rate associated with the Ilizarov method when compared to the complication profile of alternative treatments. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.
Hoekstra, H; Kempenaers, K; Nijs, S
Variable angle locking compression plates allow for lateral buttress and support of the posterolateral joint surface of tibial plateau fractures. This gives room for improvement of the surgical 3-column classification approach. Our aim was to revise and validate the 3-column classification approach to better guide the surgical planning of tibial plateau fractures extending into the posterolateral corner. In contrast to the 3-column classification approach, in the revised approach the posterior border of the lateral column in the revised approach lies posterior instead of anterior of the fibula. According to the revised 3-column classification approach, extended lateral column fractures are defined as single lateral column fractures extending posteriorly into the posterolateral corner. CT-images of 36 patients were reviewed and classified twice online according to Schatzker and revised 3-column classification approach by five observers. The intraobserver reliability was calculated using the Cohen's kappa and the interobserver reliability was calculated using the Fleiss' kappa. The intraobserver reliability showed substantial agreement according to Landis and Koch for both Schatzker and the revised 3-column classification approach (0.746 vs. 0.782 p = 0.37, Schatzker vs. revised 3-column, respectively). However, the interobserver reliability of the revised 3-column classification approach was significantly higher as compared to the Schatzker classification (0.531 vs. 0.669 p < 0.01, moderate vs. substantial agreement, Schatzker vs. revised 3-column, respectively). With the introduction of variable angle locking compression plates, the revised 3-column classification approach is a very helpful tool in the preoperative surgical planning of tibial plateau fractures, in particular, lateral column fractures that extend into the posterolateral corner. The revised 3-column classification approach is rather a practical supplement to the Schatzker classification. It has a
Otsuki, Shuhei; Murakami, Tomohiko; Morikura, Rei; Nakagawa, Kosuke; Okamoto, Yoshinori; Neo, Masashi
Low-profile fixation devices for medial opening wedge high tibial osteotomy (OWHTO) were developed in order to avoid skin irritation and additional invasion. However, the low-profile system is associated with additional risks. We report three cases of locking pin back out with the low-profile locking plate system for medial OWHTO.
Yagi, Shigenori; Muneta, Takeshi; Sekiya, Ichiro
Medial tibial stress syndrome (MTSS) and tibial stress fracture (SF) are common lower leg disorders in runners. A prospective study was done to identify the incidence of MTSS and SF in high school runners and to determine risk factors. A total of 230 runners participating in high school running teams were evaluated. All runners aged 15 years as first grade of high school were involved in the study. They were followed up for 3 years. The measured items included height, weight, body mass index (BMI), range of hip and ankle motion, straight leg raising (SLR), intercondylar and intermalleolar interval, Q-angle, navicular drop test, hip abductor strength and physical conditioning. Each runner was followed for 3 years to report occurrence of MTSS and SF. A total number of 102 MTSS (0.29 athlete exposures) and 21 SF (0.06 athlete exposures) were identified. In females, BMI significantly increased the risk of MTSS after adjustment for the other variables in this study (adjusted odds ratio, 0.51; 95 % confidence interval, 0.31-0.86). Increased internal rotation of the hip significantly increased the risk of MTSS (adjusted odds ratio, 0.91; 95 % confidence interval, 0.85-0.99). In males, limited SLR also significantly increased the risk of SF with adjustment for the other variables in this study (adjusted odds ratio, 1.38; 95 % confidence interval, 1.04-1.83). A significant relationship was found between BMI, internal hip rotation angle and MTSS in females, and between limited SLR and SF in males. Prospective cohort study, Level II.
Ankle TOTAL 78 Lateral ankle sprain 69 Medial ankle sprain 3 Ankle other 6...fracture 1 Lower leg other 21 Ankle TOTAL 41 Lateral ankle sprain 26 41 Medial ankle sprain 8 Ankle ...investigate the individual knee and ankle stiffness in the sagittal plane. We evaluated this stiffness over the period from foot strike to peak
Brock, Amanda K; Tan, Eric W; Shafiq, Babar
Periprosthetic fractures after total ankle arthroplasty are uncommon, with most cases occurring intraoperatively. We describe a post-traumatic periprosthetic fracture of the distal tibia and fibula after total ankle arthroplasty that was treated with minimally invasive plate osteosynthesis. It is important for orthopedic surgeons not only to recognize the risk factors for postoperative periprosthetic total ankle arthroplasty fractures, but also to be familiar with the treatment options available to maximize function and minimize complications. The design of the tibial prosthesis and surgical techniques required to prepare the ankle joint for implantation are important areas of future research to limit the risk of periprosthetic fractures. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Nourissat, G; Hoffman, E; Hémon, C; Rillardon, L; Guigui, P; Sautet, A
Bone comminution, serious cartilage damage, and the poor mechanical quality of osteoporotic bone create a difficult challenge for osteosynthesis of joint fractures in the elderly subject. Poor results with certain hip, elbow and shoulder fractures have lead certain authors to propose emergency arthroplasty in selected cases. We report our experience with four knee arthroplasties implanted for recent severe fracture of the proximal tibial epiphysis in elderly subjects. Four independent patients aged over 75 years presented a severe comminutive fracture of the proximal epiphysis of the tibia (Three Schatzker 5, one Schatzker 4). After obtaining the patients' informed consent, early knee arthroplasty was performed. A long-stem cemented tibial piece was used on which the epiphysis was reconstructed. Implants providing support for ligament deficits were used in all cases. Immediate weight-bearing was authorized. Follow-up ranged from two to seven years. The IKS function score (15, 60, 100, 100) depended on the patient's general status. The IKS knee score was excellent for three knees (90, 95, 95), and fair in one (45). Re-operations were not needed in any of the patients. All x-rays showed bone healing with correctly aligned limbs (less than 2 degrees deformation). There were no lucent lines at last follow-up. Early arthroplasty for complex fractures of the proximal epiphysis of the tibia is a realistic option. Using a cemented long-stem tibial piece ensures primary stability sufficient for early weight-bearing before bone healing. Use of a constrained prosthesis, or better a hinged prosthesis, can be questioned but avoids the difficulty of ligament balance on an osteoporotic knee with a destroyed joint surface. None of the patients required reoperation and the results in terms of pain were excellent. The overall outcome depends on the general status of the patient.
Zbeda, Robert M; Sculco, Peter K; Urch, Ekaterina Y; Lazaro, Lionel E; Borens, Olivier; Williams, Riley J; Lorich, Dean G; Wellman, David S; Helfet, David L
Anterior tibial stress fractures are associated with high rates of delayed union and nonunion, which can be particularly devastating to a professional athlete who requires rapid return to competition. Current surgical treatment strategies include intramedullary nailing, which has satisfactory rates of fracture union but an associated risk of anterior knee pain. Anterior tension band plating is a biomechanically sound alternative treatment for these fractures. Tension band plating of chronic anterior tibial stress fractures leads to rapid healing and return to physical activity and avoids the anterior knee pain associated with intramedullary nailing. Case series; Level of evidence, 4. Between 2001 and 2013, there were 13 chronic anterior tibial stress fractures in 12 professional or collegiate athletes who underwent tension band plating after failing nonoperative management. Patient charts were retrospectively reviewed for demographics, injury history, and surgical details. Radiographs were used to assess time to osseous union. Follow-up notes and phone interviews were used to determine follow-up time, return to training time, and whether the patient was able to return to competition. Cases included 13 stress fractures in 12 patients (9 females, 3 males). Five patients were track-and-field athletes, 4 patients played basketball, 2 patients played volleyball, and 1 was a ballet dancer. Five patients were Division I collegiate athletes and 7 were professional or Olympic athletes. Average age at time of surgery was 23.6 years (range, 20-32 years). Osseous union occurred on average at 9.6 weeks (range, 5.3-16.9 weeks) after surgery. Patients returned to training on average at 11.1 weeks (range, 5.7-20 weeks). Ninety-two percent (12/13) eventually returned to preinjury competition levels. Thirty-eight percent (5/13) underwent removal of hardware for plate prominence. There was no incidence of infection or nonunion. Anterior tension band plating for chronic tibial stress
Haller, Justin M; Holt, David; Rothberg, David L; Kubiak, Erik N; Higgins, Thomas F
High-energy tibial plateau and tibial plafond fractures have a high complication rate and are frequently treated with a staged approach of spanning external fixation followed by definitive internal fixation after resolution of soft tissue swelling. A theoretical advantage to early spanning external fixation is that earlier fracture stabilization could prevent further soft tissue damage and potentially reduce the occurrence of subsequent infection. However, the relative urgency of applying the external fixator after injury is unknown, and whether delay in this intervention is correlated to subsequent treatment complications has not been examined. Is delay of more than 12 hours to spanning external fixation of high-energy tibial plateau and plafond fractures associated with increased (1) infection risk; (2) compartment syndrome risk; and (3) time to definitive fixation, length of hospitalization, or risk of secondary surgeries? We further stratified our results based on injury site: plateau and plafond. In practical clinical terms, many of these high-energy C-type articular fractures will arrive at the regional trauma center in the evening and this investigation attempted to explore if these injuries need to be placed in temporizing fixators that evening or if they may be safely addressed in a dedicated trauma room the next morning. We performed a retrospective review of all patients at a Level I university trauma center with high-energy tibial plateau and plafond fractures who underwent staged treatment with a spanning external fixation followed by subsequent definitive internal fixation between 2006 and 2012. Patients who received a fixator within 12 hours of recorded injury time were classified as early external fixation; those who received a fixator greater than 12 hours from injury were classified as delayed external fixation. There were 80 patients (42 plateaus and 38 plafonds) in the early external fixation cohort and 79 patients (45 plateaus and 34 plafonds
Wiersema, Brent; Brokaw, David; Weber, Timothy; Psaradellis, Telly; Panero, Carlo; Weber, Chad; Musapatika, Dana
Literature on open calcaneus fractures is limited and inconsistent. This study's purpose was to report complications such as osteomyelitis, amputations, and soft tissue infections in open calcaneus fractures that were treated at a Level I Trauma Center. From January 1995 through December 2007, 1,157 calcaneus fractures were identified with 127 fractures being open (11.0%). Average followup time was 9.1 (range, 2 to 53) months. All open fractures were treated by a similar protocol of intravenous (i.v.) antibiotics, emergent irrigation and debridement (I&D), initial fracture stabilization if possible, subsequent I&Ds as needed, and delayed definitive fixation. One hundred fifteen open calcaneus fractures in 112 patients had sufficient followup for study inclusion. For this study complications were classified into four categories: superficial infections, deep infections, osteomyelitis, and amputations. Medial based wounds occurred in 63 (54.8%) fractures. The overall complication rate was 23.5% with 16 fractures (13.9%) requiring a reoperation. Eleven (9.6%) fractures experienced superficial wound infection and 14 (12.2%) had deep wound infection. Six (5.2%) amputations were required with three being for either soft tissue infection or wound necrosis. Culture-positive osteomyelitis occurred in six (5.2%) patients. Utilizing a standardized protocol, open calcaneus fractures were found to have a lower complication rate than has been previously reported.
Ketz, John; Sanders, Roy
Obtaining an accurate reduction of the posterior malleolar fragment in high-energy pilon fractures can be difficult through standard anterior or medial incisions, resulting in a less than optimal articular reduction. The purpose of this study was to report on our results using a direct approach with posterior malleolar plating in combination with staged anterior fixation in high-energy pilon fractures. Prospective clinical cohort. A Level I trauma and tertiary referral center. From January 1, 2005, to December 31, 2008, 19 Orthopaedic Trauma Association 43C pilon fractures (16 C3 and 3 C2) with a separate, displaced, posterior malleolar fragment were treated by the authors. Nine patients were treated with posterior plating of the tibia (PL) through a posterolateral approach followed by a staged direct anterior approach. Ten patients with similar fracture patterns were treated using standard anterior or anteromedial incisions (A) with indirect reduction of the posterior fragment. All 19 patients were available for follow-up at an average of 40 months (range, 28-54 months). All patients were treated with open reduction and internal fixation for their pilon fractures. Quality of reduction was assessed using postoperative plain radiographs and computed tomography. Serial radiographs were taken during the postoperative course to assess the progression of healing and the development of joint arthrosis. Clinical follow-up included physical examination and evaluation of the ankle using the American Orthopaedic Foot and Ankle Society Ankle & Hindfoot score, Maryland Foot Score as well as noting all complications. There were no differences in injury pattern or time to surgery between groups. Of the 10 patients who were in the A group, 4 (40%) had more than 2 mm of joint incongruity at the posterior articular fracture edge as compared with no patients in the PL group as measured on postoperative computed tomography scans. At latest follow-up, 7 (70%) patients in the A group
Milgrom, C; Finestone, A; Segev, S; Olin, C; Arndt, T; Ekenman, I
Background: Repetitive high bone strain and/or strain rates, such as those that occur during running, contribute to stress fractures as well as promoting maintenance of or increase in bone mass. Kinematic differences are known to exist between overground and treadmill running and these may be reflected in different bone strains and strain rates during the two running techniques. Aim: To measure in vivo strains and strain rates in human tibia during treadmill and overground running and determine if there are significant differences in strain and strain rate levels between the two running techniques. Methods: A strain gauged bone staple was mounted percutaneously along the axial direction in the mid diaphysis of the medial tibia in three subjects, and in vivo tibial strains were measured during treadmill and overground running at 11 km/h. Results: Axial compression strains (p<0.0001), tension strains (p<0.001), compression strain rates (p<0.0001), and tension strain rates (p<0.0001) were 48–285% higher during overground running than during treadmill running. Conclusions: On the basis of lower in vivo strains and strain rates, treadmill runners are at lower risk of developing tibial stress fractures, but less likely to achieve tibial bone strengthening, than overground runners. PMID:12663360
Castiglia, Marcello Teixeira; Nogueira-Barbosa, Marcello Henrique; Messias, Andre Marcio Vieira; Salim, Rodrigo; Fogagnolo, Fabricio; Schatzker, Joseph; Kfuri, Mauricio
Schatzker introduced one of the most used classification systems for tibial plateau fractures, based on plain radiographs. Computed tomography brought to attention the importance of coronal plane-oriented fractures. The goal of our study was to determine if the addition of computed tomography would affect the decision making of surgeons who usually use the Schatzker classification to assess tibial plateau fractures. Image studies of 70 patients who sustained tibial plateau fractures were uploaded to a dedicated homepage. Every patient was linked to a folder which contained two radiographic projections (anteroposterior and lateral), three interactive videos of computed tomography (axial, sagittal, and coronal), and eight pictures depicting tridimensional reconstructions of the tibial plateau. Ten attending orthopaedic surgeons, who were blinded to the cases, were granted access to the homepage and assessed each set of images in two different rounds, separated to each other by an interval of 2 weeks. Each case was evaluated in three steps, where surgeons had access, respectively to radiographs, two-dimensional videos of computed tomography, and three-dimensional reconstruction images. After every step, surgeons were asked to present how would they classify the case using the Schatzker system and which surgical approaches would be appropriate. We evaluated the inter- and intraobserver reliability of the Schatzker classification using the Kappa concordance coefficient, as well as the impact of computed tomography in the decision making regarding the surgical approach for each case, by using the chi-square test and likelihood ratio. The interobserver concordance kappa coefficients after each assessment step were, respectively, 0.58, 0.62, and 0.64. For the intraobserver analysis, the coefficients were, respectively, 0.76, 0.75, and 0.78. Computed tomography changed the surgical approach selection for the types II, V, and VI of Schatzker ( p < 0.01). The addition of
Tuhanioğlu, Ümit; Oğur, Hasan Ulaş; Çiçek, Hakan; Seyfettinoğlu, Fırat; Çiloğlu, Osman; Kapukaya, Ahmet
Aim In comparison with closed fractures, open fractures have an increased risk of infection, there are soft tissue-related problems, and difficulties are experienced in union. The aim of this study was to evaluate and discuss the results of osteosynthesis applied with a noncontact plate in Gustilo–Anderson Type 2, 3a, and 3b fractures. Method The study included 23 patients applied with debridement + noncontact plate osteosynthesis + soft tissue procedures in a single session for the treatment of an open fracture. A follow-up card was created to evaluate the patients in respect of age, gender, fracture level, fracture etiology, open fracture type, preoperative and postoperative sedimentation and C-reactive protein values, antibiotics used and duration of use, time to union, and complications. Results In all 23 patients, full bone union was obtained at mean 22.5 weeks (range: 16–36 weeks). Complications developed in 9 patients. Implant failure occurred in 3 patients. In 5 patients, infection developed which required repeated debridements. Conclusion In open fractures, noncontact plating following debridement seems to be a good alternative treatment method to intramedullar nailing, especially in metaphyseal and metaphyseo-diaphyseal fractures and in spiral oblique diafiz fractures. Noncontact plating may also be a good alternative to intramedullar nailing for open fracture treatment if the patients have additional pathologies such as contusion and thoracic injury. PMID:28652756
Hartwich, Kathleen; Lorente Gomez, Alejandro; Pyrc, Jaroslaw; Gut, Radosław; Rammelt, Stefan; Grass, René
We performed a biomechanical comparison of 2 methods for operative stabilization of pronation-abduction stage III ankle fractures; group 1: Anterior-posterior lag screws fixing the posterior tibial fragment and lateral fibula plating (LSLFP) versus group 2: locked plate fixation of the posterior tibial fragment and posterior antiglide plate fixation of the fibula (LPFP). Seven pairs of fresh-frozen osteoligamentous lower leg specimens (2 male, and 5 female donors) were used for the biomechanical testing. Bone mineral density (BMD) of each specimen was assessed by means of dual-energy x-ray absorptiometry. After open transection of the deltoid ligament, an osteotomy model of pronation abduction stage III ankle fracture was created. Specimens were systematically assigned to LSLFP (group 1, left ankles) or LPPFP (group 2, right ankles). After surgery, all specimens were evaluated via CT to verify reduction and fixation. Axial load was then applied onto each specimen using a servohydraulic testing machine starting from 0 N (Zwick/Roell, Ulm, Germany) at a speed of 10 N/s with the foot fixed in a 10 degrees pronation and 15 degrees dorsiflexion position. Construct stiffness, yield, and ultimate strength were measured and dislocation patterns were documented with a high-speed camera. The normal distribution of all data was analyzed using Shapiro-Wilk test. The group comparison was performed using paired Student t test. Statistical significance was assumed at a P value of .05. All specimens had BMD values consistent with osteoporosis. BMD values did not differ between the left and right ankles of the same pair ( P = .762). The mean BMD values between feet of men (0.603 g/cm 2 ) and women (0.329 g/cm 2 ) were statistically different ( P = .005). The ultimate strength for LSLFP (group 1) with 1139 ± 669 N and LPPFP (group 2) with 2008 ± 943 N was statistically different ( P = .036) as well as the yield in LSLFP (group 1) 812 ± 452 N and LPPFD (group 2) 1292 ± 625 N ( P
Johnson, M D; Lewis, D D; Winter, M D
A 4-month-old female intact American Pit Bull Terrier was presented for right pelvic limb lameness 1 day after the dog had been hit by an all-terrain vehicle. Orthogonal radiographs of the right stifle revealed a Salter-Harris type IV fracture through the proximal tibial physis extending caudodistally through the proximal tibial metaphysis. The distal tibia was markedly displaced cranially, laterally and proximally, resulting in complete overriding of the fracture segments. An open approach was made in order to facilitate direct reduction, but the fracture could not be sufficiently distracted and the epiphyseal segment remained fixed caudal to the remainder of the tibia. Concerns regarding possible iatrogenic trauma to the epiphysis prompted the use of a transarticular circular fixator construct to distract the fracture segments to facilitate reduction. Distraction that facilitated reduction was performed using three TrueLok Rapid Quick Adjust Struts that were positioned between the two ring components. The struts also allowed for multiplanar adjustment of alignment, which allowed the fracture to be maintained in anatomic reduction as divergent interfragmentary Kirschner wires were placed. Radiographic union was confirmed 19 days after surgery. Transient intraoperative application of a circular construct incorporating the TrueLok components facilitated accurate fracture reduction without inflicting further iatrogenic trauma to the epiphysis, after traditional direct reduction techniques proved ineffective, and afforded a successful clinical outcome in the dog reported here. © 2017 Australian Veterinary Association.
Liu, Yang; Sun, Xuebin; Zhang, Keyuan; Li, Gang; Ni, Jiati
To evaluate the clinical results of arthroscopic treatment of anterior cruciate ligament (ACL) tibial eminence avulsion fractures in adolescents with epiphyseal unclosure. Between January 2011 and October 2013, 35 knees with ACL tibial eminence avulsion fractures (35 patients with epiphyseal unclosure) were arthroscopically treated with suture fixation. There were 25 males and 10 females, aged 8-16 years (mean, 14.7 years). The causes included sports injury in 24 cases, traffic accident injury in 9 cases, and daily life injury in 2 cases. According to Meyers-McKeever classification criteria, there were 27 cases of type II and 8 cases of type III. Five cases had meniscus injury. The preoperative the International Knee Documentation Committee (IKDC) score was 48.7 ± 3.2, and Lysholm score was 51.2 ± 4.5. The time from injury to operation was 2-16 days (mean, 5 days). Primary healing of incision was obtained in all patients. The mean follow-up time was 22.4 months (range, 12-32 months). Anatomical reduction was achieved in 28 cases and satisfactory reduction in 7 cases. X-ray films showed all fractures healing at last follow-up. There was no limb shortening deformity, varus knee, or valgus knee. Lachman test results were all negative. The other knees had normal range of motion except 1 knee with limited flexion, whose range of motion returned to 0-120° after treatment. At last follow-up, the IKDC score was significantly improved to 93.2 ± 4.1 (t = -53.442, P = 0.000), and the Lysholm score was significantly increased to 96.2 ± 2.5 (t = -56.242, P = 0.000). The arthroscopic fixation technique has satisfactory results for the reduction and fixation of ACL tibial eminence avulsion fracture in the adolescents with epiphyseal unclosure because of little trauma and quick recovery.
Osti, Leonardo; Buda, Matteo; Soldati, Francesco; Del Buono, Angelo; Osti, Raffaella; Maffulli, Nicola
Introduction Arthroscopy procedures are the gold standard for the management of tibial spine avulsion. This review evaluates and compares different arthroscopic treatment options for tibial spine fractures. Source of data PubMed, Medline, Ovid, Google Scholar and Embase databases were systematically searched with no limit regarding the year of publication. Areas of agreement An arthroscopic approach compared with arthrotomy reduces complications such as soft-tissue lesions, post-operative pain and length of hospitalization. Areas of controversy The use of suture techniques, compared to cannulated screw technique, avoids a second surgery for removal of the screws, but requires longer immobilization and partial weight bearing. Growing points Clinical outcomes and radiographic results do not seem to differ in relation to the chosen method of fixation. Areas timely for developing research Further studies are needed to produce clear guidelines to deﬁne the best choice in terms of clinical outcomes, function and complications. PMID:27151952
Osti, Leonardo; Buda, Matteo; Soldati, Francesco; Del Buono, Angelo; Osti, Raffaella; Maffulli, Nicola
Arthroscopy procedures are the gold standard for the management of tibial spine avulsion. This review evaluates and compares different arthroscopic treatment options for tibial spine fractures. PubMed, Medline, Ovid, Google Scholar and Embase databases were systematically searched with no limit regarding the year of publication. An arthroscopic approach compared with arthrotomy reduces complications such as soft-tissue lesions, post-operative pain and length of hospitalization. The use of suture techniques, compared to cannulated screw technique, avoids a second surgery for removal of the screws, but requires longer immobilization and partial weight bearing. Clinical outcomes and radiographic results do not seem to differ in relation to the chosen method of fixation. Further studies are needed to produce clear guidelines to deﬁne the best choice in terms of clinical outcomes, function and complications. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: email@example.com.
Tafazal, Suhayl; Madan, Sanjeev S; Ali, Farhan; Padman, Manoj; Swift, Simone; Jones, Stanley; Fernandes, James A
The use of circular fixators for the treatment of tibial fractures is well established in the literature. The aim of this study was to compare the Ilizarov circular fixator (ICF) with the Taylor spatial frame (TSF) in terms of treatment results in consecutive patients with tibial fractures that required operative management. A retrospective analysis of patient records and radiographs was performed to obtain patient data, information on injury sustained, the operative technique used, time duration in frame, healing time and complications of treatment. The minimum follow-up was 24 months. Ten patients were treated with ICF between 2000 and 2005, while 15 patients have been treated with TSF since 2005. Two of the 10 treated with ICF and 5 of the 15 treated with TSF were open fractures. All patients went on to achieve complete union. Mean duration in the frame was 12.7 weeks for ICF and 14.8 weeks for the TSF group. Two patients in the TSF group had delayed union and required additional procedures including adjustment of fixator and bone grafting. There was one malunion in the TSF group that required osteotomy and reapplication of frame. There were seven and nine pin-site infections in the ICF and TSF groups, respectively, all of which responded to antibiotics. There were no refractures in either group. In an appropriate patient, both types of circular fixator are equally effective but have different characteristics, with TSF allowing for postoperative deformity correction. Of concern are the two cases of delayed union in the TSF group, all in patients with high-energy injuries. We feel another larger study is required to provide further clarity in this matter. Level II-comparative study.
Huang, Huajun; Zhang, Guodong; Ouyang, Hanbin; Yang, Yang; Wu, ZhangLin; Xu, Jing; Xie, Pusheng; Huang, Wenhua
To investigate the application of 3D printing and digital technology in preoperative assessment and planning of internal fixation surgery for complex tibial plateau fracture. Complex tibial plateau fractures and commonly used plates for tibial plateau were imaged using computed tomography (CT) to reconstruct the 3D fracture and plate models. The 3D models were used to perform virtual reduction and preoperative planning of internal fixation surgery with the most appropriate plates assisted by the 3D library of plates. According to the optimal plan, the 3D physical models of tibial plateau fractures and plates were 3D printed to simulate internal fixation operation. The effects of internal fixation were compared between the virtual surgery and the simulated surgery based on the 3D models. The effects of internal fixation in the simulated surgery based on the 3D models were consistent with those of the virtual surgery. No significant difference was found in the screw length between the two surgeries. The combination of 3D printing and digital design can improve the effects of internal fixation for complex tibial plateau fractures.
Yang, Peng; Du, Di; Zhou, Zhibin; Lu, Nan; Fu, Qiang; Ma, Jun; Zhao, Liangyu; Chen, Aimin
Osteotomy and internal fixation are usually the most effective way to treat the malunion of lateral tibial plateau fractures, and the accuracy of the osteotomy is still a challenge for surgeons. This is a report of a series of prospectively study of osteotomy treatment for the malunion of lateral plateau fractures with the aid of 3D printing technology. A total of 7 patients with malunion of lateral tibial plateau fractures were enrolled in the study between September 2012 to September 2014 and completed follow up. CT image data were used for 3D reconstruction, and individually 3D printed models were used for accurate measurements and detail osteotomy procedures planning. Under the premeditated operation plan, the osteotomy operations were performed. Patients were invited for follow-up examinations at 2 and 6 weeks and then at intervals of 6 to 8 weeks until 12 months or more. Mean age of the patients was 44 years (range 30-52 years), 3 cases were result of fall injuries, 2 were traffic accidents and 2 were sports injuries. Among the cases, one accompanied with craniocerebra trauma, one with pelvic fracture, one accompanied with both. According to the Schatzker Tibial Plateau classification, the original fracture type were 3 type I, 1 type II and 3 type III. The lateral tibial plateau collapse ranges from 4 mm-12mm, with an average of 9.4mm. All the operations were successfully completed, the average operation time was 77.1min (range 70-90 min), the average intraoperative blood loss was 121.4ml (range 90-180ml), the mean follow-up time was 14.4 months (range 12-18 months), and the average healing time of the osteotomy fragments was 12 weeks (range 11-13 weeks). The difference between preoperative and postoperative Rasmussen scores were statistically significant (P<0.05). All the patients were obtained functional recovery, with no complications. 3D printing technology is helpful to accurately design osteotomy operation, reduce the risk of postoperative deformity
Durst, A; Clibbon, J; Davis, B
The fibula free flap is ideal for complex jaw reconstructions, with low reported donor and flap morbidity. We discuss a distal tibial stress fracture two months following a vascularised fibula free flap procedure. Despite being an unrecognised complication, a literature review produced 13 previous cases; only two were reported in the reconstructive surgery literature, with the most recent claiming to be the first. The majority of these studies treated this fracture non-operatively; none reported their patient follow-up. Each case presented with ipsilateral leg pain, which has been cited as an early donor site morbidity in as many as 40% of fibula free flap cases. It is known that the fibula absorbs at least 15% of leg load on weight bearing. Studies have shown severe valgus deformities in up to 25% of patients with fibulectomies. We treated our patient operatively, first correcting his worsening valgus deformity with an external fixator, then reinforcing his healed fracture with a long distal tibial plate. We believe that this complication is underreported, unexpected and not mentioned during the consenting process. By highlighting the management of our case and the literature, we aim to increase awareness (and thus further reporting and appropriate management) of this debilitating complication.
Choi, Yoon Young; Rhee, Seung Joon
Traumatic uncontained bone defect in the knee joint is one of the most serious knee injuries. As the knee joint is the main weight-bearing joint of the body, the problem of weight loading should be addressed while restoring the bone defect. However, no consensus exists regarding the treatment of this injury. Two patients in separate cases initially sustained traumatic uncontained proximal tibial bone defects secondary to passenger traffic accidents. After recovery from the initial trauma, these patients underwent medial opening wedge high tibial osteotomy (MOWHTO) and femoral head allograft augmentation simultaneously. Treatment of traumatic uncontained bone defect in the knee joint should be considered separately as tumorous or osteoarthritic bone defects. Especially, the effects of the defective supporting soft tissue structures should be considered. We considered that MOWHTO was capable of solving problems of both bone stock restoration and weight loading. After the operation, the patients' knee joint pain was relieved and stable ambulation was possible. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.
Seon, Jong Keun; Park, Sang Jin; Lee, Keun Bae; Gadikota, Hemanth R; Kozanek, Michal; Oh, Luke S; Hariri, Sanaz; Song, Eun Kyoo
Screw and suture fixations are the most commonly used methods of fixation in treatment of anterior cruciate ligament tibial avulsion fractures. Even though a few biomechanical studies have compared the stability of the 2 fixation techniques, a clinical comparison has not yet been reported. The authors hypothesized that both fixations would be identical in all studied clinical outcome measures at a minimum 2-year follow-up. Cohort study; Level of evidence, 3. Thirty-three patients treated with either screw fixation (16 patients) or suture fixation (17 patients) within 1 month of the anterior cruciate ligament tibial avulsion fracture (type II or III) without associated ligamentous injury were included. All patients were evaluated at a minimum 2-year follow-up in terms of Lysholm knee scores and return to preinjury activities. Knee stability was compared based on the Lachman test and stress radiography. No significant differences were found between the 2 groups in terms of average Lysholm knee scores (91.7 in the screw group and 92.7 in the suture group, P = .413) at follow-up. All patients except 2 (1 in each group) returned to preinjury activity levels. However, flexion contractures (5 degrees to 10 degrees) were found in 3 patients in the screw group and 2 patients in the suture group without significant intergroup difference. Stabilities based on the Lachman test and instrumented stress radiography were also similar between the 2 groups at follow-up. However, 2 patients in the screw group and 1 in the suture group showed more than 5 mm laxity compared with the contralateral knee on stress radiographs. Both the screw and suture fixation techniques for the anterior cruciate ligament tibial avulsion fracture produced relatively good results in terms of functional outcomes and stability without any significant differences. However, some patients in both groups showed residual laxity or flexion contractures.
Luo, Peng; Xu, Ding; Wu, Jia; Chen, Yi-Heng
This article is a systematic review of the published literature about the biomechanics, functional outcomes, and complications of a locked plate as an external fixator in treating tibial fractures. We searched the PubMed, Ovid Medline, Embase, ScienceDirect, and Cochrane Library databases to retrieve the relevant studies. Studies published in English and Chinese which assessed adult patients and more than 4 cases who had sustained any type of fresh tibial fracture treated with the external locking plate, provided that they reported functional outcomes, range of motion (ROM), union or complication rates, and the biomechanical studies of external locked plating are also included. The electronic search strategy revealed 248 studies, and 2 studies were identified as relevant through manual search of references. Finally, 12 studies were included in this systematic review. These consist of 3 pure biomechanical studies, 8 case series, and 1 study including both of biomechanics and case series. Due to the heterogeneity of biomechanical studies, we can only conclude that external locked plate shows inferior structural stiffness than internal locked plate. The clinical studies reported that external locked plating gave a satisfactory ROM of the knee and ankle, functional outcomes, union rate, and low complication rate. We can only conclude that external locked plate shows inferior structural stiffness than internal locked plate because of the heterogeneity of biomechanical studies. The clinical studies showed locked plating as an external fixator in treating tibial fractures can be considered as a safe and successful procedure. However, as yet, there is unconvincing evidence that it is superior to standard techniques with regards to clinical and functional outcomes. More and well-designed studies about this technique should be carried out.
Viceconti, M; Sudanese, A; Toni, A; Giunti, A
In modern orthopaedic practice, circular external fixators are frequently preferred to plaster cast for various reasons. The realignment of the two fractured bone segments is usually performed under a continuous fluoroscopy checking which involves a long radiation exposure time for both patients and surgeon. In order to overcome this problem, a computer controlled external fixator is under development. One relevant problem which this project faced in its initial stage was the difficulty to define in geometrical terms the manual reduction trajectory normally adopted by the surgeon. Basically it was a typical problem of empirical knowledge transfer from the surgeon to the engineer. Thus, it was necessary to create a common ground where the two experts could carry out the necessary analyses in order to define an empirical algorithm capable of suggesting a correction trajectory. The problem was solved by developing a simulation program called S.E.R.F. (Simulation Environment of a Robotic Fixator) provided with an extremely powerful graphic output, able to visualize the whole reduction trajectory from any viewpoint in space. The authors suggest the use of this kind of tool every time the techno-clinical information exchange is a critical issue.
Russell, Thomas A; Leighton, Ross K
Bone graft augmentation is often selected to treat defects associated with unstable tibial plateau fractures. This prospective, randomized, multicenter study was undertaken to determine the efficacy of bioresorbable calcium phosphate cement compared with standard autogenous iliac bone graft in the treatment of these osseous defects. One hundred and twenty acute, closed, unstable tibial plateau fractures (Schatzker types I through VI) in 119 adult patients were prospectively enrolled in twelve study sites in North America between 1999 and 2002. Randomization for the type of grafting of the subarticular defect was done at the time of surgery, with use of a 2:1 ratio, to treatment with calcium phosphate cement (eighty-two fractures) or autogenous iliac bone graft (thirty-eight fractures). After open reduction, standard plate-and-screw or screw-only fixation was used and then either the cement or the bone graft was placed in the defect cavity for subarticular support. Follow-up included standard radiographs, evaluated by multiple reviewers to avoid bias, and knee range-of-motion assessment at six months to one year or later. The age, weight, height, and sex of the patients and the fracture patterns were comparable in the two groups, as were union rates and time to union. There was a significantly (p = 0.009) higher rate of articular subsidence during the three to twelve-month follow-up period in the bone graft group. The bioresorbable calcium phosphate cement used in this study appears to be a better choice, at least in terms of the prevention of subsidence, than autogenous iliac bone graft for the treatment of subarticular defects associated with unstable tibial plateau fractures. Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.
Bhandari, Mohit; Tornetta, Paul; Rampersad, Shelly-Ann; Sprague, Sheila; Heels-Ansdell, Diane; Sanders, David W; Schemitsch, Emil H; Swiontkowski, Marc; Walter, Stephen
Inadequate sample size and power in randomized trials can result in misleading findings. This study demonstrates the effect of sample size in a large clinical trial by evaluating the results of the Study to Prospectively evaluate Reamed Intramedullary Nails in Patients with Tibial fractures (SPRINT) trial as it progressed. The SPRINT trial evaluated reamed versus unreamed nailing of the tibia in 1226 patients, and in open and closed fracture subgroups (N = 400 and N = 826, respectively). We analyzed the reoperation rates and relative risk comparing treatment groups at 50, 100, and then increments of 100 patients up to the final sample size. Results at various enrollments were compared with the final SPRINT findings. In the final analysis, there was a statistically significant decreased risk of reoperation with reamed nails for closed fractures (relative risk reduction 35%). Results for the first 35 patients enrolled suggested that reamed nails increased the risk of reoperation in closed fractures by 165%. Only after 543 patients with closed fractures were enrolled did the results reflect the final advantage for reamed nails in this subgroup. Similarly, the trend toward an increased risk of reoperation for open fractures (23%) was not seen until 62 patients with open fractures were enrolled. Our findings highlight the risk of conducting a trial with insufficient sample size and power. Such studies are not only at risk of missing true effects but also of giving misleading results.
Cuéllar-Avaroma, Alberto; King-Martínez, Ana Cristina; Hernández-Salgado, Armando; Torres-González, Rubén
We undertook this study to identify factors associated with surgical complications of complex fractures of the tibial plateau. We designed a case-control study with 56 patients with a diagnosis of complex fracture in the tibial plateau (IV-VI Schatzker) and with 12.9 +/- 3.2 (8-18) months of follow-up. Risk factor exposure was defined as having one or more of the following characteristics: age >60 years; co-morbidity (diabetes mellitus, systemic arterial hypertension); time of "Kidde" (>60, >90, >120 min) and fracture type IV, V or VI. A case was considered with one or more complications. Mean age was 50.1 +/- 15.7 (17-87) years old; 35 patients (62.5%) were males. Homogeneity between groups was shown for age, sex, side effects, type of fracture and time of follow-up; 41.1% of patients had pathological history. All surgeries used pneumatic compression (Kidde) for 91 +/- 27.2 (40-175) min. The implants used were plate plus cancellous screws (53.6%), external fixators plus cancellous screws (35.7%), double plate and intramedullary nail. Complications appeared in 37.5% of all patients. Complications reported were superficial infection (16.1%), residual angular deformities (10.7%, varum [7.1%]), peroneal nerve injury (5.4%), non-union (3.5%) and deep venous thrombosis (1.8%); 22.2% of all patients presented more than one complication. Statistically significant risk factors were age >60 years and pneumatic compression >120 min. Patients with one of these characteristics had a three-times risk of complications. No association was demonstrated between type of fracture, surgical treatment, time between injury and the surgery, with development of complications.
Mitchell, Phillip M; Weisenthal, Benjamin M; Collinge, Cory A
To evaluate the incidence of knee sepsis after suprapatellar (SP) nailing of open tibia fractures. Retrospective; Setting: ACS level 1 trauma center. We reviewed 139 open tibia fractures that underwent SP nailing as definitive treatment over a 5-year period (January 1, 2011 to January 1, 2016). Most patients (90%, n = 126) underwent intramedullary nailing at the time of their initial surgery. We defined knee sepsis as intra-articular infection requiring operative debridement, either open or arthroscopically, within 1 month's time. Open tibia fractures treated with an SP tibial nail. Demographic data, fracture characteristics, Gustilo and Anderson classification of open fractures, and occurrence of knee sepsis. In 139 open tibia fractures, there were no cases of knee sepsis in the 30 days after treatment with an SP intramedullary nail. Eighty-seven percent of our cohort had Gustilo and Anderson type II (41%) or type III (46%) open fractures. Most open fractures (83%) underwent primary wound closure during the index procedures. Twenty-five limbs (18%) had evidence of infection at the open fracture site of their open fracture necessitating operative intervention and/or antibiotics: none, however, developed knee sepsis. Although the SP approach carries intra-articular risks, we found a low risk of knee sepsis using this technique in the treatment of open tibia fractures. Our data suggest that there is no greater risk of intra-articular infection using an SP portal as compared with an infrapatellar one. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Khan, Sher Baz; Mohib, Yasir; Rashid, Rizwan Haroon; Rashid, Haroonur
Intra-medullary (IM) nailing is standard of care for unstable tibial shaft fractures. Malrotation is very common but it is under-recognised, inpart because of variation in normal anatomy and partly due to difficulty in accurately assessing rotation. This study was planned to evaluate the frequency of rotational mal-alignment after reamed tibia IMnailing. This cross-sectional study was conducted at Aga khan University Hospital, Karachi, and comprised patients with tibia shaft fractures managed with IMnailing from January to December 2014. All the patients were assessed intra-operatively for rotational alignment using the knee and ankle fluoroscopic images. There were 81 patients with a mean age of 38±16.9 years. There were 64(79%) male patients. Overall the incidence of malrotation was in 20(24.7%) cases. Rotational mal-alignment is one of the preventable complications after IMnailing which can be assesed intra-operatively under fluoroscope.
Mechanistic understanding of fracture opening and closure in geologic media is of significant importance to nature resource extraction and waste management, such as geothermal energy extraction, oil/gas production, radioactive waste disposal, and carbon sequestration and storage). A dynamic model for subsurface fracture opening and closure has been formulated. The model explicitly accounts for the stress concentration around individual aperture channels and the stress-activated mineral dissolution and precipitation. A preliminary model analysis has demonstrated the importance of the stress-activated dissolution mechanism in the evolution of fracture aperture in a stressed geologic medium. The model provides a reasonable explanation for some key features of fracture opening and closure observed in laboratory experiments, including a spontaneous switch from a net permeability reduction to a net permeability increase with no changes in a limestone fracture experiment.
Heiney, Jake P; Redfern, Roberta E; Wanjiku, Stephen
There is a growing need to develop tools that allow for better reductions of difficult to treat fractures in minimally disruptive ways. One such technique has been developed using the inflatable bone tamp and a fast setting calcium phosphate. KYPHON(®) XPANDER Inflatable Bone Tamp and the KYPHON(®) Osteo Introducer(®) System were used to reduce the articular fractures and a fast-setting calcium phosphate was introduced into those voids and metal hardware was applied as deemed necessary. Subjects were skeletally mature patients treated for articular fractures of the calcaneus, tibial plateau, tibial pilon, or distal radius. Post-operative day zero and week 12 radiographs were objectively and subjectively evaluated by three independent orthopaedic surgeons. Their objective scores were then translated into subjective categories based on the Heiney-Redfern scaled scoring (H-R score) system established herein. Overall, the thorough radiographic analysis by independent reviewers indicates that the technique is capable of obtaining and maintaining articular reductions in a good or adequate manner at 12-weeks post-operatively. Introduced is a potential novel evaluation scale scoring system for these articular fractures that evaluates the important anatomic considerations reproducibly in fracture reductions. There are many potential benefits that remain speculative to this type of tool within a procedure, and therefore this tool and technique warrants further research. Copyright © 2013 Elsevier Ltd. All rights reserved.
Reilly, Rachel M; Robertson, Thomas; O'Toole, Robert V; Manson, Theodore T
Antibiotic-impregnated cement nails are used to treat postoperative deep infections after primary intramedullary nail insertion for the treatment of tibial fractures. Few data exist regarding the efficacy of this treatment strategy. We hypothesized that such treatment with antibiotic nails results in a high rate of infection clearance at intermediate follow-up. We conducted a retrospective review at our Level I trauma center. Patients who received intramedullary nails to stabilize tibial fractures (from 2000 to 2011) and subsequently required antibiotic nails to treat deep postoperative infection (n=55) were considered for study inclusion. Patients with less than 6 months of follow-up were excluded, leaving 41 patients in the study group (average age, 41 years; average follow-up, 20 months). Thirty-one patients (76%) had no evidence of infection after treatment. The 10 patients for whom treatment failed were shown to have infection within the first 6 months. Two experienced persistent infection after antibiotic nail removal, necessitating massive débridement and ring fixator placement. Four patients underwent repeat antibiotic nail insertion after persistent infection. Three infections resulted in eventual above-knee amputations, and one chronic infection resulted in the need for multiple débridement and saucerization procedures. No complications associated with use of the antibiotic nails were observed. The use of antibiotic nails for treatment of tibial infections seems to be a reasonable option, clearing 76% of infections at the 6-month time frame. Further investigation is needed to compare this treatment algorithm with other strategies, such as antibiotic treatment without nail removal and massive débridement with ring fixator placement. Copyright Â© 2016. Published by Elsevier Ltd.
Ozkaya, Ufuk; Parmaksizoglu, Atilla S; Gul, Murat; Sokucu, Sami; Kabukcuoglu, Yavuz
The purpose of this study was to evaluate the clinical performances of stainless steel nonlocking plates and titanium locking plates in minimally invasive medial plating of extra-articular metaphyseal fractures of the distal tibia. Between 2004 and 2006, 43 patients who sustained closed fractures of the distal tibia metaphysis were managed with either a stainless steel nonlocking plate (Group 1, n = 21) or a titanium locking plate (Group 2, n = 22). Clinical and radiographic data were retrospectively reviewed. Function was assessed with use of the American Orthopaedic Foot and Ankle Society ankle-hindfoot instrument. The average followup period was 25 months. The average AOFAS foot and ankle scores in Group 1 and Group 2 at final followup were 85 and 81, respectively. Fracture reduction was anatomical or nearly anatomical without angular displacement in all cases except one patient in Group 2. (p > 0.05) The average time to full, unprotected weightbearing in Group 1 and Group 2 were 15 weeks and 18 weeks, respectively (p < 0.05). Minimally invasive medial plating with titanium locking plates resulted in prolonged secondary healing both in comminuted and simple fracture patterns compared to conventional stainless steel nonlocking plates. We believe that in biological fixation of distal tibial fractures, similarly good results may be obtained with both materials as the locking technology had a greater effect on stability.
Robertson, G A J; Wood, A M
This review aims to provide information on the time taken to resume sport following tibial diaphyseal stress fractures (TDSFs). A systematic search of Medline, EMBASE, CINHAL, Cochrane, Web of Science, PEDro, Sports Discus, Scopus and Google Scholar was performed using the keywords 'tibial', 'tibia', 'stress', 'fractures', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'. Twenty-seven studies were included: 16 reported specifically on anterior TDSFs and 5 on posterior TDSFs. The general principles were to primarily attempt non-operative management for all TDSFs and to consider operative intervention for anterior TDSFs that remained symptomatic after 3-6 months. Anterior TDSFs showed a prolonged return to sport. The best time to return to sport and the optimal management modalities for TDSFs remain undefined. Management of TDSFs should include a full assessment of training methods, equipment and diet to modify pre-disposing factors. Future prospective studies should aim to establish the optimal treatment modalities for TDSFs. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
Kuroyanagi, Gen; Yoshihara, Hiroyuki; Yamamoto, Naohiro; Suzuki, Hiroyuki; Yamada, Kunio; Yoshida, Yukio; Otsuka, Takanobu; Takada, Naoya
Forged composites of raw particulate unsintered hydroxyapatite/poly-L-lactide (F-u-HA/PLLA) devices possess high mechanical strength, bioactivity, and radio-opacity. The aim of this study was to assess the efficacy of F-u-HA/PLLA screws in the treatment of lateral tibial condylar fractures. From January 2005 to December 2010, a total of 7 patients with displaced closed lateral tibial condylar fractures (Schatzker type II) were treated using F-u-HA/PLLA screws. Open reduction and internal fixation was performed using 2 or 3 F-u-HA/PLLA screws. After surgery, weight bearing was not allowed for 6 weeks. Range of motion exercise was initiated after removal of the plaster splint. Radiographs were evaluated for fracture healing, joint depression, and the radioopacity of F-u-HA/PLLA screws. Clinical outcomes and postoperative complications were also assessed. Average follow-up was 44 months. All fractures were successfully healed. Average values for joint depression were 4.7 mm (range, 2-9 mm) preoperatively, 0.4 mm (range, 0-1 mm) postoperatively, and 0.4 mm (range, 0-1 mm) at final follow-up. Whole shadows of F-u-HA/PLLA screws were observed during the follow-up period. Breakage of screws, osteolysis, and a radiolucent zone around the screws were not observed at final follow-up. Average knee flexion and extension were 134° (range, 110° to 150°) and -1° (range, -10° to 0°), respectively. No patient had wound infection, late aseptic tissue response, or foreign body reaction postoperatively. None of the patients reported pain at final follow-up. These results suggest that F-u-HA/PLLA screws could be an alternative option for the treatment of lateral tibial condylar fractures. [Orthopedics. 201x; xx(x):xx-xx.]. Copyright 2018, SLACK Incorporated.
Anderson, Christian N; Nyman, Jeffry S; McCullough, Kirk A; Song, Yanna; Uppuganti, Sasidhar; O'Neill, Kevin R; Anderson, Allen F; Dunn, Warren R
Tibial eminence fractures occur most commonly in skeletally immature children. Several techniques using physeal-sparing fracture fixation have been described, but their structural properties have not been evaluated. To determine the strength and resistance to displacement of physeal-sparing techniques used to fix tibial eminence fractures. Controlled laboratory study. Skeletally immature porcine knees were randomized into 4 treatment groups: (1) ultra-high molecular weight polyethylene suture-suture button (UHMWPE/SB), (2) suture anchor, (3) polydioxanone suture-suture button (PDS/SB), and (4) screw fixation. A prospective analysis of bone mineral density using dual-energy x-ray absorptiometry was performed on all specimens. Fracture fragments were created in a standardized manner and measured for size comparison. After fracture fixation, biomechanical testing was performed with cyclical and load-to-failure protocols by loading the tibia with an anterior shear force. In load-to-failure testing, screw fixation had a significantly lower median peak failure load (186.4 N; lower quartile [LQ], 158.4 N; upper quartile [UQ], 232.6 N) than did UHMWPE/SB (465.8 N; LQ, 397.8 N; UQ, 527.8 N), suture anchors (440.5 N; LQ, 323.0 N; UQ, 562.3 N), and PDS/SB (404.3 N; LQ, 385.9 N; UQ, 415.6 N). UHMWPE/SB demonstrated a significantly higher median yield load (465.8 N; LQ, 397.8 N; UQ, 527.8 N) than did PDS/SB (306.7 N; LQ, 271.4, N; UQ, 405.7 N) and screw fixation (179.0 N; LQ, 120.2 N; UQ, 232.5 N). During cyclical testing, screw fixation demonstrated significantly lower percentage survival of specimens (0%) compared with the other groups (UHMWPE/SB, 100%; suture anchor, 78%; PDS/SB, 78%). After 1000 cycles of loading, PDS/SB fixation had significantly more median creep (6.76 mm; LQ, 6.34 mm; UQ, 8.28 mm) than did UHMWPE/SB (4.43 mm; LQ, 3.80 mm; UQ, 4.73 mm) and suture anchor fixation (3.06 mm; LQ, 2.59 mm; UQ, 4.28 mm). The lowest median stiffness was observed in the PDS
Liu, Yin-Wen; Kuang, Yong; Gu, Xin-Feng; Zheng, Yu-Xin; Li, Zhi-Qiang; Wei, Xiao-En; Zhang, Ming-Cai; Zhan, Hong-Sheng; Shi, Yin-yu
To evaluate the clinical effects of close reduction combined with minimally invasive percutanous plate osteosynthesis (MIPPO) for proximal and distal tibial fractures. From March 2007 to December 2010, 56 patients with proximal and distal tibial fractures were treated with close reduction combined with MIPPO technique. There were 39 males and 17 females,aged from 22 to 67 years with an average of 41.3 years. Left fracture was in 25 cases and right fracture was in 31 cases; proximal tibial fracture was in 15 cases and distal tibial fractures was in 41 cases; 34 cases caused by fall down and 22 cases caused by road accident. The mean time from injury to operation was 1.7 d. Clinical manifestation included pain, swelling of leg with limitation of activity. According to the standard of Johner-Wruhs, clinical effects were evaluated. The mean operative time was 46 min in 56 patients. All fractures obtained satisfactory reduction and the location of plate was good. Incisions healed with one-stage and no superficial or deep infection was found. All the patients were followed up from 8 to 23 months with an average of 14.2 months. Only one fracture complication with delayed union,and after auto grafting with ilium bone,the fracture got union. Other 55 cases obtained bone healing in 15 to 20 weeks after operation and no internal fixation failure was found. The time of walking was 4-6 months after operation,without limping at 7 months after operation. Both lower extremities were symmetrical and the function of knee and ankle got complete recovery. According to the criteria of Johner-Wruhs score,46 cases obtained excellent results,9 good and 2 fair. Treatment of proximal and distal tibial fractures with close reduction and MIPPO technique can not only preserve soft tissue,simplify operative procedure and decrease wound, but also can obtain rigid internal fixation and guarantee early function exercises of knee and ankle joints. The method has the advantages of less soft tissue
Zhao, Y W; Xie, J B; Ding, G Z
Objective: To explore the short-term effects of expanded anterolateral approach in treating fracture involved the posterolateral tibial plateau. Methods: A retrospective analysis of the clinical data from 16 patients undergoing extended anterolateral approach for fracture involved the posterolateral tibial plateau in the First Affiliated Hospital of Wannan Medical College between January 2013 and July 2016 was done. The patients were treated with 3.5 mm proximal "L" type proximal tibial locking compression plate with four locking screws through the nail row technique. The X-rays examinations were carried out immediately after the operation and at 1.5, 3, 6, and 12 months later, to continuously measure the tibial plateau angle (TPA) and posterior slope angle (PA). The Rasmussen radiology score was used to assess the reduction. One year later, the modified Rasmussen knee score was used to assess the recovery of knee function, the Lysholm score was applied to evaluate the cartilage injury, softening and degeneration, and lateral stress test and dial test were carried out to evaluate the stability of the knee. Results: The group consisted of 11 males and 5 females; aged 25 to 71 years, mean (47±12) years; schatzker type Ⅱ 9 cases, type Ⅴ 6 cases and type Ⅵ 1 case. There were 9 cases of type B in Orthopedic Trauma Association (OTA) classification, and 7 cases of type C. X-ray was immediately performed after operation and it showed that 14 cases got anatomic reduction, 2 cases left<2 mm of steps. Rasmussen radiology score was 14 to 18 points, mean (17.0±1.5) points. X-ray examination showed no significant difference in TPA immediately after operation and 1.5, 3, 6, 12 months later ( F =0.05, P =0.99), and there was no significant difference in PA among the time points ( F =0.02, P =1.00). At one-year of follow-up, the modified Rasmussen knee score ranged from 18 to 29 with an average of (25.0±3.3) points, of which 7 were excellent, 8 were good and 1 was fair
Wysocki, Robert W; Kapotas, James S; Virkus, Walter W
Fractures of the proximal and distal one thirds of the tibial shaft have historically higher malunion rates than those of the midshaft. This retrospective case series evaluates the postoperative radiographic outcome of intramedullary nailing of proximal and distal one-third tibial shaft fractures using intraoperative two-pin external fixation, often referred to as traveling traction. Between 2000 and 2005, 15 consecutive patients with proximal third and 27 consecutive patients with distal third displaced extra-articular fractures of the tibia were treated with statically locked intramedullary nailing and supplementary intraoperative two-pin rectangular frame external fixation. The external fixation was removed once the proximal and distal locking screws were in place. The alignment of the fractures was determined using standard postoperative anteroposterior and lateral radiographs. Postoperatively, 14 of 15 patients with proximal fractures and 25 of 27 patients with distal fractures had less than 5 degrees of angular deformity in both the coronal and sagittal planes and less than 1 cm shortening. Statically locked intramedullary nailing with simultaneous intraoperative traveling traction external fixation as treatment for proximal and distal one-third extra-articular tibial shaft fractures is successful in achieving a high rate of acceptable postoperative alignment.
Prasad, Kodali Siva R K; Vali, Hamza; Hussain, Altaf
We are reporting an unusual combination of Hawkins Group I fracture of the neck of left talus in association with Salter Harris Type III distal tibial epiphyseal injury of medial malleolus in a child with cerebral palsy and hemiplegia of contralateral limbs and discussed the possible mechanism as well as management. Fractures of medial malleolus usually occur in Hawkins Group III fracture-dislocations in adults. Forced dorsiflexion of talus against the anterior edge of tibia appears to be the accepted common mechanism, despite limited experimental and clinical evidence incriminating axial compression. Fracture of medial malleolus implicates supination. We managed this unusual pattern of injury conservatively. At 15 months, the child was asymptomatic with no radiological evidence of avascular necrosis of body of talus or growth disturbance of distal tibial epiphysis. Copyright © 2013 Elsevier Ltd. All rights reserved.
Yang, Kyu-Hyun; Won, Yougun; Kang, Dong-Hyun; Oh, Jin-Cheol; Kim, Sung-Jun
To determine the effect of interfragmentary appositional (gap-closing) screw fixation in minimally invasive plate osteosynthesis (MIPO) for distal tibial fractures on the clinical and radiologic results. Prospective nonrandomized study. Level I trauma center. Sixty patients who were diagnosed as distal metadiaphyseal oblique or spiral tibial fracture without displaced articular fragment. Thirty patients (group A) of the 60 patients were treated with MIPO without appositional screw fixation, and the other 30 (group B) were treated with the screw. Radiologic union, clinical union, clinical functional score [American Orthopaedic Foot and Ankle Society (AOFAS) score], and complications. The time for initial callus formation and radiologic union was significantly longer in group A than those in group B (76.8 vs. 58.0 days, P = 0.044; 409 vs. 258.7 days, P = 0.002, respectively). The rate of clinical union during 1 year was significantly higher in group B than in group A (P = 0.0063). Four nonunion patients in group A achieved bone union after placement of an additional bone graft. None of the patients in group B diagnosed with delayed union or nonunion (P < 0.001). None of the patients of both groups had malreduction, skin problems, or infection. Overall, the AOFAS score did not significantly differ between groups A and B (85.4 vs. 87.0, P = 0.43). The use of additional interfragmentary appositional screw fixation in distal tibia MIPO for the fixation of oblique or spiral fracture promoted callus formation and union rate compared with MIPO without appositional screw fixation. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Xu, Yun-Qin; Li, Qiang; Shen, Tu-Gang; Su, Pei-Hua; Wang, Gang; Yao, You-Rong; Deng, Pan; Luo, Zheng-Li; Wei, Qiang-Qiang; Tang, Yong
To explore optimal choice of surgical treatment and operative approach for closed complex tibial plateau fractures and its influencing factors. From January 2003 to January 2011, 95 patients with closed complex tibial plateau fractures were estimated Schatzker V and Vl, and treated with three different surgical methods. The methods included single plate through anterolateral incision (Group A, 22 cases), double plates through inside and outside incisions (Group B, 36 cases), and double plates through antero-midline incisions (Group C, 37 cases). There were 56 males and 39 females, ranged the age from 19 to 57 years (averaged, 36.3 years), 50 cases in left, 45 cases in right. According to Schatzker classification, 51 cases were type V, 44 cases were VI. The data of operation time, intraoperative blood loss, complications (infectious of wound, necrosis, bad incision, collapse fracture, loosen of internal fixation, fracture failure)and recovery of function of lower limb joint were collected. There were no significant difference among three groups in operation time (P > 0.05); blood loss in group A was obvious better than other groups (P < 0.05); collapse of joint surface and failure rate of internal fixation in group A was higher than other groups (P > 0.05); Merchant score after 1 year were higher in group B, C than group A. For lower limb function, 10 cases got excellent results, 5 good, 4 fair and 3 poor in group A; 21 cases got excellent results, 11 good, 3 fair and 1 poor in group B; 23 cases got excellent results, 11 good,2 fair and 1 poor in group C. The blood loss in group A was least, but fracture exposure and joint surface was not satisfactory, and stable fixation could not be achieved, the long-term result was not good. For fractures with double condyles and dislocated involved, double plates through inside and outside incisions or double plates through antero-midline incisions was suggested,which benefit good reduction of joint surface, stable fixation
Martínez-Rondanelli, Alfredo; Escobar-González, Sara Sofía; Henao-Alzate, Alejandro; Martínez-Cano, Juan Pablo
A four-column classification system offers a different way of evaluating tibial plateau fractures. The aim of this study is to compare the intra-observer and inter-observer reliability between four-column and classic classifications. This is a reliability study, which included patients presenting with tibial plateau fractures between January 2013 and September 2015 in a level-1 trauma centre. Four orthopaedic surgeons blindly classified each fracture according to four different classifications: AO, Schatzker, Duparc and four-column. Kappa, intra-observer and inter-observer concordance were calculated for the reliability analysis. Forty-nine patients were included. The mean age was 39 ± 14.2 years, with no gender predominance (men: 51%; women: 49%), and 67% of the fractures included at least one of the posterior columns. The intra-observer and inter-observer concordance were calculated for each classification: four-column (84%/79%), Schatzker (60%/71%), AO (50%/59%) and Duparc (48%/58%), with a statistically significant difference among them (p = 0.001/p = 0.003). Kappa coefficient for intr-aobserver and inter-observer evaluations: Schatzker 0.48/0.39, four-column 0.61/0.34, Duparc 0.37/0.23, and AO 0.34/0.11. The proposed four-column classification showed the highest intra and inter-observer agreement. When taking into account the agreement that occurs by chance, Schatzker classification showed the highest inter-observer kappa, but again the four-column had the highest intra-observer kappa value. The proposed classification is a more inclusive classification for the posteromedial and posterolateral fractures. We suggest, therefore, that it be used in addition to one of the classic classifications in order to better understand the fracture pattern, as it allows more attention to be paid to the posterior columns, it improves the surgical planning and allows the surgical approach to be chosen more accurately.
Millar, Stuart C; Arnold, John B; Thewlis, Dominic; Fraysse, François; Solomon, Lucian B
Classification systems such as the Schatzker and AO/OTA have been proposed for standardised assessment of tibial plateau fractures and to guide clinical decision making. However, there has been no comprehensive literature review of all classification systems for tibial plateau fractures, including assessment of their reliability. The aim of this systematic review was to identify and appraise previously established classification systems for tibial plateau fractures and determine their reliability for fracture classification. Six databases were searched from inception until October 2016. Classification systems for tibial plateau fractures were identified. No restriction was placed on imaging modality (plain film X-ray, CT, MRI). Data synthesis was performed to identify common features of the systems, their prevalence within the literature and studies of intra and inter-rater reliability of fracture classification using Kappa coefficient (κ). Thirty-eight classification systems were identified, five of which were a sub-classification of a single fracture type from a previous tool. The Schatzker and AO/OTA classification systems were the most commonly reported. Of the tools identified only five have been tested for inter and intra-observer reliability (Schatzker, AO/OTA, Duparc, Hohl and Luo). Reliability of more simplistic classification systems, such as that by Luo et al. (three-column) was typically high (intra-κ = 0.67-0.81, inter-κ = 0.71-0.87), but with the disadvantage of providing less information on fracture patterns and morphology. Intra and inter-observer reliability using plain film X-ray was frequently moderate (κ = 0.40-0.60), with 2D and 3D CT typically improving reliability of classification. Only 11 of the 32 complete classification systems identified association of fracture classification with clinical outcome. Frequently used systems for classification of tibial plateau fractures display moderate intra and inter-observer reliability
Whitelaw, G P; Wetzler, M J; Levy, A S; Segal, D; Bissonnette, K
Forty-two competitive athletes with posterior medial pain in the lower one-half of the tibia were evaluated by plain roentgenograms and bone scans. Twenty stress fractures were diagnosed in 17 patients by plain roentgenograms or bone scans or both. The remaining 25 patients were diagnosed as having shin splints. All 42 patients subsequently had a pneumatic leg brace applied to the affected limb or limbs. The 17 patients with stress fractures were able to ambulate without pain and were allowed to resume light training in an average of one week. Their injuries were nontender to palpation. The patients were allowed to resume intensive training at an average of 3.7 weeks postinjury. Patients returned to competition at the preinjury level in an average of 5.3 weeks after application of the brace. The pneumatic leg brace allowed the athletes with tibial stress fractures to begin pain-free ambulation and rehabilitation, thus facilitating the maintenance of their cardiovascular fitness and permitting an early return to competition.
Beytemür, Ozan; Albay, Cem; Adanır, Oktay; Yüksel, Serdar; Güleç, Mehmet Akif
This study aims to evaluate the functional and radiographic results and treatment complications of AO/OTA (Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association) type 43C1 and C2 fractures treated with intramedullary nailing. We retrospectively evaluated 35 AO/OTA type 43C1 and C2 patients (26 males, 9 females; mean age 39.8±16.9 years; range 19 to 82 years) treated with intramedullary nailing. Two interfragmentary screws out of nail were applied in 10 patients (29%), while one interfragmentary screw out of nail was applied in 17 patients (49%). Intramedullary nailing was applied in eight patients (23%) without external screws. Fracture union, union time, alignment problems, and complications were evaluated. Clinical evaluation of patients was conducted using the Olerud and Molander score and by measuring the ankle joint range of motion. Union was achieved in all 35 patients. Mean union time was 16.5±2.8 weeks (range 12 to 24 weeks) and mean Olerud and Molander score was 88±8.24. Varus deformity was detected in one patient, valgus deformity was detected in two patients, and rotation deformity was detected in one patient. Superficial infection was detected in three patients (9%). Deep infection was not detected in any patient. Intramedullary nailing is not contraindicated for simple intra-articular distal tibial fractures. In these fractures, intramedullary nailing performed in accordance with its technique, with an additional percutaneous screw if necessary, is a successful treatment option with high fracture union rates, high functional results, and low complication rates.
Roßbach, B P; Faymonville, C; Müller, L P; Stützer, H; Isenberg, J
The aim of this article is to present the functional results and the effect on quality of life of surgically treated tibial plateau fractures in physically active and working patients with multiple and serious injuries. In addition, the relationships between functional and radiological outcome were evaluated and compared with activity in daily and professional life. In all, 41 injured patients were followed up a mean of 47 months after surgical treatment and examined with radiological, functional, as well as quality of life score. In the radiological scoring, a mean value of 72 points (max 100 points) was achieved. In the activity score, there was an average of 63.5 points (max 100 points). When evaluating the health-related quality of life, an average score of 69.6 points was achieved. There was a significant relationship between radiological and activity scores and the radiological and life quality scores. Furthermore, the relationship between activity and quality of life scores was considered significant. Surgeon's influence on the functional outcome could be confirmed. The functional and the radiological results were moderate. Quality of life was permanently affected by the consequences of tibial plateau fracture in 12 patients; 11 patients were not re-employed. However, the quality of life was assessed as good or very good and 28 patients had returned to work. The quality of life was firmly linked to the radiological and functional parameters, which tended to be influenced by the quality of the primary surgical treatment when looking at the overall population.
Kolb, Werner; Guhlmann, Hanno; Windisch, Christoph; Koller, Heiko; Grützner, Paul; Kolb, Klaus
High tibial osteotomy has been recognized as a beneficial treatment for osteoarthritis of the medial compartment of the knee. The purpose of this prospective study was to assess the short-term results of opening-wedge high tibial osteotomies with locked plate fixation. From September 2002 to November 2005, fifty-one consecutive medial opening-wedge high tibial osteotomies were performed. The mean age of the patients at the time of the index operation was forty-nine years. The preoperative and postoperative factors analyzed included the grade of arthritis of the tibiofemoral compartment (the Ahlbäck radiographic grade), the anatomic tibiofemoral angle, patellar height, the Hospital for Special Surgery rating system score, and the Lysholm and Gillquist knee score. Postoperatively, one superficial wound infection occurred. Fifty of the fifty-one osteotomies healed after an average period of 12.9 weeks (range, eight to sixteen weeks) without bone grafts. A nonunion developed in a sixty-two-year-old patient who was a cigarette smoker. The average postoperative tibiofemoral angle was 9° of valgus. Forty-nine patients were followed for a mean of fifty-two months. The average score on the Hospital for Special Surgery rating system was 86 points at the time of the most recent follow-up. The rating was excellent in twenty-eight patients (57%), good in twelve (24%), fair in four (8%), and poor in five (10%). The average score on the Lysholm and Gillquist knee-scoring scale was 83 points. According to these scores, the outcome was excellent in nine patients (18%), good in thirty-one (63%), fair in three (6%), and poor in six (12%). Four knees failed after an average of thirty-six months. Our results suggest that an opening-wedge high tibial osteotomy with locked plate fixation allows a correct valgus angle to be achieved with good short-term results.
Haupt, Samuel; Frima, Herman; Sommer, Christoph
Lower leg fractures of the tibia with or without fracture of the fibula are very common. Proximal tibiofibular joint (PTFJ) dislocation is a very rare injury that can occur together with a tibia shaft fracture. As there is only scarce literature about this injury available, we would like to present our experience with the treatment of this entity. We present a small case series of seven patients. In most cases, the tibia fracture was nailed in a closed technique. After distal locking the proximal fibula was exposed by a lateral approach exposing and preserving the peroneal nerve. After anatomical reduction into the corresponding articular facet of the proximal tibia, the fibula was transfixed to the tibia with a positioning screw. This indirectly provided a correct length and rotation of the tibia, which could finally be locked to the nail by inserting the proximal locking bolts. The positioning screw was removed after six weeks prior to full loading. Six of seven patients had been followed up by at least 7 months post-treatment. Out of 663 prospectively collected tibia shaft fractures treated at our institution from 1/2001 to 7/2014, we found seven patients with associated PTFJ dislocation. All except one had been caused by a high energy trauma. After one year, five patients showed excellent results with full range of motion and returning to their sporting activities as before the accident. Two patients have impaired function due to associated injuries. None complained of persistent pain or instability of the PTFJ. PTFJ dislocation with tibia shaft fracture can easily be overlooked if one is not familiar with this injury. It is important to diagnose and treat this uncommon dislocation anatomically to achieve good results. Otherwise, as the literature shows, it can lead to chronic instability of the proximal fibula with snapping, proximal fibular pain and even peroneal nerve palsy. Furthermore in complex tibial fractures correct length and rotation only can be
Harrison, W J
Open tibia fractures are common injuries, particularly in developing countries.Pedestrian or bicycle to motor car contact is the most common mechanism. These injuries result in high morbidity and often long-term disability. HIV infection complicates open fractures by raising the incidence of infectionin the open wound (5 of 7 patients in our series). This risk may be compounded if internal fixation techniques are used (5 of 12 HIV patients with internal fixation of any open fracture). There is also a suggestion that HIV may delay bone union (4 of 7 patients united at 6 months). External fixation offers an alternative method of fracture stabilisation. It avoids the risks associated with putting metal-ware in the wound, but creates a new issue of pin track sepsis. We found that pin track infection was more common in patients with HIV, but the rate at which pins required removal was 7%. We consider external fixation to be a lower-risk strategy than internal fixation in such patients but open fracture wound sepsis remains a problem. We have not yet demonstrated a difference in severity or frequency of complications in patients of low CD4 count, but logically one expects septic complications to increase as CD4 count falls. Antiretroviral medication decreases viral load and elevates the CD4 count. Research is underway regarding potential effectiveness of such drugs in reducing wound and fracture healing complications. Above all, meticulous and timely all-round care is required to achieve satisfactory results in immune-compromised patients. This includes, debridement, bony stability, and soft-tissue reconstruction.
Wang, Yukai; Luo, Congfeng; Zhu, Yi; Zhai, Qilin; Zhan, Yu; Qiu, Weijian; Xu, Yafeng
This study introduces an updated Three-Column Concept for the classification and treatment of complex tibial plateau fractures. A combined preoperative assessment of fracture morphology and injury mechanism is utilized to determine surgical approach, implant placement and fixation sequence. The effectiveness of this updated concept is demonstrated through evaluation of both clinical and radiographic outcome measures. From 2008 to 2012, 355 tibial plateau fractures were treated using the updated Three-Column Concept. Standard radiographic and computed tomography imaging are used to systematically assess and classify fracture patterns as follows: (1) identify column(s) injured and locate associated articular depression or comminution, (2) determine injury mechanism including varus/valgus and flexion/extension forces, and (3) determine surgical approach(es) as well as the location and function of applied fixation. Quality and maintenance of reduction and alignment, fracture healing, complications, and functional outcomes were assessed. 287 treated fractures were followed up for a mean period of 44.5 months (range: 22-96). The mean time to radiographic bony union and full weight-bearing was 13.5 weeks (range: 10-28) and 14.8 weeks (range: 10-26) respectively. The average functional Knee Society Score was 93.0 (range: 80-95). The average range of motion of the affected knees was 1.5-121.5°. No significant difference was found in knee alignment between immediate and 18-month post-operative measurements. Additionally, no significant difference was found in functional scores and range of motion between one, two and three-column fracture groups. Twelve patients suffered superficial infection, one had limited skin necrosis and two had wound dehiscence, that healed with nonoperative management. Intraoperative vascular injury occurred in two patients. Fixation of failure was not observed in any of the fractures treated. An updated Three-Column Concept assessing fracture
Pinheiro, Antônio L B; Soares, Luiz G P; da Silva, Aline C P; Santos, Nicole R S; da Silva, Anna Paula L T; Neves, Bruno Luiz R C; Soares, Amanda P; Silveira, Landulfo
The aim of the present study was to assess, by means of Raman spectroscopy, the repair of complete surgical tibial fractures fixed with wire osteosynthesis (WO) treated or not with infrared laser (λ780 nm) or infrared light emitting diode (LED) (λ850 ± 10 nm) lights, 142.8 J/cm 2 per treatment, associated or not to the use of mineral trioxide aggregate (MTA) cement. Surgical tibial fractures were created on 18 rabbits, and all fractures were fixed with WO and some groups were grafted with MTA. Irradiated groups received lights at every other day during 15 days, and all animals were sacrificed after 30 days, being the tibia removed. The results showed that only irradiation with either laser or LED influenced the peaks of phosphate hydroxyapatite (~ 960 cm -1 ). Collagen (~ 1450 cm -1 ) and carbonated hydroxyapatite (~ 1070 cm -1 ) peaks were influenced by both the use of MTA and the irradiation with either laser or LED. It is concluded that the use of either laser or LED phototherapy associated to MTA cement was efficacious on improving the repair of complete tibial fractures treated with wire osteosynthesis by increasing the synthesis of collagen matrix and creating a scaffold of calcium carbonate (carbonated hydroxyapatite-like) and the subsequent deposition of phosphate hydroxyapatite.
Ochsner, P E
This paper reviews records of Liestal Country hospital, AO Catalogue files and National Swiss Insurance Industry actuarials regarding open fractures. Specific regards are tended toward prognosis forecasting, complications and outcome assessments with respect to industrial "down time" resulting from bone infections and/or pseudarthroses. Evaluation of injuries is contingent upon the Gustilo Classification (1987) which bases prognosis on soft tissue preservation in open fracture injuries. We adhere to well accepted protocols which provide for adequate local primary débridement and stabilization of structural osseous components by means of appropriate fracture fixation. In addition, we have implemented protocols for the preservation of bony vascular elements along with sequential provisions for cancellous bone and soft tissue grafting. Outcome assessments on the range of cases reviewed confirm a traditional perspective that open fractures demonstrate considerably greater morbidity than closed fractures. However, by comparison with previous studies, the results of this series show positive progress toward optimal wound healing. While this more aggressive approach tends initially to be quite expensive, we believe initial costs to the carrier are justified by improved outcome, prognosis and industrial down time.
Hu, Sun-Jun; Chang, Shi-Min; Zhang, Ying-Qi; Ma, Zhuo; Du, Shou-Chao; Zhang, Kai
The posterolateral (PL) tibial plateau quadrant is laterally covered by the fibular head and posteriorly covered by a mass of muscle ligament and important neurovascular structures. There are several limitations in exposing and fixing the PL tibial plateau fractures using a posterior approach. The aim of this study is to present a novel anterolateral supra-fibular-head approach for plating PL tibial plateau fractures. Five fresh and ten preserved knee specimens were dissected to measure the following parameters:1) the vertical distance from the apex of the fibular head to the lateral plateau surface, 2) the transverse distance between the PL platform and fibula collateral ligament (FCL), and 3) the tension of the FCL in different knee flexion positions. Clinically, isolated PL quadrant tibial plateau fractures were treated via an anterolateral supra-fibular-head approach and lateral rafting plate fixation. The outcome of the patients was assessed after a short to medium follow-up period. The distance from the apex of the fibular head to the lateral condylar surface was 12.2 ± 1.6 mm on average. With the knee extended and the FCL tensioned, the transverse distance between the PL platform and the FCL was 6.7 ± 1.1 mm. With the knee flexed to 60° and the FCL was in the most relaxed position, the distance increased to 21.1 ± 3.0 mm. Clinically, a series of 7 cases of PL tibial plateau fractures were treated via this anterolateral supra-fibular-head approach. The patient was placed in a lateral decubitus position with the knee flexed to approximately 60 degrees. After the posterior retraction of the FCL, the plate was placed more posteriorly to provide a raft or horizontal belt fixation of the PL tibial plateau fragment. After an average of 14.3 months of follow up, the knee range of motion(ROM) was 121.4° ± 8.8° (range: 105°-135°), the HSS score was 96.7 ± 2.6 (range: 90-100), and the SMFA dysfunction score was 22.4 ± 3.8 (range: 16-28) points. The
Müller, Michael; Disch, Aleaxander C; Zabel, Nicole; Haas, Norbert P; Schaser, Klaus D
Background The severity of associated soft tissue trauma in complex injuries of the extremities guides fracture treatment and decisively determines patient's prognosis. Trauma-induced microvascular dysfunction and increased tissue pressure is known to trigger secondary soft tissue damage and seems to adversely affect skeletal muscle function. Methods 20 patients with isolated tibial fractures were included. Blood pressure and compartment pressure (anterior and deep posterior compartment) were measured continuously up to 24 hours. Corresponding perfusion pressure was calculated. After 4 and 12 weeks isokinetic muscle peak torque and mean power of the ankle joint in dorsal and plantar flexion were measured using a Biodex dynamometer. Results A significant inverse correlation between the anterior perfusion pressure at 24 hours and deficit in dorsiflexion at 4 weeks was found for both, the peak torque (R = -0.83; p < 0.01) and the mean power (R = -0.84; p < 0.01). The posterior perfusion pressure at 24 h and the plantar flexion after 4 weeks in both, peak torque (R = -0.73, p =< 0.05) and mean power (R = -0.7, p =< 0.05) displayed a significant correlation. Conclusion The functional relationship between the decrease in intramuscular perfusion pressures and muscle performance in the early rehabilitation period indicate a causative and prognostic role of early posttraumatic microcirculatory derangements and skeletal muscle function. Therapeutic concepts aimed at effective muscle recovery, early rehabilitation, and decreased secondary tissue damage, should consider the maintenance of an adequate intramuscular perfusion pressure. PMID:18419823
Shah, Siddharth Mahesh; Roberts, Jason; Picard, Frederic
Medial open wedge high tibial osteotomy (MOWHTO) is a commonly performed procedure for symptomatic medial compartment osteoarthritis (OA). However, little is known about its effects on ipsilateral ankle or hindfoot. The aim of our study was to determine the incidence of ankle or hindfoot problems after MOWHTO and examine its association with radiological indices. Thirty-five knees (32 patients) undergoing navigated MOWHTO were evaluated for the presence of new-onset ankle or hindfoot symptoms after surgery. Pre- and postoperative hip-knee-ankle (HKA) angle, medial proximal tibial angle (MPTA), and tibial plafond inclination (TPI) were measured and compared on standing lower limb alignment radiographs. The mean postoperative change in HKA angle, MPTA, and TPI was 8.8°, 7.0°, and 8.4°, respectively. New-onset unexplained ankle or hindfoot symptoms were seen in 20% of the cases after surgery. Postoperative change in TPI was significantly greater in symptomatic patients as compared with asymptomatic ones (12.8° ± 4.9° vs. 8.1° ± 4.8°, p = 0.03). The odds ratio (OR) for developing ankle or hindfoot symptoms in cases with ≥ 10° change in TPI postoperatively was 10.8 ( p = 0.04). Ankle or hindfoot symptoms were successfully managed with conservative treatment in all cases. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Axibal, Derek P; Mitchell, Justin J; Mayo, Meredith H; Chahla, Jorge; Dean, Chase S; Palmer, Claire E; Campbell, Kristen; Vidal, Armando F; Rhodes, Jason T
Historically, bicycle accidents were described as the most common mechanism for pediatric anterior tibial spine fractures (ATSFs). There is a paucity of current literature examining the demographic factors associated with these injuries. The purpose of this cohort study was to characterize the epidemiology of ATSFs presenting to a single tertiary referral pediatric hospital. A consecutive cohort of 122 pediatric patients with ATSFs between 1996 and 2014 were reviewed. Radiographic variables, classification of fractures (Meyers and McKeever type), age, sex, height, weight, body mass index, and mechanism of injury were retrieved. Categories of mechanism of injury included organized sports (football, soccer, basketball, lacrosse, wrestling, and gymnastics), bicycling, outdoor sports (skiing, skateboarding, and sledding), fall, motor vehicle collision/pedestrian versus motor vehicle, and trampoline. Organized sports-related injuries represented the most common cause of ATSFs (36%). Other common mechanisms of injury included bicycle accidents (25%), outdoor sports (18%), and falls (11%). There was a higher proportion of males (69%) compared with females (31%). Males (mean age, 11.6 y) were significantly older than females (mean age, 9.8 y) (P=0.004). Younger patients (aged 11.5 y and below) were more likely to have displaced fractures (type III), whereas type I and type II were more common in patients above 11.5 years (P=0.02). Patients with fracture type I were significantly taller than patients with fracture type III. No other variables were found to differ significantly according to fracture severity, including sex, weight, and body mass index. To our knowledge, our study represents both the largest (n=122) and most up-to-date epidemiological ATSF study in pediatric patients. A higher rate of ATSF occurs due to organized sports rather than bicycling or motor vehicle collision. This 18-year data collection represents a change in the paradigm, and is likely
Iorio, R; Pagnottelli, M; Vadalà, A; Giannetti, S; Di Sette, P; Papandrea, P; Conteduca, F; Ferretti, A
The purpose of our study was to compare clinical and radiological results of two groups of patients treated for medial compartment osteoarthritis of the knee with either conventional or computer-assisted open-wedge high tibial osteotomy (HTO). Goals of surgical treatment were a correction of the mechanical axis between 2° and 6° of valgus and a modification of posterior tibial slope between -2° and +2°. Twenty-four patients (27 knees) affected by varus knee deformity and operated with HTO were prospectively followed-up. They were randomly divided in two groups, A (11 patients, conventional treatment) and B (13 patients, navigated treatment). The American Knee Society Score and the Modified Cincinnati Rating System Questionnaire were used for clinical assessment. All patients were radiologically evaluated with a comparative lower limb weight-bearing digital radiograph, a standard digital anteroposterior, a latero-lateral radiograph of the knee, and a Rosenberg view. Patients were followed-up at a mean of 39 months. Clinical evaluation showed no statistical difference (n.s.) between the two groups. Radiological results showed an 86% reproducibility in achieving a mechanical axis of 182°-186° in group B compared to a 23% in group A (p = 0.0392); furthermore, in group B, we achieved a modification of posterior tibial slope between -2° and +2° in 100% of patients, while in group A, this goal was achieved only in 24% of cases (p = 0.0021). High tibial osteotomy with navigator is more accurate and reproducible in the correction of the deformity compared to standard technique. Therapeutic study, Level II.
Hughes, Travis M; Rowan, Flynn A; Truchan, Lisa M
The tibia is the most commonly fractured long bone. Tibia fractures are simple, and most are amenable to immediate closed reduction. Reported cases of irreducibility resulting from entrapment of soft-tissue structures are rare. We report the case of a 23-year-old man who, in a high-speed motor vehicle crash, sustained a closed lower leg fracture that was later found to have a unique pattern in which the fibula was entrapped in the medullary cavity of the tibia. Limited open reduction was performed, and the entrapped distal fibula was removed with use of a bone hook. The tibia was reduced, and a nail placed in standard fashion. The postoperative course leading to full recovery was unremarkable. This irreducible fracture pattern, not previously reported, should be considered during difficult closed reductions in order to prevent unnecessary neurovascular or bony injury.
Florio, C S
A computational model was used to compare the local bone strengthening effectiveness of various isometric exercises that may reduce the likelihood of distal tibial stress fractures. The developed model predicts local endosteal and periosteal cortical accretion and resorption based on relative local and global measures of the tibial stress state and its surface variation. Using a multisegment three-dimensional leg model, tibia shape adaptations due to thirty-three combinations of hip, knee, and ankle joint angles and the direction of a single or sequential series of generated isometric resultant forces were predicted. The maximum stress at a common fracture prone region in each optimized geometry was compared under likely stress fracture-inducing midstance jogging conditions. No direct correlations were found between stress reductions over an initially uniform circular hollow cylindrical geometry under these critical design conditions and the exercise-based sets of active muscles, joint angles, or individual muscle force and local stress magnitudes. Additionally, typically favorable increases in cross-sectional geometric measures did not guarantee stress decreases at these locations. Instead, tibial stress distributions under the exercise conditions best predicted strengthening ability. Exercises producing larger anterior distal stresses created optimized tibia shapes that better resisted the high midstance jogging bending stresses. Bent leg configurations generating anteriorly-directed or inferiorly-directed resultant forces created favorable adaptations. None of the studied loads produced by a straight leg was significantly advantageous. These predictions and the insight gained can provide preliminary guidance in the screening and development of targeted bone strengthening techniques for those susceptible to distal tibial stress fractures. This article is protected by copyright. All rights reserved.
Allen, Christopher S; Flynn, Timothy W; Kardouni, Joseph R; Hemphill, Mae H; Schneider, Carrie A; Pritchard, Allyson E; Duplessis, David H; Evans-Christopher, Greer
Single blind randomized controlled replication study. Evaluate the effect of a pneumatic leg brace on return-to-activity and pain in soldiers with tibial stress fractures. Thirty-one subjects diagnosed with tibial stress fractures were randomly assigned to either a brace or control group. Dependent variables included time to pain-free single-leg hopping, visual analog pain scale, and time to a pain-free 1-mile run. Twenty subjects (10 brace, 10 control) completed a detailed functional progression culminating in a 1-mile run. There was no difference between groups for time to pain-free hop (p > 0.86; power = 0.43) and time to pain-free 1-mile run (p > 0.24; power = 0.92). Subjects in both groups experienced statistically significant improvements in pain measurements (p < 0.002), but no difference was found between groups (p > 0.93). The current study demonstrated no added benefit of Aircast leg braces in the treatment of tibial stress fractures in the military training environment.
Canavese, Federico; Botnari, Alexei; Andreacchio, Antonio; Marengo, Lorenza; Samba, Antoine; Dimeglio, Alain; Pereira, Bruno; Mansour, Mounira; Rousset, Marie
The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced tibial shaft fractures with intact fibula in children after nonoperative management and operative treatment by elastic stable intramedullary nailing. A study was performed on 80 consecutive children, 56 males, 24 females from 2 Institutions, with displaced and closed tibial shaft fracture with intact fibula. All patients underwent regular clinical and radiographic follow-up visits for at least 2 years after injury. In total, 26 patients (group A-Institution I) were treated surgically by elastic stable intramedullary nailing and 54 patients (18 patients from group B-Institution I and 36 patients from group C-Institution II) were treated nonoperatively with closed reduction and casting. groups A, B, and C did not significantly differ on sex (P=0.37), side (P=0.54), and fracture site (P=0.14).Valgus deformity was significantly controlled in group A patients only (P=0.001); during follow-up in group B patients (P=0.017), and showed no significant change between pretreatment images and last follow-up in group C patients (P=0.71). Procurvatum deformity was significantly controlled in group A patients only (P=0.001); it showed no significant improvement after conservative treatment in group B (P=0.73) and C patients (P=0.8). Recurvatum was significantly improved in group A (P<0.001) and C patients (P<0.001) but remained unchanged in group B patients (P=0.15). Varus deformity improved significantly in all patient groups.Immobilization time was significantly shorter in group A compared with group B and C patients (P<0.001).However, numerical differences, although statistically significant, were not clinically relevant for all variables but immobilization time. This study showed good functional and radiologic outcomes in the pediatric population who had sustained closed, traumatic, displaced fracture of tibial diaphysis without associated fibula fracture
Kent, Michael; Mumith, Aadil; McEwan, Jo; Hancock, Nicholas
The surgical treatment of distal tibial fractures is challenging and controversial. Recently, locking plate fixation has become popular, but the outcomes of this treatment are mixed with complication rates as high as 50 % in the published literature. There are no reports specifically relating to the financial and resource costs of failed treatment in the literature. Retrospective service analysis of patients who had undergone locking plate fixation of a distal third tibial fracture between 2008 and 2011 with at least 12 months follow-up. Rates of readmission, reoperation, bony union and infection were ascertained. The financial and resource (hospital stay and number of outpatient appointments) implications of failed treatment were calculated. Forty-two patients were identified. There were 31 type A fractures, one type B fracture and 10 type C fractures. Three injuries were open. Twenty patients were treated with minimally invasive percutaneous osteosynthesis (MIPO). The readmission and reoperation rates were 26 % (n = 11) and 19 % (n = 8), respectively. A total of 89 % of readmissions were due to infection. All patients had received appropriate antibiotic regimens. The average costs of successful and failed treatment were £ 5538 and £ 18,335, respectively. The average time to union was 24.5 weeks. The rate of non-union was 21 % (n = 9). The rate of infection was 28 % (n = 12), with all patients with open fracture incurring an infection. Tourniquet time had no effect on the incidence of complications. Smokers were more likely to incur a complication (p < 0.05), and non-union was lower in the MIPO group (p < 0.05). The length and total cost of inpatient care were significantly lower in the MIPO group (p < 0.05). MIPO patients were five times less likely to incur readmission or reoperation. Failed treatment was three times more expensive and four times longer than successful treatment. The study identified a large burden to the service following failure of locking
Smith, Evan J; Kuang, Xiangyu; Pandarinath, Rajeev
Tibial shaft fractures comprise a large portion of operatively treated long bone fractures, and present with the highest rate of open injuries. Intramedullary fixation has become the standard of care for both open and closed injuries. The rates of short term complications and hospital length of stay for open and closed fractures treated with intramedullary fixation is not fully known. Previous series on tibia fractures were performed at high volume centers, and data were not generalizable, further they did not report on length of stay and the impact of preoperative variables on infections, complications and reoperation. We used a large surgical database to compare these outcomes while adjusting for preoperative risk factors. Data were extracted from the ACS-NSQIP database from 2005 to 2014. Cases were identified based on CPT codes for intramedullary fixation and categorized as closed vs open based on ICD9 code. In addition to demographic and case data, primary analysis examined correlation between open and closed fracture status with infection, complications, reoperation and hospital length of stay. Secondary analysis examined preoperative variables including gender, race, age, BMI, and diabetes effect on outcomes. There were 272 cases identified. There were no significant demographic differences between open and closed tibia fracture cases. Open fracture status did not increase the rate of infection, 30day complications, reoperation, or length of stay. The only preoperative factor that correlated with length of stay was age. There was no correlation between BMI, presence of insulin dependent and nondependent diabetes, and any outcome measure. When considering the complication rates for open and closed tibial shaft fractures treated with intramedullary fixation, there is no difference between 30-day complication rate, length of stay, or return to the operating room. Our reported postoperative infection rates were comparable to previous series, adding validity to
Bible, Jesse E; McClure, D Jake; Mir, Hassan R
To analyze the rate of postoperative infection and nonunion after tibial fractures in patients treated for acute compartment syndrome (ACS) using (1) single-incision versus (2) dual-incision fasciotomy technique. Retrospective. Level I trauma center. Review of all adult tibial fractures operatively treated (n = 2756) over a 12-year period identified 175 patients with concurrent ACS requiring fasciotomy. Of 60 patients treated with intramedullary nails, 36 patients had single-incision fasciotomy and 24 had dual-incision fasciotomy. Of 81 patients treated with plate fixation, 59 patients had single-incision fasciotomy and 22 had dual-incision fasciotomy. Tibial fixation with fasciotomy for ACS. Occurrence of postoperative infection and nonunion. Both fasciotomy groups were similar across recorded patient and treatment characteristics. Need for skin graft was similar between fasciotomy groups. For patients treated with intramedullary nail (n = 60), 1 infection (2.8%) occurred in single-incision group versus 2 (8.3%) in dual-incision group (P = 0.558). Seven nonunions (19.4%) occurred in single-incision group versus 3 (12.5%) in dual-incision group (P = 0.726). For plate fixation patients (n = 81), 15 infections (25.4%) occurred with single-incision fasciotomy versus 5 infections (22.7%) with dual-incision fasciotomy (P = 1.000). Seven nonunions (11.9%) occurred with single-incision group versus 4 nonunions (18.2%) with dual-incision group (P = 0.479). This is the first study to compare a single-incision fasciotomy technique to a dual-incision technique in the setting of tibial fractures with ACS, with similar infection and nonunion rates with either technique. The choice of fasciotomy technique can be based on surgeon experience or patient condition as opposed to a suspected elevated infection or nonunion risk with either technique. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Bové, J C
The aim of this work was to study the behavior of an inert porous alumina ceramic spacer used with a plate fixation for open-wedge tibial valgus osteotomy in patients with osteoarthritis of the knee and genu varum. The population included 50 patients who underwent surgery between October 1994 and December 2000. There were 31 women and 19 men, mean age 55 years at surgery (26 right knees and 24 left knees). Patients were reviewed at 3 weeks, 6 weeks, 3 months, 6 months, and one year, then every 2 years. Clinical and radiological data were available for all patients. Mean follow-up was 16 months. Two patients were lost to follow-up at 5 and 6 months. The results of the open-wedge tibial osteotomy were in agreement with the usual outcome reported in the literature concerning pain relief, functional recovery, joint motion, angle correction, and good preservation of the clinical and radiological result. Three fracture lines were observed on the lateral tibial plateau but did not affect final outcome or angle correction. There was however one case with loss of correction due to fracture of the screws. Radiographically, at 6 months, there were 9 thin lucent lines around the spacer (24%) which did not affect final outcome. Bone healing was achieved at 3 months on the average in all cases except 2 (4%) where healing was achieved at 8 and 13 months. The porous alumine spacer is a reliable biocompatible and mechanically stable element helpful for achieving bone healing. Integration into bone tissue was radiographically satisfactory. There were no specific complications related to use of the spacer.
Leenders, A M; Schotanus, M G M; Wind, R J P; Borghans, R A P; Kort, N P
Patient-specific instrumentation (PSI) for unicompartmental knee arthroplasty (UKA) has been available for a few years. However, limited literature is available on this subject. Hence, the aim of this cohort study is to evaluate the 2 years' results of our first experiences with the use of PSI in UKA. It is hypothesised that there is no advantage in rate of adverse events and in radiological and functional outcomes in comparison to literature on the conventional method. This cohort included 129 knees of 122 patients, operated by one surgeon. Outcome measures were the rate of adverse events (AEs); implant position as determined on radiographs; the accuracy of the default and approved planning of the implant sizes and the patient-reported outcome measures (PROMs) preoperatively, and at 3, 12 and 24 months, postoperatively. A total of 6 (4.9%) AEs were observed in this study, with 4 (3.3%) tibial fractures being the main complication. The mean postoperative biomechanical axis was 176.4° and in the majority of cases, the radiographic criteria, as determined by the manufacturer, were met. The tibial component showed 20 (16.4%) outliers in the sagittal and 3 (2.5%) outliers in the frontal plane. There were no outliers of the femoral component. For the femoral and tibial components, respectively, in 125 (96.9%) and 79 (61.7%) cases, there was an agreement between approved planning and implanted component size. All PROMs improved significantly after surgery. Tibial fracture was the most common AE, probably related to the transition from cemented to uncemented UKA. Perioperative modifications to the surgical technique were made in order to prevent this AE. Improvements should be made to the operation technique of the uncemented tibial plateau to obtain an adequate placement and at the same time reduce the risk for tibial fracture. The PSI technique was a reliable tool for the placement of the femoral component. Functional outcome was in line with literature on the
Tiedeken, Nathan C; Hampton, David; Shaffer, Gene
High energy fractures of the distal tibial plafond and calcaneus have been associated with high functional morbidity and wound complications. Although both of these fractures result from a similar mechanism, they have rarely been reported to occur on an ipsilateral extremity. The combination of these 2 injuries on the same extremity would increase the likelihood of an adverse surgical or functional outcome. We present the case and management strategy of a 43-year-old male with bilateral open pilon fractures and closed calcaneal fractures after falling from a height. A staged protocol was used for the bilateral pilon fractures, with external fixation until operative fixation on day 9. Nonoperative management of the calcaneal fractures resulted in a successful functional outcome at 10 months of follow-up. Treatment of this fracture pattern must incorporate the condition of the soft tissues, an understanding of the fractures, and minimize patient risk factors to optimize the functional and surgical outcomes. Copyright © 2014 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Ostrum, Robert F; Avery, Matthew C
Rotational ankle fractures are incredibly common, resulting in a wide spectrum of bony and ligamentous injury patterns. After open reduction of an ankle fracture, the treating surgeon must always evaluate syndesmotic stability. If the syndesmosis is determined to be unstable, a reduction of the distal tibiofibular joint should be performed. Failure to adequately identify and treat injuries to the syndesmosis may result in continued ankle instability and poor patient outcomes. Lateral fluoroscopic images are necessary to assess a closed reduction of the syndesmosis before stabilization, although the accuracy of this tool has been questioned in several studies. Significant controversy surrounds many aspects of this injury and its treatment, including methods of diagnosis, ideal reduction clamp positioning, diameter and number of syndesmotic screws, and number of tibial cortices to be engaged. In the accompanying video, we describe our approach for the treatment of a bimalleolar ankle fracture with syndesmotic injury, using a posterior fibular plate and single tricortical syndesmotic screw.
Ogrodnik, Peter J; Moorcroft, C Ian; Thomas, Peter B M
An automated loading and measurement device has been developed for assessment of the mechanical properties of a healing human tibial fracture. The characteristics of the device are presented with assessments of errors. This paper constitutes a small part of a long term research project determining a clinically quantifiable end point for fracture healing in humans, hence a sample of results is presented to demonstrate the potential application of the device. A more detailed analysis of the results will be the basis of further publications. The initial results confirm that the non-linear behaviour of callus cannot be ignored in fracture assessment methodologies. They further reinforce the requirement to measure load-rate when measuring fracture stiffness. Polar plots of stiffness demonstrate that when measuring fracture stiffness not only should load-rate be considered, but also the orientation of measurement. The results from this work support the view that fracture stiffness should be measured in at least two planes. A new material property for the assessment of fracture healing, the gamma ratio gamma, is examined and preliminary results are shown. The paper also demonstrates how creep properties of a healing tibia can be assessed and proposes that this property may form the basis for future fracture assessment investigations.
Inklebarger, James; Taylor, Matthew J.D.; Griffin, Murray; Clarke, Tim
Tibial eminence avulsion fracture at the ACL footprint may be caused by high-energy forces such as a fall, in which the ACL ligament proves stronger than the forces that hold the bone together. For reasons of bone maturity however, tibial spine avulsion fractures where the ACL remains intact, typically occur in children but are rare in adults. This case demonstrates a rare type of adult tibial avulsion fracture with intact ACL and subsequent fragment fixation failure in which vitamin D deficiency may have been contributory. Because there is a high rate of inadequate vitamin D levels in patients undergoing orthopaedic surgery and a known impact on bone healing complications, post-operative bone fixation failure may also occur. This case report may therefore prompt further awareness for considering pre-surgical vitamin D deficiency screening in adults presenting with rare avulsion fractures, and may further demonstrate its impact on surgical outcomes. PMID:24876463
Adanır, Oktay; Yüksel, Serdar; Beytemur, Ozan; Güleç, M Akif
Combination of the Galeazzi fracture and dislocation of the elbow joint in same extremity is very rare. In this article, we report a 26-year-old male patient with a posterolateral dislocation of the elbow and ipsilateral volar type Galeazzi fracture. We performed closed reduction for the elbow dislocation during admission to the emergency department. Patient was taken to the operating room in the sixth hour of his application to emergency department and open wound on the ulnovolar region of the wrist was closed primarily after irrigation and debridement. We performed open reduction and internal fixation of the radial fracture with a dynamic compression plate. After fixation, we evaluated the stability of the elbow joint and distal radioulnar joint. Distal radioulnar joint was unstable under fluoroscopic examination and fixed with one 1.8 mm Kirschner wire in a pronated position. Then, elbow joint was stable. One year after surgery, patient had no pain or sings of instability. At the last follow-up, range of motion of the elbow was 10°-135° and forearm pronation and supination were 70°.
El-Mowafi, Hani; El-Hawary, Ahmed; Kandil, Yasser
Pilon fractures usually result from high energy trauma, and are commonly associated with extensive soft tissue damage which prevents the use of open reduction and internal fixation. This study was designed to evaluate the use of the Ilizarov external fixator in the treatment of pilon fractures of the ankle, and to determine whether arthroscopy of the ankle could improve the outcome. From February 2011 to May 2013 a total of 23 patients with unilateral closed pilon fractures were divided into two groups treated with and without arthroscopy during fixation with the Ilizarov external fixator. The fractures were classified according to the AO Rüdi and Allgőwer classification. Follow up ranged from 10 to 37 months with a mean of 18 months. All cases were evaluated at follow up by the AOFAS and the Bone et al. grading system. According to Bone et al. there were 3 cases excellent, 4 cases good, 2 cases fair, and 2 cases poor in Group A (without arthroscopy), whereas there were 4 cases excellent, 6 cases good, 2 cases fair in Group B (with arthroscopy). The AOFAS score for Group A was 77.8±5.8, and for Group B was 78.4±6.9. We concluded that the Ilizarov external fixator is an excellent method in treating pilon fractures as it minimizes the need for extensive surgery. We also conclude that the use of arthroscopy during pilon fracture fixation did not add statistically significant improvement to our results and it needs longer term investigation to assess its advantage - if any - to the final outcome. level 2. Copyright © 2015 Elsevier Ltd. All rights reserved.
Agneskirchner, J D; Freiling, D; Hurschler, C; Lobenhoffer, P
Since a significant number of implant failures have been reported in association with the procedure of open wedge valgus high tibial osteotomy, the initial biomechanical stability of different fixation devices was investigated in this study. Fifteen third generation Sawbones composite tibiae were used as a model. Four different plates were tested: a short spacer plate (OWO) (n = 4), a short spacer plate with multi-directional locking bolts (MSO) (n = 5), a prototype version of a long spacer plate with multi-directional locking bolts (MSOnew) (n = 2), and a long medial tibia plate fixator with locking bolts (MPF) (n = 4). All opening wedge osteotomies were performed by the same surgeon (PL) in a standardized fashion. Axial compression of the tibiae was performed using a materials testing machine under standardized alignment of the loading axis. Single load to failure tests as well as load-controlled cyclical failure tests were performed. The required force and cycles to failure were recorded. Osteotomy gap motion was measured using linear displacement transducers. Residual stability after failure of the opposite lateral cortex was analysed. Failure occurred at the lateral cortex bone-bride in all tested implants. The rigid long plate fixator (MPF) resisted the greatest amount of force (2,881 N) in the single load to failure tests. In the cyclical load-to-failure tests, the constructs with MPF resisted more than twice the amount of loading cycles when compared to the short spacer plates. The osteotomy gap motion was smallest in the MPF, with a reduction of the displacements of up to 65, 66 and 88%, when compared to OWO, MSO and MSOnew, respectively. The highest residual stability after failure of the lateral cortex was observed in MPF as well. The results suggest that the implant design strongly influences the primary stability of medial opening wedge tibial osteotomy. A rigid long plate fixator with angle-stable locking bolts yields the best results.
effects of load carriage on running characteristics and tibial mechanical stress: implications for stress-fracture injuries in women Chun Xu1, Amy Silder2...kinematics and kinetics of the body, as well as the tibial mechanical stress during running. We also compared the biomechanics of walking (studied...running with load carriage. More importantly, our results underscore the need to incorporate the cumulative effect of mechanical stress when evaluating
Marsh, J L; Muehling, V; Dirschl, D; Hurwitz, S; Brown, T D; Nepola, J
Assess whether postoperative ankle motion after fixation of a fracture of the tibial plafond, treated with articulated external fixation, leads to a better outcome when compared with similar treatment without postoperative ankle motion. Multicenter randomized trial. Three Level I trauma centers. Fifty-five patients were enrolled and entered into a Web-based database and randomized into 1 of 2 groups. Forty-one patients were evaluated at a 1-year follow-up visit, and 31 were seen at 2 years or longer after injury. Patients were treated with a hinged external fixator and limited internal fixation of the articular surface. They were divided postoperatively into two groups, 1 of which had a locked hinge and the other had a mobile hinge and a motion protocol. A general health status questionnaire, the SF-36 (short-form 36); a joint-specific ankle questionnaire, the Ankle Osteoarthritis Score (AOS); and range of motion (ROM) of the ankle joint. There were no significant differences between the two groups at either follow-up interval in the ankle ROM measurement, the AOS pain and disability scale, or the SF-36 physical component summary (PCS) and mental component summary (MCS) scales. These results indicate that treatment protocols that use long periods of cross-joint external fixation that immobilizes the ankle as definitive treatment result in similar patient outcomes compared to otherwise identical treatment protocols that incorporate and use an articulated hinge for ankle motion. However, the results should be interpreted with caution because the patient numbers were too small to detect potentially meaningful differences in outcomes and the follow-up was too short to assess for differences in the development of arthrosis.
Han, Seung-Beom; Bae, Ji-Hoon; Lee, Sung-Jae; Jung, Tae-Gon; Kim, Kang-Hee; Kwon, Jae Ho
Purpose The purpose of this study was to evaluate the biomechanical properties of a new anatomical locking metal block plate by comparing the initial biomechanical stability of three different fixation constructs for open wedge high tibial osteotomy (HTO). Materials and Methods Sawbones composite tibiae were used to make a 10-mm opening osteotomy model with uniplane technique. The osteotomy was secured with three different types of plates: Group I, new osteotomy plate without a metal block (n=5); Group II, new osteotomy plate with a 10-mm metal block (n=5); and Group III, two short metal block plates (n=5). Single load to failure test and staircase load-controlled cyclical failure test were performed. In the single load to failure test, the yield load, maximum failure load, and the displacement of the osteotomy gap were measured. In the staircase cyclical load to failure test, the total number of cycles to failure was recorded. Failure modes were observed during both single and cyclic load tests. Results Group II showed the highest yield and ultimate loads (1829±319 N, 3493±1250 N) compared to Group I (1512±157 N, 2422±769 N) and Group III (1369±378 N, 2157±210 N, p<0.05). The displacement of the opening gap in Group II (0.34±0.35 mm) was significantly lesser than the other groups (p<0.05). In the staircase cyclical load to failure test, the total number of cycles to failure was 12,860 at 950 N in Group III, 20,280 at 1,140 N in Group I, and 42,816 at 1,330 N in Group II (p<0.05). All the specimens showed complete fracture of the intact lateral sawbones area and slight displacement of the distal fragment of the specimens in the single load to test. None of the specimens showed deformed or broken screws and plates during the single load to test. During the fatigue test with staircase cyclic loading, no fracture of the lateral sawbones area was observed. Conclusions This study demonstrated that the new anatomical locking metal block plate could provide
Background Theoretical considerations suggest that leg length increases after opening wedge high tibial osteotomy (HTO) and decreases after closing wedge HTO; however, in vivo studies have yielded conflicting results. This meta-analysis therefore assessed changes in leg length after opening wedge and closing wedge HTO. Methods All studies comparing pre- and postoperative leg length in patients who underwent opening and/or closing wedge HTO were included. Two reviewers independently recorded data from each study in terms of sample size as well as preoperative and postoperative leg length of open wedge and/or closed wedge HTO groups. Results Four studies were included in the meta-analysis. Although pooled results showed leg length changes from before to after surgery were –6.93 mm (95% confidence interval [CI]: –17.53 to 3.67 mm; P = 0.20) in opening wedge HTO and 1.97 mm (95% CI: –7.13 to 11.07 mm; P = 0.67) in closing wedge HTO, respectively, these values were statistically not significant. However, the difference in the pooled mean leg length change from before to after surgery between opening wedge and closing wedge HTO was 8 mm, a difference that was significant (95% CI: 6.53 to 9.46 mm; P<0.001). Conclusion The change in leg length was not statistically significant for either opening or closing wedge HTO. However, leg length change from before to after surgery was 8 mm greater for opening wedge HTO than for closing wedge HTO. PMID:28704523
Larsen, Peter; Laessoe, Uffe; Rasmussen, Sten; Graven-Nielsen, Thomas; Berre Eriksen, Christian; Elsoe, Rasmus
Despite the high number of studies evaluating the outcomes following tibial shaft fractures, the literature lacks studies including objective assessment of patients' recovery regarding gait pattern. The purpose of the present study was to evaluate whether gait patterns at 6 and 12 months post-operatively following intramedullary nailing of a tibial shaft fracture are different compared with a healthy reference population. The study design was a prospective cohort study. The primary outcome measurement was the gait patterns at 6 and 12 months post-operatively measured with a 6-metre-long pressure-sensitive mat. The mat registers footprints and present gait speed, cadence as well as temporal and spatial parameters of the gait cycle. Gait patterns were compared to a healthy reference population. 49 patients were included with a mean age of 43.1 years (18-79 years). Forty-three patients completed the 12-month follow-up (88%). Gait speed and cadence were significantly increased between the 6- and 12-month follow-up (P<0.001). At 6-month follow-up, patients showed considerable asymmetry in the injured leg compared with the non-injured leg: single-support time 12.8% shorter, swing-time 12.8% longer, step-length 11.9% shorter, and rotation of the foot increased by 32.3%. At the 12-month follow-up, gait asymmetry become almost normalized compared to a healthy reference group. In patients treated by intramedullary nailing following a tibial shaft fracture, gait asymmetry accompanied with slower speed and cadence are common during the first 6 months and become normalized compared with a healthy reference population between 6 and 12 months post-operatively. Copyright Â© 2016 Elsevier B.V. All rights reserved.
Briteño-Vázquez, M; Santillán-Díaz, G; González-Pérez, M; Gallego-Izquierdo, T; Pecos-Martín, D; Plaza-Manzano, G; Romero-Franco, N
The objective of this study is to analyze the effectiveness of low power laser irradiation in the bone consolidation of tibial fractures in rats. An experimental, comparative, prospective study with control group was designed. Twenty Wistar rats were grouped into control (n = 10) and experimental groups (n = 10). A tibial fracture, with a mechanical drill, was inflicted in all rats. The experimental group received ten days of low power arsenide-gallium laser irradiation of 850 nm (KLD, Sao Paulo, Brasil)-100 mW, 8 J/cm(2), 64 s. Before and after the laser treatment, a radiologic analysis was carried out in both groups, in which the rats were graded from 0 to IV according the Montoya scale of bone consolidation. Also, we histopathologically analyzed the bone to estimate the proliferation of fibroblasts, bone matrix, and angiogénesis with a microscopy, which were graded as I (thin layer of fibroblasts and osteoid matrix), II (thick layer of fibroblasts and osteoid matrix), or III (thick layer of fibroblasts and osteoid matrix and new blood vessels). Radiologic data showed that the experimental group had a higher bone consolidation of Montoya scale after ten days of laser irradiation compared to control group (P < 0.004). Histopathologic data showed more fibroblasts and angiogenesis presence in the group receiving laser irradiation, compared to control group (P < .002). The low power laser radiation therapy may expedite the bone repair after tibial fractures in rats, according to radiologic and histopathologic analysis.
Barnes, D; McDowell, D
Between May 2001 to August 2004, 35 patients had open nailing of long bones. There were 40 fractures fixed. Of these 40 fractures, there were 25 femoral fractures, 11 were tibial fractures and 4 were humeral fractures. There were 33 (82.5%) closed fractures and 7 (17.5%) open fractures. In the group of patients with open fractures, there were two Grade I, two Grade II and three Grade IIIB. Seven (20%) patients were lost to follow-up; all of whom had closed fractures. The final analysis as it relates to complications was done using 28 patients with 32 fractures. The majority of fractures healed without significant complication. All the patients with closed fractures went on to bony union. There was one non-union and three delayed unions. There were two infections (osteomyelitis) and this was from the open fracture cohort. This represents an infection rate of 28.6% in this cohort. Two (7.0%) patients had persistent pain and one (3.6%) patient had early removal of the nail because of failure of fixation. The mean time from injury to surgery for the fractured femur was 15.5 (range 0-49) days; fractured tibia 24.4 (range 0-40), days and fractured humerus 41.5 (20-81) days. The mean hospital stay was 18.9 (range 9-37) days for patients with fractured femur; for fractured tibia, it was 20.5 (range 3-82) days and for fractured humerus, it was 22.7 (range 3-82) days. The mean postoperative stay was 4.1 (range 1-14) days for fractured femur, 4.5 (range 1-14) days for fractured tibia and 4.0 (range 1-10) days for fractured humerus. The mean time to healing (consolidation) as defined by X-rays was 5.0 (range 3-11) months for fractured femur 5.2 (range 3-11) months for tibia and 7.0 (range 6-8) months for fractured humerus.
Ogawa, Hiroyasu; Matsumoto, Kazu; Ogawa, Takahiro; Takeuchi, Kentaro; Akiyama, Haruhiko
Medial opening wedge high tibial osteotomy (HTO) is a realignment of the lower limb. Despite accurate preoperative planning and careful surgical techniques, many HTOs result in alignment correction errors. These alignment correction errors may be due to soft tissue laxity around the knee such as varus or valgus laxity. The purpose of this study was to examine the relationship of varus and valgus laxity of the knee and alignment correction errors, and to have a formula to predict the subsequent degree of these correction errors. Fifty knees from 41 patients undergoing opening wedge HTO for knee osteoarthritis were involved. Standing full-length anteroposterior radiographs of the lower limb and the tibia, and varus and valgus stress radiographs of the knee were used to evaluate alignment and joint laxity. Parameters were global correction (the change in the hip-knee-ankle angle), bony correction (the change in the medial proximal tibial angle), and soft tissue correction (global correction - bony correction). The average of global correction, bony correction, and soft tissue correction were 12.8° ± 4.3°, 9.4° ± 3.2°, and 3.4° ± 2.5°, respectively. Preoperative varus laxity was moderately correlated with soft tissue correction (R = 0.58), and in which the slope of the line in the scatter plot represented 0.59, implying that soft tissue correction increases by 0.59° for every 1° of preoperative varus laxity. Preoperative varus laxity is correlated with soft tissue correction, suggesting that more accurate alignment correction could be achieved by surgical planning taking into account preoperative varus laxity as a factor of soft tissue correction.
Jeong, Soon-Taek; Hwang, Sun-Chul; Kim, Dong-Hee; Nam, Dae-Cheol
We introduce a case of traumatic dislocation of the posterior tibial tendon with avulsion fracture of the medial malleolus in a 52-year-old female patient who was treated surgically with periosteal flap and suture anchor fixation. Based in the posteromedial ridge of the distal tibia, a quadrilateral periosteal flap was created and folded over the tendon, followed by fixation on the lateral aspect of the groove by use of multiple suture anchors. Clinical and radiological findings 25 months postoperatively showed well-preserved function of the ankle joint with stable tendon gliding.
Laubach, Stephen E.; Lamarche, Juliette; Gauthier, Bertand D. M.; Dunne, William M.
This issue of the Journal of Structural Geology titled Spatial arrangement of faults and opening-mode fractures explores a fundamental characteristic of fault and fracture arrays. The pattern of fault and opening-mode fracture positions in space defines structural heterogeneity and anisotropy in a rock volume, governs how faults and fractures affect fluid flow, and impacts our understanding of the initiation, propagation and interactions during the formation of fracture patterns. This special issue highlights recent progress with respect to characterizing and understanding the spatial arrangements of fault and fracture patterns, providing examples over a wide range of scales and structural settings.
Franzone, Jeanne M; Finkelstein, Mark S; Rogers, Kenneth J; Kruse, Richard W
Evaluation of the union of osteotomies and fractures in patients with osteogenesis imperfecta (OI) is a critical component of patient care. Studies of the OI patient population have so far used varied criteria to evaluate bony union. The radiographic union score for tibial fractures (RUST), which was subsequently revised to the modified RUST, is an objective standardized method of evaluating fracture healing. We sought to evaluate the reliability of the modified RUST in the setting of the tibias of patients with OI. Tibial radiographs of 30 patients with OI fractures, or osteotomies were scored by 3 observers on 2 separate occasions. Each of the 4 cortices was given a score (1=no callus, 2=callus present, 3=bridging callus, and 4=remodeled, fracture not visible) and the modified RUST is the sum of these scores (range, 4 to 16). The interobserver and intraobserver reliabilities were evaluated using intraclass coefficients (ICC) with 95% confidence intervals. The ICC representing the interobserver reliability for the first iteration of scores was 0.926 (0.864 to 0.962) and for the second series was 0.915 (0.845 to 0.957). The ICCs representing the intraobserver reliability for each of the 3 reviewers for the measurements in series 1 and 2 were 0.860 (0.707 to 0.934), 0.994 (0.986 to 0.997), and 0.974 (0.946 to 0.988). The modified RUST has excellent interobserver and intraobserver reliability in the setting of OI despite challenges related to the poor quality of the bone and its dysplastic nature. The application and routine use of the modified RUST in the OI population will help standardize our evaluation of osteotomy and fracture healing. Level III-retrospective study of nonconsecutive patients.
Cong, R J; Liu, J F; Jiang, Y; Dilixiati, Duolikun; Hou, X D; Zheng, L P
Objective: To explore the influence of the lower extremity abnormal alignment and the joint surface, and to explore the surgical skills. Methods: Twenty-two cases of tibial plateau Schatzker Ⅵ fracture internal fixation failure revision from January 2012 to January 2017 in Department of Orthopedics, Shanghai 10(th) Hospital.One year follow-up after initial surgery to make sure of failure.Three-dimensional CT scan, radiography, infection index, gait analysis, knee joint ROM, femur tibia angle, tibial plateau tibial shaft angle and posterior slope if tibial plateau were observed. The medial approach and bi-planer osteotoma were used.Autogenous iliac bone graft, postoperative fast recovery channel were used.Follow-up point included preoperative and postoperative 7 days, 6 weeks, 3 months, and 6 months.Obvervational index included double lower limbs radiography, knee society score(KSS), complications such as infection, skin necrosis, joint main passive activity, double lower limbs alignment the last follow-up SF-36 scale.Rate was compared by χ(2) test, measurement data using paired sample t test.Correlation was analyzed by Pearson correlation regression testing. Results: Twenty-two patients received follow-up.KSS, more than 21 cases were benign, with good gait.One case was poor, with claudication gait.Not skin necrosis, no deep infection cases, 1 case get blisters 2 days postoperatively, and disappear after 5 days with detumescence and cold therapy.Whether restoring force line affect the KSS significantly(χ(2)=22.000, P =0.000). Knee joint ROM, SF-36 score, KSS and lower limb alignment were improved significantly. In different individual the articular surface and anatomical angle recovered greatly but the posterior slope angle was quite difference which has no correlation with KSS and SF-36 scale( P >0.01). Conclusions: Revision of Schatzker type Ⅵ tibial plateau fracture failure should focus on the recovery of lower limb alignment.moderate overcorrect bone
Complex tibial fractures are associated with lower social classes and predict early exit from employment and worse patient-reported QOL: a prospective observational study of 46 complex tibial fractures treated with a ring fixator.
Elsoe, Rasmus; Larsen, Peter; Petruskevicius, Juozas; Kold, Søren
The long-term outcomes following complex fractures of the tibia are reported to carry a risk of knee pain, malalignment, articular injury and post-traumatic osteoarthritis. The main objective of this study was to account for the patient-reported quality of life (QOL) 12 months after ring fixator removal in patients with a complex tibial fracture. Secondary objectives included a review of the socio-economic characteristics of the patient group and the rate of return to work in the study period. A prospective follow-up study was conducted of 60 patients with complex fractures of the tibia treated with ring external fixation. Patient-reported outcomes, radiological outcomes and socio-economic status including employment status of the patients were obtained 12 months after frame removal. Forty-six patients completed the assessment 12 months after frame removal (77%). The mean age of the patient at the time of fracture was 54.6 years (range 31-86). There were 19 males and 27 females. At 12 months after frame removal, the mean EQ5D-5L index was 0.66 (CI 0.60-0.72). The mean EQ5D-5L VAS was 69 (CI 61-76). When this was compared to the established reference population from Denmark, the study population showed a significantly worse EQ5D-5L index. The majority of patients (87%) were in the lower social classes suggesting a higher degree of social deprivation in the study population. Twenty-seven per cent of patients who were employed prior to injury had returned to employment at approximately 19 months following fracture. The onset of post-traumatic osteoarthritis was present in the knee joint in 29% of patients following a proximal intra-articular fracture, whereas osteoarthritis was present at the ankle joint in 35% of patients following a distal intra-articular fracture 12 months after frame removal. This study indicates that at 12 months after frame removal there are poorer patient-reported QOL as when compared to reference populations. Furthermore, this study
Pérez-Mañanes, Rubén; Burró, Juan Arnal; Manaute, Jose Rojo; Rodriguez, Francisco Chana; Martín, Javier Vaquero
Opening wedge osteotomy has recently gained popularity, thanks to the recent implementation of locking plates, which have shown equivalent stability with greater reproducibility, accuracy, and longevity than the closing wedge techniques and a lower prosthetic conversion rate. We present a new "do-it-yourself" cutting guides system for tibial opening osteotomy. Using a conventional computed tomography digital image, a positioning guide and wedge spacers were printed in three dimensions (3D) for implementing the osteotomy and obtaining the planned correction. The surgeon makes the whole process in a do-it-yourself style. This new technique was used in eight cases. Previous opening osteotomies with the standard technique were used as control (20 cases). Surgical time, fluoroscopic time, and accuracy of the axial correction were measured. The use of a custom positioning guide reduced the surgical (31 minutes less) and fluoroscopic times (6.9 times less) while achieving a high-axis correction accuracy compared with the standard technique. Digitally planned and executed osteotomies under 3D printed osteotomy positioning guides help the surgeon to minimize human error while reducing surgical time. The reproducibility of this technique is very robust, allowing a transfer of the steps planned in a virtual environment to the operating table. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Tan, Hong-Lue; Dai, Peng-Yi; Liu, Wei-Feng; Yuan, Yan-Hao
To explore the clinical efficacy of double-plate fixation for the treatment of old tibial plateau fractures with Schatzker type IV through anterior midline and posteromedial approaches. From July 2013 to July 2015, 15 patients with old tibial plateau fractures were treated with internal fixation using locking reconstructive plate for the posteromedial fragment and anatomical locking plate for anteromedial fragment through antero midline and posteromedial approaches. There were 9 males and 6 females, with an average age of 49.2 years old (ranged, 21 to 61 years old). Eight patients had injured in the left side and 7 in the right side. According to Schatzker classification, all patients were type IV. The mean interval from injury to operation was 26.5 days (ranged, 21 to 65 days). The main clinical symptoms before operation were knee joint swelling, pain, deformity and limitation of motion. The X-ray and CT confirmed the fracture type. The indexes such as tibial plateau tibial shaft angle (TPA), femoral tibial angle (FTA) and posterior slope angle (PSA) were compared between immediate postoperation and final follow-up using postoperative X-ray film. The knee functions were evaluated using the HSS (Hospital for Special Surgery) knee score system. Two patients had incision complications which healed by correct treatment, 1 patient had traumatic arthritis. All patients were followed up for mean 16.6 months (ranged, 13 to 24 months). No infections, deep venous thrombosis, implant loosening and breakage, fragment displacement, plateau surface collapse and bone nonunion found. The bone union time ranged from 3 to 8 months (mean 6.07 months) after operation. The average immediate postoperative value of TPA, FTA and PSA were(86.81±1.67)°, (168.00±3.29)° and(10.20±1.47)° respectively; and(86.47±1.67)°, (168.53±3.03)° and (10.54±1.21)° respectively at the final follow-up evaluation, showing no statistical differences( P >0.05). According to the HSS score system, 26
Aurich, Matthias; Koenig, Veit; Hofmann, Gunther
Posttraumatic osteoarthritis (PTOA) of the knee is a common complication after intra- and extra-articular fractures. Moreover, PTOA may also be a result of isolated cartilage defects, meniscus resections, and ligament injuries. There are various methods of treatment of knee joint fractures. However, in the final stage of a PTOA, when nonoperative treatment fails, endoprosthetic joint replacement is the method of choice. Primary total knee replacement (TKR) for the treatment for a fracture of the knee joint is a rare indication, even at major treatment centers. It is performed in elderly patients with the inability to be mobilized with partial- or non-weight bearing; in cases with considerable bone destruction; in cases with symptomatic osteoarthritis (OA) in the elderly; and, it is often associated with the primary use of a modular implant. However, TKR in the acute situation should always be an individual decision. Secondary TKR after knee joint fracture shows overall good functional results. However, the results are inferior when compared with TKR for primary OA. In addition, the complication rates of TKR for PTOA are much higher. Problems with the extensor mechanism after tibial plateau fractures are common. There are also problems caused by preexisting scars, nonunion (possibly due to a low grade infection), malalignment, restricted movement, or instability. Copyright © 2017. Published by Elsevier Taiwan.
Brady, Rhys D; Grills, Brian L; Church, Jarrod E; Walsh, Nicole C; McDonald, Aaron C; Agoston, Denes V; Sun, Mujun; O'Brien, Terence J; Shultz, Sandy R; McDonald, Stuart J
Concomitant traumatic brain injury (TBI) and long bone fracture are commonly observed in multitrauma and polytrauma. Despite clinical observations of enhanced bone healing in patients with TBI, the relationship between TBI and fracture healing remains poorly understood, with clinical data limited by the presence of several confounding variables. Here we developed a novel trauma model featuring closed-skull weight-drop TBI and concomitant tibial fracture in order to investigate the effect of TBI on fracture healing. Male mice were assigned into Fracture + Sham TBI (FX) or Fracture + TBI (MULTI) groups and sacrificed at 21 and 35 days post-injury for analysis of healing fractures by micro computed tomography (μCT) and histomorphometry. μCT analysis revealed calluses from MULTI mice had a greater bone and total tissue volume, and displayed higher mean polar moment of inertia when compared to calluses from FX mice at 21 days post-injury. Histomorphometric results demonstrated an increased amount of trabecular bone in MULTI calluses at 21 days post-injury. These findings indicate that closed head TBI results in calluses that are larger in size and have an increased bone volume, which is consistent with the notion that TBI induces the formation of a more robust callus.
Wang, Tie-Jun; Ju, Wei-Na; Qi, Bao-Chang
Abstract Rationale: Anatomical characteristics, such as subcutaneous position and minimal muscle cover, contribute to the complexity of fractures of the distal third of the tibia and fibula. Severe damage to soft tissue and instability ensure high risk of delayed bone union and wound complications such as nonunion, infection, and necrosis. Patient concerns: This case report discusses management in a 54-year-old woman who sustained fractures of the distal third of the left tibia and fibula, with damage to overlying soft tissue (swelling and blisters). Plating is accepted as the first choice for this type of fracture as it ensures accurate reduction and rigid fixation, but it increases the risk of complications. Diagnosis: Closed fracture of the distal third of the left tibia and fibula (AO: 43-A3). Interventions: After the swelling was alleviated, the patient underwent closed reduction and fixation with an Acumed fibular nail and minimally invasive plating osteosynthesis (MIPO), ensuring a smaller incision and minimal soft-tissue dissection. Outcomes: At the 1-year follow-up, the patient had recovered well and had regained satisfactory function in the treated limb. The Kofoed score of the left ankle was 95. Lessons: Based on the experience from this case, the operation can be undertaken safely when the swelling has been alleviated. The minimal invasive technique represents the best approach. Considering the merits and good outcome in this case, we recommend the Acumed fibular nail and MIPO technique for treatment of distal tibial and fibular fractures. PMID:28328865
Blanke, F; Loew, S; Ferrat, P; Valderrabano, V; Ochsner, P E; Majewski, M
Open ankle dislocation fractures are one of the most severe injuries of the ankle. Development of posttraumatic arthrosis is well known. However, there are just a few case reports describing evidence of posttraumatic osteonecrosis (PON) of distal tibia. The pathophysiological mechanism remains unclear and the question of morphologic or personal risk factors cannot be answered. The goal of this study was to evaluate the morphologic characteristics of open dislocated ankle fractures in correlation with the development of PON to facilitate early identification of patients with higher risk of posttraumatic osteonecrosis. In this study data from 28 patients with open dislocation fractures of the ankle between 1975 and 2006 found at our databases were evaluated retrospectively. For each patient we documented personal data, mechanism of injury, type of lateral malleolar fracture, severity of open fracture, degree of tibiotalar dislocation, presence of medial malleolar fracture, presence of deltoid ligament rupture, time until joint reduction and kind of surgical treatment. We also documented clinical complications and number of surgeries. Presence of PON was examined by radiographs, magnetic resonance imaging (MRI) or histological analysis. Within 12 out of 28 patients with open ankle dislocation fractures a PON of the distal tibia could be found. Nine out of 15 patients with high-energy trauma and 12 out of 19 patients with type C fibular fracture developed PON. 73% of male patients and 88% of the patients with type III soft tissue damage according to Gustillo developed PON. However, if patients suffered from type C fibular fracture, total talus dislocation and grade III soft tissue damage ("necrotic triad") PON was developed in 100% of cases. Other patient's characteristics like late joint reduction, postoperative infection or bimalleolar fracture showed no higher proportion of patients with PON. In this study we were able to identify clinical manifestations and risk
Swenson, E J; DeHaven, K E; Sebastianelli, W J; Hanks, G; Kalenak, A; Lynch, J M
A total of 18 competitive and recreational athletes were enrolled in a randomized, prospective study looking at the effect of pneumatic leg braces on the time to return to full activity after a tibial stress fracture. All patients had positive bone scans and 15 had positive radiographic findings by Week 12. There were two treatment groups. The traditional treatment group was treated with rest and, after 3 pain-free days, a gradual return to activity. The pneumatic leg brace (Aircast) group had the brace applied to the affected leg and then followed the same return to activity guidelines. The guidelines consisted of a detailed functional progression that allowed pain-free return to play. The brace group was able to resume light activity in 7 days (median) and the traditional group began light activity in 21 days (median). The brace group returned to full, unrestricted activity in 21 +/- 2 days, and the traditional group required 77 +/- 7 days to resume full activity. The Aircast pneumatic brace is effective in allowing athletes with tibial stress fractures to return to full, unrestricted, pain-free activity significantly sooner than traditional treatment.
Daolagupu, Arup K; Mudgal, Ashwani; Agarwala, Vikash; Dutta, Kaushik K
Extraarticular distal tibial fractures are among the most challenging fractures encountered by an orthopedician for treatment because of its subcutaneous location, poor blood supply and decreased muscular cover anteriorly, complications such as delayed union, nonunion, wound infection, and wound dehiscence are often seen as a great challenge to the surgeon. Minimally invasive plate osteosynthesis (MIPO) and intramedullary interlocking nail (IMLN) are two well-accepted and effective methods, but each has been historically related to complications. This study compares clinical and radiological outcome in extraarticular distal tibia fractures treated by intramedullary interlocking nail (IMLN) and minimally invasive plate osteosynthesis (MIPO). 42 patients included in this study, 21 underwent IMLN and 21 were treated with MIPO who met the inclusion criteria and operated between June 2014 and May 2015. Patients were followed up for clinical and radiological evaluation. In IMLN group, average union time was 18.26 weeks compared to 21.70 weeks in plating group which was significant ( P < 0.0001). Average time required for partial and full weight bearing in the nailing group was 4.95 weeks and 10.09 weeks respectively which was significantly less ( P < 0.0001) as compared to 6.90 weeks and 13.38 weeks in the plating group. Lesser complications in terms of implant irritation, ankle stiffness, and infection, were seen in interlocking group as compared to plating group. Average functional outcome according to American Orthopedic Foot and Ankle Society score was measured which came out to be 96.67. IMLN group was associated with lesser duration of surgery, earlier weight bearing and union rate, lesser incidence of infection and implant irritation which makes it a preferable choice for fixation of extra-articular distal tibial fractures. However, larger randomized controlled trials are required for confirming the results.
Atef, Ashraf; El Tantawy, Ahmad
The treatment of open and unstable metaphyseo-diaphyseal fractures of the tibia in adolescents is challenging. It is important to choose a fixation method that can maintain alignment, allow wound care and not violate the growth plate. The aim of this work was to evaluate the efficacy of using flexible intramedullary nails (FIN) augmented by external fixator (EF) in the management of such fractures. A total of 26 males, with a mean age of 14.08 years and average body weight of 49.8 kg, presented with open metaphyseo-diaphyseal tibial fractures. All cases were treated using FIN augmented by mono-lateral EF. The fractures were located at the upper third in 17 cases and at the lower third in nine cases. The fracture pattern was spiral in eight cases, oblique in seven and multi-fragmentary in 11. The results were evaluated according to the scoring system for femoral TENs. All fractures united primarily after an average eight to 12 weeks with no evident angular deformity or limb-length discrepancy. None of the cases required cast immobilization or revision procedure. Twenty patients had excellent results, six patients showed good results and none had poor results. Fracture characteristics as well as patients' characteristics had no statistically significant effect (p > 0.005) on the final end results. The use of FIN augmented by EF is a good alternative in the management of open metaphyseo-diaphyseal tibial fractures in adolescents. This fixation provides more stability, allows easy access to the wound and early patients' ambulation.
Crowley, D J; Kanakaris, N K; Giannoudis, P V
Modern principles for the treatment of open fractures include stabilisation of the bone and management of the soft tissues. Wound debridement and irrigation is thought to be the mainstay in reducing the incidence of infection. Although numerous studies on animals and humans have focused on the type of irrigation performed, little is known of the factors which influence irrigation. This paper evaluates the evidence, particularly with regard to additives and the mode of delivery of irrigation fluid. Normal saline should be used and although many antiseptics and antibiotics have been employed, no consensus has been reached as to the ideal additive. Despite the advocates of high-pressure methods highlighting the improved dilutional ability of such techniques, the results are inconclusive and these irrigation systems are not without complications. New systems for debridement are currently being investigated, and an ideal method has yet to be determined.
Xu, Guo-hui; Liu, Bo; Zhang, Qi; Wang, Juan; Chen, Wei; Liu, Yue-ju; Peng, A-qin; Zhang, Ying-ze
The purpose of this study was to compare monotonic biomechanical properties of gourd-shaped LCP fixation with LCP fixation of human tibial shaft in gap fracture mode. Twenty paired fresh cadaveric human tibias were randomly divided into 4 groups (5 pairs each): (1) axial loading single cycle to failure testing, (2) torsion single cycle to failure testing, (3) 4-point bending single cycle to failure testing, and (4) dynamic 4-point bending testing. A 7-hole 4.5 mm gourd-shaped LCP was secured on the anteromedial surface of 1 randomly selected bone from each pair, respectively, using 6 locking screws in the 1st, 2nd, 3rd, 5th, 6th and 7th hole with the middle hole unfilled and just located at the mid-diaphysis of the tibia. A 7-hole 4.5 mm LCP was secured on the other bone with the same method. Standard AO/ASIF techniques were used. After fixation finished, a 10 mm gap in the mid-diaphysis of tibia was created, centrally located at the unfilled hole. The axial, torsional, and bending stiffness and failure strengths were calculated from the collected data in static testings and statistically compared using paired Student's t-test. The 4-point bending fatigue lives of the two constructs were calculated from the dynamic testing data and also statistically compared using paired Student's t-test. Failure modes were recorded and visually analyzed. P<0.05 was considered significant. Results showed that the axial, torsional and bending stiffness of gourd-shaped LCP construct was greater (4%, 19%, 12%, respectively, P<0.05) than that of the LCP construct, and the axial, torsional and bending failure strengths of gourd-shaped LCP construct were stronger (10%, 46%, 29%, respectively, P<0.05) than those of the LCP construct. Both constructs failed as a result of plate plastic torsional deformation. After axial loading and 4-point bending testings, LCP failed in term of an obvious deformation of bent apex just at the unfilled plate hole, while the gourd-shaped LCP failed in term
Ziegler, Raphaela; Goebel, Lars; Cucchiarini, Magali; Pape, Dietrich; Madry, Henning
To evaluate whether medial open wedge high tibial osteotomy (HTO) results in structural changes in the articular cartilage in the lateral tibiofemoral compartment of adult sheep. Three experimental groups received biplanar osteotomies of the right proximal tibiae: (a) closing wedge HTO (4.5° of tibial varus), (b) opening wedge HTO (4.5° tibial valgus; standard correction), and (c) opening wedge HTO (9.5° of valgus; overcorrection), each of which was compared to the contralateral knees that only received an arthrotomy. After 6 months, the macroscopic and microscopic characteristics of the articular cartilage of the lateral tibiofemoral compartment were assessed. The articular cartilage in the central region of the lateral tibial plateau in sheep had a higher safranin O staining intensity and was 4.6-fold thicker than in the periphery (covered by the lateral meniscus). No topographical variation in the type-II collagen immunoreactivity was seen. All lateral tibial plateaus showed osteoarthritic changes in regions not covered by the lateral meniscus. No osteoarthritis was seen in the peripheral submeniscal regions of the lateral tibial plateau and the lateral femoral condyle. Opening wedge HTO resulting in both standard and overcorrection was not associated with significant macroscopic and microscopic structural changes between groups in the articular cartilage of the lateral tibial plateau and femoral condyle after 6 months in vivo. Opening wedge HTO resulting in both standard and overcorrection is a safe procedure for the articular cartilage in an intact lateral tibiofemoral compartment of adult sheep at 6 months postoperatively.
Oznur, Ali; Marangoz, Salih; Tasatan, Ersin; Alparslan, Mümtaz; Atesalp, Ali Sabri
The treatment protocol of closed calcaneal fractures has been described in the literature extensively. However, treatment of open calcaneal fractures has not been discussed in detail. Various treatment alternatives have been suggested including external fixator, primary subtalar distraction arthrodesis, and partial calcanectomy according to the type of fracture. We have retrospectively reviewed 36 adult patients with 39 open calcaneal fractures who were treated with our new philosophy. Average follow-up time was 9.29 years (range, 1.25–28 years). The American Orthopaedic Foot and Ankle Society (AOFAS) scoring system was used in functional evaluation. The average score was 77.9 (range, 67–92). All of the patients had limited subtalar movement. We propose an algorithm for the management of open calcaneus fractures, although treatment largely depends on the physical status of the patient, type of the fracture, localisation of the open wound and the surgeon’s choice. PMID:17581751
Li, Jiaming; Wang, Decheng; He, Zhiliang; Shi, Hao
To determine the efficacy of modified titanium tension band plus patellar tendon tunnel steel 8 "reduction band" versus titanium cable tension band fixation for the treatment of patellar lower pole fracture. 58 patients with lower patella fracture were enrolled in this study, including 30 patients treated with modified titanium cable tension band plus patellar tibial tunnel wire "8" tension band internal fixation (modified group), and 28 patients with titanium cable tension band fixation. All patients were followed up for 9∼15 months with an average of 11.6 months. Knee flexion was significantly improved in the modified group than in the titanium cable tension band group (111.33 ± 13 degrees versus 98.21 ± 21.70 degrees, P = 0.004). The fracture healing time showed no significant difference. At the end of the follow-up, the improvement excellent rate was 93.33% in the modified group, and 82.14% in the titanium cable tension band group. Titanium cable tension band internal fixation loosening was found in 2 cases, including 1 case of treatment by two surgeries without loose internal fixation. The modified titanium cable tension band with "8" tension band fixation showed better efficacy for lower patella fractures than titanium cable tension band fixation.
Laubach, S. E.; Lamarche, J.; Gauthier, B. D. M.; Dunne, W. M.; Sanderson, David J.
Spatial arrangement is a fundamental characteristic of fracture arrays. The pattern of fault and opening-mode fracture positions in space defines structural heterogeneity and anisotropy in a rock volume, governs how faults and fractures affect fluid flow, and impacts our understanding of the initiation, propagation and interactions during the formation of fracture patterns. This special issue highlights recent progress with respect to characterizing and understanding the spatial arrangements of fault and fracture patterns, providing examples over a wide range of scales and structural settings. Five papers describe new methods and improvements of existing techniques to quantify spatial arrangement. One study unravels the time evolution of opening-mode fracture spatial arrangement, which are data needed to compare natural patterns with progressive fracture growth in kinematic and mechanical models. Three papers investigate the role of evolving diagenesis in localizing fractures by mechanical stratigraphy and nine discuss opening-mode fracture spatial arrangement. Two papers show the relevance of complex cluster patterns to unconventional reservoirs through examples of fractures in tight gas sandstone horizontal wells, and a study of fracture arrangement in shale. Four papers demonstrate the roles of folds in fracture localization and the development spatial patterns. One paper models along-fault friction and fluid pressure and their effects on fault-related fracture arrangement. Contributions address deformation band patterns in carbonate rocks and fault size and arrangement above a detachment fault. Three papers describe fault and fracture arrangements in basement terrains, and three document fracture patterns in shale. This collection of papers points toward improvement in field methods, continuing improvements in computer-based data analysis and creation of synthetic fracture patterns, and opportunities for further understanding fault and fracture attributes in
Lin, Wang; Su, Yu; Lin, ChenShou; Guo, WeiZhong; Wu, JinQing; Wang, YingYing; Zhang, ShenShen; Liu, ShouKun; Liu, Wen; Chen, Lian
The purpose of this study was to describe the operative procedures and clinical outcomes of a new three-column internal fixation system with anatomical locking plates on the tibial plateau to treat complex three-column fractures of the tibial plateau. From June 2011 to May 2015, 14 patients with complex three-column fractures of the tibial plateau were treated with reduction and internal fixation through an anterolateral approach combined with a posteromedial approach. The patients were randomly divided into two groups: a control group which included seven cases using common locking plates, and an experimental group which included seven cases with a new three-column internal fixation system with anatomical locking plates. The mean operation time of the control group was 280.7 ± 53.7 minutes, which was 215.0 ± 49.1 minutes in the experimental group. The mean intra-operative blood loss of the control group was 692.8 ± 183.5 ml, which was 471.4 ± 138.0 ml in the experimental group. The difference was statistically significant between the two groups above. The differences were not statistically significant between the following mean numbers of the two groups: Rasmussen score immediately after operation; active extension-flexion degrees of knee joint at three and 12 months post-operatively; tibial plateau varus angle (TPA) and posterior slope angle (PA) immediately after operation, at three and at 12 months post-operatively; HSS (The Hospital for Special Surgery) knee-rating score at 12 months post-operatively. All fractures healed. A three-column internal fixation system with anatomical locking plates on tibial plateau is an effective and safe tool to treat complex three-column fractures of the tibial plateau and it is more convenient than the common plate.
Lee, Do Kyung; Kim, Kwang Kyoun; Ham, Chang Uk; Yun, Seok Tae; Kim, Byung Kag; Oh, Kwang Jun
The purpose of this study was to investigate whether surgical experience could improve surgical competency in medial open wedge high tibial osteotomy (MOWHTO). One hundred consecutive cases of MOWHTO were performed with preoperative planning using the Miniaci method. Surgical errors were defined as under- or overcorrection, excessive posterior slope change, or the presence of a lateral hinge fracture. Each of these treatment failures was separately evaluated using the cumulative summation test for learning curve (LC-CUSUM). The LC-CUSUM showed competency in prevention of undercorrection, excessive posterior slope change, and lateral hinge fracture after 27, 47, and 42 procedures, respectively. However, the LC-CUSUM did not signal achievement of competency in prevention of overcorrection after 100 procedures. Furthermore, the failure rate for overcorrection showed an increasing tendency as surgical experience increased. Surgical experience may improve the surgeon's competency in prevention of undercorrection, excessive posterior slope change, and lateral hinge fracture. However, it may not help reduce the incidence of overcorrection even after performance of 100 cases of MOWHTO over a period of 6 years.
Roussignol, X; Gauthe, R; Rahali, S; Mandereau, C; Courage, O; Duparc, F
Arthroscopic treatment of tears in the middle and posterior parts of the medial meniscus can be difficult when the medial tibiofemoral compartment is tight. Passage of the instruments may damage the cartilage. The primary objective of this cadaver study was to perform an arthroscopic evaluation of medial tibiofemoral compartment opening after pie-crusting release (PCR) of the superficial medial collateral ligament (sMCL) at its distal insertion on the tibia. The secondary objective was to describe the anatomic relationships at the site of PCR (saphenous nerve, medial saphenous vein). We studied 10 cadaver knees with no history of invasive procedures. The femur was held in a vise with the knee flexed at 45°, and the medial aspect of the knee was dissected. PCR of the sMCL was performed under arthroscopic vision, in the anteroposterior direction, at the distal tibial insertion of the sMCL, along the lower edge of the tibial insertion of the semi-tendinosus tendon. Continuous 300-N valgus stress was applied to the ankle. Opening of the medial tibiofemoral compartment was measured arthroscopically using graduated palpation hooks after sequential PCR of the sMCL. The compartment opened by 1mm after release of the anterior third, 2.3mm after release of the anterior two-thirds, and 3.9mm after subtotal release. A femoral fracture occurred in 1 case, after completion of all measurements. Both the saphenous nerve and the medial saphenous vein were located at a distance from the PCR site in all 10 knees. PCR of the sMCL is chiefly described as a ligament-balancing method during total knee arthroplasty. This procedure is usually performed at the joint line, where it opens the compartment by 4-6mm at the most, with some degree of unpredictability. PCR of the sMCL at its distal tibial insertion provides gradual opening of the compartment, to a maximum value similar to that obtained with PCR at the joint space. The lower edge of the semi-tendinosus tendon is a valuable landmark
Joshi, Sachin; Bhatia, Chirag; Gondane, Ashwin; Rai, Avinash; Singh, Sumer; Gupta, Shobhit
The posterior cruciate ligament (PCL) presents commonly with avulsion fractures of its tibial attachment. An avulsion fracture of the PCL, if not surgically fixed, may lead to secondary changes in the knee joint. Various fixation techniques have been explored with use of lag screws, steel wires, absorbable screws, suture anchors and straddle nails. The purpose of this study was to evaluate the clinical and functional outcome of open reduction and internal fixation of tibial avulsion injuries of the PCL using cannulated cancellous screws. We performed open reduction and internal fixation using cannulated cancellous screws in 14 patients (mean age, 33.9 years) with isolated PCL avulsion injuries. Patients with a duration of injury more than 12 weeks were excluded. The minimum follow-up period was 12 months. Results were assessed radiologically and clinically. Final functional outcome was assessed using the Lysholm knee scoring system. The average follow-up period was 13.5 months. At the final follow-up, all 14 patients achieved fracture union. The average flexion was 121.7°±9.2° with full extension achieved in all patients. Mild instability (1+) was noted in 4 patients. The Lysholm functional score was excellent in 11 patients, good in 2 patients and fair in 1 patient with an average score of 97±7.6. Stable early fixation for PCL avulsion injuries with early controlled mobilization provided excellent to good results. However, fixation should not be discouraged for late-presenting patients because good to fair results can be achieved in such cases.
Akamatsu, Yasushi; Ohno, Satoshi; Kobayashi, Hideo; Kusayama, Yoshihiro; Kumagai, Ken; Saito, Tomoyuki
The coronal subluxation of the proximal tibia relative to the distal femur is a common radiological finding in patients with knee osteoarthritis. The purpose was to evaluate whether the coronal subluxation was corrected after opening wedge high tibial osteotomy (OWHTO), and whether this subluxation was one cause of inconsistency between the actual and predicted alignments (correction loss). Fifty-one patients (55 knees) were treated with OWHTO. The change of location between the intersection points of the femoral and tibial axes on the tibial plateau (subluxation-C), the change of location between the lines through the most lateral points of the lateral femoral and tibial condyles (subluxation-L), and joint space angle (JSA) were compared in standing knee radiographs before and one year after OWHTO. The subluxation-C and subluxation-L were converted to a percentage of the tibial plateau width. The mean subluxation-C of 6.5% before OWHTO significantly increased to a mean subluxation-C of 7.3% one year after OWHTO. The mean subluxation-L of 6.3% and JSA of 4.5° before OWHTO significantly decreased to a subluxation-L of 1.8% and JSA of 3.3° one year after OWHTO. The change in subluxation-L correlated with the change in femorotibial angle and correction loss (r=0.634, P<0.001 and r=0.463, P<0.001, respectively). The proximal tibia shifted medially relative to the distal femur after OWHTO. This medial shift correlated with the correction loss. The coronal subluxation might be one cause of correction loss. Copyright © 2016 Elsevier B.V. All rights reserved.
Perttunen, J R; Nieminen, H; Tukiainen, E; Kuokkanen, H; Asko-Seljavaara, S; Komi, P V
Gait patterns of the preferred speed were investigated on 17 patients recovering (9 months-14 years) after reconstruction of severe tibial fractures. A novel data-acquisition system was used to record the plantar pressures as well as electromyographic (EMG) activities during walking. The results indicated incomplete recovery of symmetrical gait patterns. In particular, the duration of the stance phase was shorter on the operated side (mean (SD) 701 (90) ms compared with 765 (128) ms, p < 0.001). The peak pressure points under the foot were different on bilateral comparison, the operated side being regularly higher under the lateral forefoot area. This may imply attempts to reduce the loading of the ankle joint during stance. The pressure distribution models reflected these asymmetrical patterns more specifically than the EMG activities of the lower leg muscles examined.
Watt, D A L; Grotz, M R W; Giannoudis, P V; Kay, S P J
Early, primary amputations are still necessary for certain patients sustaining high impact lower limb trauma. For cases with extensive proximal tibial bone loss a turn-up bone flap technique has been described to achieve a below-knee stump suitable for a prosthesis. However, in certain circumstances, for example if posterior soft tissues are injured, this type of reconstruction is not possible. This case report demonstrates that converting a severe open proximal tibial fracture to a successful below-knee amputation is also possible with acute limb shortening, flap cover and planned subsequent trans-tibial amputation.
Holmberg, Anna; Thórhallsdóttir, Valdís Gudrún; Robertsson, Otto; W-Dahl, Annette; Stefánsdóttir, Anna
Prosthetic joint infection (PJI) is a leading cause of early revision after total knee arthroplasty (TKA). Open debridement with exchange of tibial insert allows treatment of infection with retention of fixed components. We investigated the success rate of this procedure in the treatment of knee PJIs in a nationwide material, and determined whether the results were affected by microbiology, antibiotic treatment, or timing of debridement. 145 primary TKAs revised for the first time, due to infection, with debridement and exchange of the tibial insert were identified in the Swedish Knee Arthroplasty Register (SKAR). Staphylococcus aureus was the most common pathogen (37%) followed by coagulase-negative staphylococci (CNS) (23%). Failure was defined as death before the end of antibiotic treatment, revision of major components due to infection, life-long antibiotic treatment, or chronic infection. The overall healing rate was 75%. The type of infecting pathogen did not statistically significantly affect outcome. Staphylococcal infections treated without a combination of antibiotics including rifampin had a higher failure rate than those treated with rifampin (RR = 4, 95% CI: 2-10). In the 16 cases with more than 3 weeks of symptoms before treatment, the healing rate was 62%, as compared to 77% in the other cases (p = 0.2). The few patients with a revision model of prosthesis at primary operation had a high failure rate (5 of 8). Good results can be achieved by open debridement with exchange of tibial insert. It is important to use an antibiotic combination including rifampin in staphylococcal infections.
Arthur, Elizabeth G; Arthur, Gerald L; Keeler, Matthew R; Bryan, Jeffrey N
To critically evaluate whether open fracture fixation is a significant risk factor for latent osteosarcoma development. Case-control study. Dogs undergoing open fracture repair and dogs diagnosed with osteosarcoma. Records were retrieved from the Veterinary Medical Database VMDB (1970-2000) for dogs undergoing surgical repair of a fracture and dogs diagnosed with osteosarcoma. Dogs with open reduction of joint luxation, dogs diagnosed with bacterial cystitis, and dogs diagnosed with urinary bladder transitional cell carcinoma (UBTCC) were queried as comparison populations. Relative risk for osteosarcoma development was determined. From a population of 19,041 fractures treated surgically, 15 of those dogs subsequently appeared in the VMDB with osteosarcoma affecting the same bone. The relative risk of a fracture repair and associated orthopedic implants and osteosarcoma occurrence was equivalent to the relative risk of open joint reduction and osteosarcoma occurrence (95% confidence interval; 0.998-1.00). The relative risk of having bacterial cystitis and appearing again in the VMDB with UBTCC was higher than the risk of open fracture repair and a subsequent diagnosis of osteosarcoma (P < .02). The incidence of fracture-related osteosarcoma may be significantly less than previously estimated based on cases queried from the VMDB. Although possible cases of implant-associated osteosarcoma were identified, their occurrence was rare. Elective implant removal for the purpose of reducing the risk of osteosarcoma after fracture repair may not be warranted and merits further investigation. © Copyright 2015 by The American College of Veterinary Surgeons.
Deng, Zhouming; Jin, Wei; Ping, Ansong; Wei, Renxiong
Introduction Non-union of the tibia complicated by osteomyelitis is one of the most challenging problems in orthopaedic surgery. There remains a significant amount of debate and controversy regarding the optimal medical management of infected tibial non-union. There are few articles which have reported the outcomes of treatment for infected non-union of tibia from single-stage reconstruction with open bone grafting plus vacuum-assisted closure (VAC). Material and methods Our report covers experience between March 2007 and February 2010 of open bone grafting plus VAC in one stage for patients with infected tibial non-union. The time for bone union and wound healing to occur, the duration of hospitalisation, and the rate of resolution of infection were all analysed. The main outcome measures were based on a clinical scoring system that assessed functional ability, range of knee and ankle motion, shortening, infection and pain. Fifteen patients were involved in this study. Results All patients were followed up for an average of 22.6 months (range: 14–42 months). Bone union was achieved in 93.3% (14/15) of patients after a mean of 5.93 months (range: 3–10 months). All wounds healed within an average period of 5 weeks (range: 3–10 weeks), and the function and appearance of all limbs were satisfactory. Conclusions Open bone grafting combined with VAC in a one-stage procedure can be a feasible alternative to the treatment of infected tibial non-union, especially for those wounds which are not good candidates for microsurgery; however, further studies are required to confirm the likely benefits. PMID:25276163
Piórek, A; Adamiak, Z; Jaskólska, M; Zhalniarovich, Y
The treatment of comminuted tibial shaft fractures in canine patients is burdened by significant risk which involves bone healing complications, such as delayed bone union. Complications may result from iatrogenic damage to blood vessels during fracture stabilization. To minimize this risk, treatment methods increasingly often rely on the concept of biological osteosynthesis. One of such methods involves the treatment of fractures with the use of new hybrid fixator consisted of an interlocking nail connected with type I external fixator. Connection of the nail with external fixator has been recently developed to maximize treatment efficiency. This manner of stabilization increases bone-fixator construct strength on forces acting in the place of fracture. It also enables fracture fixation with minimal damage of the blood supply of bone fragments. This article describes surgical procedure of stabilization of comminuted tibial bone fractures in four dogs by the use of interlocking nail connected with external fixator type I, discusses and evaluates the results of clinical treatment with the involvement of the said fixator. To control bone consolidation process the radiograms were taken in 6 and 8 week of healing. In all cases, the reviewed methods of clinical treatment were successful in producing bone union after eight week of healing. During the whole period of observations no complication was observed. In all cases the intramedullary nail were left in the medullary canal after the healing process was finished. The fixator supported quick restoration of limb function after treatment.
Tsukanov, Iu T; Noskov, V K; Dziuba, G G; Epanchintsev, P M
Analysed herein are the outcomes of treating a total of 96 patients with closed comminuted fractures of crural bones. By the duration of antithrombotic prevention, the patients were subdivided into two groups: the Comparison Group comprising 45 patients with a brief course of anticoagulant treatment (mean 5.8 +/- 1.3 days) and the Study Group consisting of 51 patients receiving anticoagulant treatment till achieving full restoration of the supporting function of the limb (averagely 21.2 +/- 2.1 days). In the Comparison Group, thrombosis of the deep veins localizing exclusively on the crus was registered by the results of duplex scanning in 13 patients (28.9%). In two thirds of the cases (10 cases, 76.9%) thrombosis occurred predominantly on days 6 - 14, while in 3 cases (7.7%) it occurred on days 15 -21 after the injury. In the Study Group patients with protracted anticoagulation prevention, thrombosis of the deep veins was revealed in 9.8% of cases (5 patients). Of the five Study Group patients with thromboses of tibial veins four were subjected to prolonged prevention with indirect anticoagulants and only one - with fraxiparine. It was found that the development of venous thrombi in fractures significantly (p <0.05) makes the terms of consolidation 1.6-fold longer. A conclusion was made that because a high risk of the development of thrombosis of the deep veins preserves during the whole period of restoration of the supporting function of the extremity in fractures of the crural bones, the patients concerned should, based on early (within the first 3-7 days) stable osteosynthesis making it possible to activate the patient and to restore the function of the limb, be subjected to a prolonged course of anticoagulant preventive treatment till the final changeover of the patient to the full load on the affected extremity.
Pamukoff, Derek N; Blackburn, J Troy
Greater lower extremity joint stiffness may be related to the development of tibial stress fractures in runners. Musculotendinous stiffness is the largest contributor to joint stiffness, but it is unclear what factors contribute to musculotendinous stiffness. The purpose of this study was to compare plantar flexor musculotendinous stiffness, architecture, geometry, and Achilles tendon stiffness between male runners with and without a history of tibial stress fracture. Nineteen healthy runners (age = 21 ± 2.7 years; mass = 68.2 ± 9.3 kg; height = 177.3 ± 6.0 cm) and 19 runners with a history of tibial stress fracture (age = 21 ± 2.9 years; mass = 65.3 ± 6.0 kg; height = 177.2 ± 5.2 cm) were recruited from community running groups and the university's varsity and club cross-country teams. Plantar flexor musculotendinous stiffness was estimated from the damped frequency of oscillatory motion about the ankle follow perturbation. Ultrasound imaging was used to measure architecture and geometry of the medial gastrocnemius. Dependent variables were compared between groups via one-way ANOVAs. Previously injured runners had greater plantar flexor musculotendinous stiffness (P < .001), greater Achilles tendon stiffness (P = .004), and lesser Achilles tendon elongation (P = .003) during maximal isometric contraction compared with healthy runners. No differences were found in muscle thickness, pennation angle, or fascicle length.
OʼToole, Robert V; Gary, Joshua L; Reider, Lisa; Bosse, Michael J; Gordon, Wade T; Hutson, James; Quinnan, Stephen M; Castillo, Renan C; Scharfstein, Daniel O; MacKenzie, Ellen J
The treatment of high-energy open tibia fractures is challenging in both the military and civilian environments. Treatment with modern ring external fixation may reduce complications common in these patients. However, no study has rigorously compared outcomes of modern ring external fixation with commonly used internal fixation approaches. The FIXIT study is a prospective, multicenter randomized trial comparing 1-year outcomes after treatment of severe open tibial shaft fractures with modern external ring fixation versus internal fixation among men and women of ages 18-64. The primary outcome is rehospitalization for major limb complications. Secondary outcomes include infection, fracture healing, limb function, and patient-reported outcomes including physical function and pain. One-year treatment costs and patient satisfaction will be compared between the 2 groups, and the percentage of Gustilo IIIB fractures that can be salvaged without soft tissue flap among patients receiving external fixation will be estimated.
Hankemeier, S; Hufner, T; Wang, G; Kendoff, D; Zeichen, J; Zheng, G; Krettek, C
High tibial osteotomy (HTO) is an established therapy for the treatment of symptomatic varus malaligned knees. A main reason for disappointing clinical results after HTO is the under- and overcorrection of the mechanical axis due to insufficient intraoperative visualisation. Twenty legs of fresh human cadaver were randomly assigned to navigated open-wedge HTO (n=10) or conventional HTO using the cable method (n=10). Regardless of the pre-existing alignment, the aim of all operations was to align the mechanical axis to pass through 80% of the tibial plateau (beginning with 0% at the medial edge of the tibial plateau and ending with 100% at the lateral edge). This overcorrection was chosen to ensure a sufficient amount of correction. Thus, the medial proximal tibia angle (MPTA) increased by 9.1+/-2.9 degrees (range 5.2 degrees -12.3 degrees ) on the average after navigated HTO and by 8.9+/-2.9 degrees (range 4.7 degrees -12.6 degrees ) after conventional HTO. After stabilization with a fixed angle implant, the alignment was measured by CT. After navigated HTO, the mechanical axis passed the tibial plateau through 79.7% (range 75.5-85.8%). In contrast, after conventional HTO, the average intersection of the mechanical axis was at 72.1% (range 60.4-82.4%) (P=0.020). Additionally, the variability of the mean corrections was significantly lower in the navigated group (3.3% vs. 7.2%, P=0.012). Total fluoroscopic radiation time was significantly lower in the navigated group (P=0.038) whereas the mean dose area product was not significantly different (P=0.231). The time of the operative procedure was 23 min shorter after conventional HTO (P<0.001). Navigation systems provide intraoperative 3-dimensional real time control of the frontal, sagittal, and transverse axis and may increase the accuracy of open-wedge HTO. Future studies have to analyse the clinical effects of navigation on corrective osteotomies.
Lansdaal, Joris Radboud; Mouton, Tanguy; Wascher, Daniel Charles; Demey, Guillaume; Lustig, Sebastien; Neyret, Philippe; Servien, Elvire
The need for a period of non-weight bearing after medial opening wedge high tibial osteotomy remains controversial. It is hypothesized that immediate weight bearing after medial opening wedge high tibial osteotomy would have no difference in functional scores at one year compared to delayed weight bearing. Fifty patients, median age 54 years (range 40-65), with medial compartment osteoarthritis, underwent a medial opening wedge high tibial osteotomy utilizing a locking plate without bone grafting. Patients were randomized into an Immediate or a Delayed (2 months) weight bearing group. All patients were assessed at one-year follow-up and the two groups compared. The primary outcome measure was the IKS score. Secondary outcome measures included the IKDC score, the VAS pain score and rate of complications. The functional scores significantly improved in both groups. The IKS score increased from 142 ± 31 to 171 ± 26 in the Immediate group (p < 0.001) and from 148 ± 22 to 178 ± 23 in the Delayed group (p < 0.001). The IKDC score increased from 49 ± 17 pre-operatively to 68 ± 14 one-year post-operatively in the Immediate group (p < 0.0001) and from 44 ± 16 to 69 ± 19 in the Delayed group (p < 0.001). The average VAS for pain 2 months after surgery was 3 ± 3 in the Immediate group and 3 ± 2 in the Delayed (n.s.). There was no significant difference between the two groups in any of the outcome measures. The mean mechanical femorotibial angle changed from 6° of varus (0°-15° of varus, SD = 3°) to 4° of valgus (5°-11° of valgus, SD = 3°) in the Immediate group and from 5° of varus (0°-10° of varus, SD = 3°) to 3° of valgus (2° of varus to 8° of valgus, SD = 3°) in the Delayed group. No difference was seen between groups, and no loss of correction was observed in any patient. Two cases of non-union occurred, one in each group. One infection and one deep vein thrombosis occurred in the Immediate group. Immediate
Wagoner, Amanda L; Allen, Matthew J; Zindl, Claudia; Litsky, Alan; Orsher, Robert; Ben-Amotz, Ron
Various materials are used to construct splints for mid-diaphyseal tibial fracture stabilization. The objective of this study was to compare construct stiffness and inter-fragmentary bone motion when fibreglass (FG) or thermoplastic (TP) splints are applied to either the lateral or cranial aspect of the tibia in a mid-diaphyseal fracture model. A coaptation bandage was applied to eight cadaveric canine pelvic limbs, with a custom-formed splint made of either FG or TP material applied to either the lateral or cranial aspect of the osteotomized tibia. Four-point bending tests were performed to evaluate construct stiffness and inter-fragmentary motion in both frontal and sagittal planes. For a given material, FG or TP, construct stiffness was not affected by splint location. Construct stiffness was significantly greater with cranial FG splints than with cranial TP splints ( p < 0.05), but this difference was not significant when comparing splints applied laterally ( p = 0.15). Inter-fragmentary motions in the sagittal and frontal planes were similar across splint types for cranial splints, but for lateral splints there was a 64% reduction in frontal plane motion when FG was used as the splint material ( p = 0.03). FG produces a stiffer construct, but the difference is not reflected in a reduction in inter-fragmentary motion. For lateral splints, FG splints are associated with reduced inter-fragmentary motion as compared with TP and may therefore have slight superiority for this application. Schattauer GmbH Stuttgart.
Mohamed Haflah, Nor Hazla; Ng, Min Hwei; Mohd Yunus, Mohd Heikal; Naicker, Amaramalar Selvee; Htwe, Ohnmar; Fahmi, Muhammad; Ishak, Mohamad Fikeri; Seet, Wan Tai; Khairoji, Khairul Anuar; Maarof, Manira; Chua, Kien Hui; Shamsuddin, Sharen Aini; Idrus, Ruszymah
Open fracture Gustilo-Anderson grade IIIC is associated with higher risk of infection and problems with soft tissue coverage. Various methods have been used for soft tissue coverage in open fractures with large skin defect. We report a case of a patient who had grade IIIC open fracture of the tibia with posterior tibial artery injury. The patient underwent external fixation and reduction. Because of potential compartment syndrome after vascular repair, fasciotomy of the posterior compartment was performed. This wound, however, became infected and because of further debridement, gave rise to a large skin defect. A tissue engineered skin construct, MyDerm TM was employed to cover this large defect. Complete wound closure was achieved 35 days postimplantation. The patient then underwent plating of the tibia for nonunion with no adverse effect to the grafted site. The tibia eventually healed 5 months postplating, and the cosmetic appearance of the newly formed skin was satisfactory.
Fourie, J A; Bowerbank, P
The aim of this research was to establish whether interferential currents (IFC) could significantly reduce the healing time for fractures of the tibia and thereby prevent nonunion. Males between the ages of 12 and 86, who had sustained fractures of the tibiae, were entered into this double blind clinical trial. According to strict inclusion and exclusion criteria, a final sample of 227 cases (208 subjects) were entered by block randomization into two groups; an experimental group (n = 41) and placebo group (n = 35). A further group was entered retrospectively--control group (n = 151). IFCs were applied to the experimental group via suction electrodes for 30 minutes per day for 10 days, using a beat frequency of 10-25 Hz and a swing mode of 6 integral of 6. The placebo group had only suction electrodes applied, the intermittent mode produced a rhythmical massage effect; subjects in this group commented on pain relief which resulted in the addition of the control group as a check on the possible effect of intermittent suction. The control group received no intervention. The data were analysed using analysis of covariance which resulted in a finding of no significant difference in the time taken to union for the three groups. This means that to date there is no reason to believe that IFCs (using the parameters of this trial) can reduce the healing time for new fractures of the tibia or prevent nonunion. However, further investigation is recommended.
Boomsma, E.; Pyrak-Nolte, L. J.
In the field, fractures may be isolated or connected to fluid reservoirs anywhere along the perimeter of a fracture. These boundaries affect fluid circulation, flow paths and communication with external reservoirs. The transport of drop like collections of colloidal-sized particles (particle swarms) in open and partially closed systems was studied. A uniform aperture synthetic fracture was constructed using two blocks (100 x 100 x 50 mm) of transparent acrylic placed parallel to each other. The fracture was fully submerged a tank filled with 100cSt silicone oil. Fracture apertures were varied from 5-80 mm. Partially closed systems were created by sealing the sides of the fracture with plastic film. The four boundary conditions study were: (Case 1) open, (Case 2) closed on the sides, (Case 3) closed on the bottom, and (Case 4) closed on both the sides and bottom of the fracture. A 15 μL dilute suspension of soda-lime glass particles in oil (2% by mass) were released into the fracture. Particle swarms were illuminated using a green (525 nm) LED array and imaged with a CCD camera. The presence of the additional boundaries modified the speed of the particle swarms (see figure). In Case 1, enhanced swarm transport was observed for a range of apertures, traveling faster than either very small or very large apertures. In Case 2, swarm velocities were enhanced over a larger range of fracture apertures than in any of the other cases. Case 3 shifted the enhanced transport regime to lower apertures and also reduced swarm speed when compared to Case 2. Finally, Case 4 eliminated the enhanced transport regime entirely. Communication between the fluid in the fracture and an external fluid reservoir resulted in enhanced swarm transport in Cases 1-3. The non-rigid nature of a swarm enables drag from the fracture walls to modify the swarm geometry. The particles composing a swarm reorganize in response to the fracture, elongating the swarm and maintaining its density. Unlike a
Arnold, John B; Tu, Chen Gang; Phan, Tri M; Rickman, Mark; Varghese, Viju Daniel; Thewlis, Dominic; Solomon, Lucian B
To identify and describe the characteristics of existing practices for postoperative weight bearing and management of tibial plateau fractures (TPFs), identify gaps in the literature, and inform the design of future research. Seven electronic databases and clinical trial registers were searched from inception until November 17th 2016. Studies were included if they reported on the surgical management of TPFs, had a mean follow-up time of ≥1year and provided data on postoperative management protocols. Data were extracted and synthesized according to study demographics, patient characteristics and postoperative management (weight bearing regimes, immobilisation devices, exercises and complications). 124 studies were included involving 5156 patients with TPFs. The mean age across studies was 45.1 years (range 20.8-72; 60% male), with a mean follow-up of 34.9 months (range 12-264). The most frequent fracture types were AO/OTA classification 41-B3 (29.5%) and C3 (25%). The most commonly reported non-weight bearing time after surgery was 4-6 weeks (39% of studies), with a further 4-6 weeks of partial weight bearing (51% of studies), resulting in 9-12 weeks before full weight bearing status was recommended (55% of studies). Loading recommendations for initial weight bearing were most commonly toe-touch/<10kg (28%), 10kg-20kg (33%) and progressive (39%). Time to full weight bearing was positively correlated with the proportion of fractures of AO/OTA type C (r=0.465, p=0.029) and Schatzker type IV-VI (r=0.614, p<0.001). Similar rates of rigid (47%) and hinged braces were reported (58%), most frequently for 3-6 weeks (43% of studies). Complication rates averaged 2% of patients (range 0-26%) for abnormal varus/valgus and 1% (range 0-22%) for non-union or delayed union. Postoperative rehabilitation for TPFs most commonly involves significant non-weight bearing time before full weight bearing is recommended at 9-12 weeks. Partial weight bearing protocols and brace use were
Hu, Xin-Jia; Wang, Hua
The aim of the present study was to investigate the biomechanical effects of varying the length of a limited contact-dynamic compression plate (LC-DCP) and the number and position of screws on middle tibial fractures, and to provide biomechanical evidence regarding minimally invasive plate osteosynthesis (MIPO). For biomechanical testing, 60 tibias from cadavers (age at mortality, 20–40 years) were used to create middle and diagonal fracture models without defects. Tibias were randomly grouped and analyzed by biomechanic and three-dimensional (3D) finite element analysis. The differences among LC-DCPs of different lengths (6-, 10- and 14-hole) with 6 screws, 14-hole LC-DCPs with different numbers of screws (6, 10 and 14), and 14-hole LC-DCPs with 6 screws at different positions with regard to mechanical characteristics, including compressing, torsion and bending, were examined. The 6-hole LC-DCP had greater vertical compression strain compared with the 10- and 14-hole LC-DCPs (P<0.01), and the 14-hole LC-DCP had greater lateral strain than the 6- and 10-hole LC-DCPs (P<0.01). Furthermore, significant differences in torque were observed among the LC-DPs of different lengths (P<0.01). For 14-hole LC-DCPs with different numbers of screws, no significant differences in vertical strain, lateral strain or torque were detected (P>0.05). However, plates with 14 screws had greater vertical strain compared with those fixed with 6 or 10 screws (P<0.01). For 4-hole LC-DCPs with screws at different positions, vertical compression strain values were lowest for plates with screws at positions 1, 4, 7, 8, 11 and 14 (P<0.01). The lateral strain values and vertical strain values for plates with screws at positions 1, 3, 6, 9, 12 and 14 were significantly lower compared with those at the other positions (P<0.01), and torque values were also low. Thus, the 14-hole LC-DCP was the most stable against vertical compression, torsion and bending, and the 6-hole LC-DCP was the least stable
Chrcanovic, Bruno Ramos
The purpose of the study was to review the literature regarding the evolution of current thoughts on management of diacapitular fractures (DFs) of the mandibular condyle. An electronic search in PubMed was undertaken in March 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies reporting clinical series of DFs, including both animal and human studies, without date or language restrictions. The search strategy initially yielded 108 references. Twenty-eight studies were identified without repetition within the selection criteria. Additional hand-searching of the reference lists of selected studies yielded three additional papers. The current indications for open reduction and internal fixation (ORIF) of DFs described in the literature are: (a) fractures affecting the lateral condyle with reduction of mandibular height; (b) fractures in which the proximal fragment dislocates laterally out of the glenoid fossa, which cannot be reduced by closed or open treatment of another part of the mandibular fracture. The indications for conservative treatment are: (a) fractures that do not shorten the condylar height (a fracture with displacement of the medial parts of the condyle); (b) undisplaced fractures; (c) comminution of the condylar head, when the bony fragments are too small for stable fixation; and (d) fractures in children. As the temporomandibular joint disk plays an important role as a barrier preventing ankylosis, it is important to reposition the disk (if displaced/dislocated) during the surgical treatment of DFs. The lateral pterygoid muscle should never be stripped from the medially displaced fragment because its desinsertion disrupts circulation to the medial bony fragment, and also because this muscle helps to restore the muscle function after surgery. ORIF of selected DFs improves prognosis by anatomical bone and soft tissue recovery when combined with physical
Background May-Thurner Syndrome (MTS) represents an anatomic variation of the iliac vessels, in which the left common iliac vein is compressed by an overriding iliac artery. Patients with this abnormality are predisposed to the formation of a left-sided iliofemoral deep venous thrombosis (DVT). While DVT is a familiar complication in the setting of lower extremity trauma, there are no previous reports of MTS complicating the care of patients requiring orthopaedic surgery. Case presentation We present the case of an extensive limb-threatening DVT in a patient with previously undiagnosed MTS, resulting after internal fixation of a left tibial plateau fracture. Four days after surgery, despite standard prophylactic anticoagulation, the patient developed an extensive occlusive DVT, extending from the common iliac vein to the popliteal vein. Successful diagnosis required a CT venogram in addition to standard lower extremity ultrasound exam. Severe lower extremity edema continued to worsen despite formal anticoagulation. Urgent mechanical thrombolysis was undertaken, followed by staged catheter-directed thrombolysis with recombinant tissue plasminogen activator (rTPA) and intraluminal stenting. Following this treatment, the patient was noted to have gradual but dramatic resolution of his lower extremity edema and swelling. Conclusion The present case demonstrates the potential danger that may accompany MTS in the setting of lower extremity trauma. When an extensive left lower extremity DVT complicates the care of a patient with extremity trauma, clinicians should have a low threshold to pursue the diagnosis of MTS with advanced imaging studies. Venography remains the gold standard in diagnosis, but CT and MRI venography are less invasive and should allow for accurate diagnosis. In this case, formal anticoagulation proved to be ineffective, and endovascular intervention was required. PMID:23628366
Foit, Niels A; Chen, Qing-Min; Cook, Blaze; Hammerberg, Eric Mark
May-Thurner Syndrome (MTS) represents an anatomic variation of the iliac vessels, in which the left common iliac vein is compressed by an overriding iliac artery. Patients with this abnormality are predisposed to the formation of a left-sided iliofemoral deep venous thrombosis (DVT). While DVT is a familiar complication in the setting of lower extremity trauma, there are no previous reports of MTS complicating the care of patients requiring orthopaedic surgery. We present the case of an extensive limb-threatening DVT in a patient with previously undiagnosed MTS, resulting after internal fixation of a left tibial plateau fracture. Four days after surgery, despite standard prophylactic anticoagulation, the patient developed an extensive occlusive DVT, extending from the common iliac vein to the popliteal vein. Successful diagnosis required a CT venogram in addition to standard lower extremity ultrasound exam. Severe lower extremity edema continued to worsen despite formal anticoagulation. Urgent mechanical thrombolysis was undertaken, followed by staged catheter-directed thrombolysis with recombinant tissue plasminogen activator (rTPA) and intraluminal stenting. Following this treatment, the patient was noted to have gradual but dramatic resolution of his lower extremity edema and swelling. The present case demonstrates the potential danger that may accompany MTS in the setting of lower extremity trauma. When an extensive left lower extremity DVT complicates the care of a patient with extremity trauma, clinicians should have a low threshold to pursue the diagnosis of MTS with advanced imaging studies. Venography remains the gold standard in diagnosis, but CT and MRI venography are less invasive and should allow for accurate diagnosis. In this case, formal anticoagulation proved to be ineffective, and endovascular intervention was required.
Boone, Philip M; Chan, Yiu Man; Hunter, Jill V; Pottkotter, Louis E; Davino, Nelson A; Yang, Yaping; Beuten, Joke; Bacino, Carlos A
Haploinsufficiency of SATB2 causes cleft palate, intellectual disability with deficient speech, facial and dental abnormalities, and other variable features known collectively as SATB2-associated syndrome. This phenotype was accompanied by osteoporosis, fractures, and tibial bowing in two previously reported adult patients; each possessed SATB2 mutations either predicted or demonstrated to escape nonsense-mediated decay, suggesting that the additional bone defects result from a dominant negative effect and/or age-dependent penetrance. These hypotheses remain to be confirmed, as do the specific downstream defects causing bone abnormalities. We report a SATB2 mutation (c.2018dupA; p.(H673fs)) in a 15-year-old patient whose SATB2-associated syndrome phenotype is accompanied by osteoporosis, fractures, progressive tibial bowing, and scoliosis. As this homeodomain-disrupting and predicted truncating mutation resides within the final exon of SATB2, escape from nonsense-mediated decay is likely. Thus, we provide further evidence of bone phenotypes beyond those typically associated with SATB2-associated syndrome in individuals with potential dominant-negative SATB2 alleles, as well as evidence for age-dependence of bone features. Elevations in alkaline phosphatase, urinary N-telopeptide/creatinine ratio, and osteocalcin in the patient indicate increased bone turnover. We propose surveillance and treatment with osteoclast inhibitors to prevent fractures and to slow progressive bone deformities. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.
Diffo Kaze, Arnaud; Maas, Stefan; Belsey, James; Hoffmann, Alexander; Pape, Dietrich
The purpose of the present study was to compare the mechanical static and fatigue strength of the size 2 osteotomy plate "Activmotion" with the following five other common implants for the treatment of medial knee joint osteoarthritis: the TomoFix small stature, the TomoFix standard, the Contour Lock, the iBalance and the second generation PEEKPower. Six fourth-generation tibial bone composites underwent a medial open-wedge high tibial osteotomy (HTO), according to standard techniques, using size 2 Activmotion osteotomy plates. All bone-implant constructs were subjected to static compression load to failure and load-controlled cyclic fatigue failure testing, according to a previously defined testing protocol. The mechanical stability was investigated by considering different criteria and parameters: maximum forces, the maximum number of loading cycles, stiffness, the permanent plastic deformation of the specimens during the cyclic fatigue tests, and the maximum displacement range in the hysteresis loops of the cyclic loading responses. In each test, all bone-implant constructs with the size 2 Activmotion plate failed with a fracture of the lateral cortex, like with the other five previously tested implants. For the static compression tests the failure occurred in each tested implant above the physiological loading of slow walking (> 2400 N). The load at failure for the Activmotion group was the highest (8200 N). In terms of maximum load and number of cycles performed prior to failure, the size 2 Activmotion plate showed higher results than all the other tested implants except the ContourLock plate. The iBalance implant offered the highest stiffness (3.1 kN/mm) for static loading on the lateral side, while the size 2 Activmotion showed the highest stiffness (4.8 kN/mm) in cyclic loading. Overall, regarding all of the analysed strength parameters, the size 2 Activmotion plate provided equivalent or higher mechanical stability compared to the previously tested
Agneskirchner, Jens Dominik; Hurschler, Christof; Wrann, Christiane D; Lobenhoffer, Philipp
The objective of this study was to quantify the effect of different loading axes and of a valgus opening wedge high tibial osteotomy (HTO) on tibiofemoral cartilage pressure. Six human knee specimens were tested with a load of 1000N in extension in a materials testing machine using a specially designed fixture. Pressure in the medial and lateral joint compartment was recorded using pressure-sensitive films. Different loading alignments (varus, straight, and valgus) were simulated. A medial opening wedge HTO was performed adjusting the loading axis to slight valgus. The first measurement was performed with intact medial collateral ligament (MCL). Then the MCL was dissected gradually and the cartilage pressure again analyzed. There was a significant correlation of the load distribution with the position of the loading axis. The medial compartment was predominantly loaded in the varus setting. The more lateral the loading line intersected the knee, the more pressure was redistributed laterally. The opening wedge HTO without the MCL release resulted in a significant increase of the pressure medially (P = .002). Only after a complete release of the MCL was a significant decrease of pressure medially observed after opening wedge HTO (P = .003). The position of the loading axis in the frontal plane has a strong effect on the tibiofemoral cartilage pressure distribution of the knee. The medial compartment is predominantly loaded in a varus knee; a neutral mechanical axis slightly loads the lateral more than the medial compartment. In valgus alignment, the main load runs through the lateral compartment. A medial opening wedge HTO maintains high medial compartment pressure despite the fact that the loading axis has been shifted into valgus. Only after complete release of the distal fibers of the MCL does the opening wedge HTO produce a decompression of the medial joint compartment.
Chen, Yen-Nien; Lee, Pei-Yuan; Chang, Chih-Han; Chang, Chih-Wei; Ho, Yi-Hung; Li, Chun-Ting; Peng, Yao-Te
Elastic stable intramedullary nailing (ESIN) is a treatment strategy for the management of diaphyseal long-bone fractures in adolescents and children, but few studies have investigated the mechanical stability of tibial diaphyseal fractures treated with various degrees of prebending of the elastic nails. Therefore, the aim of this study was to compare the mechanical stability, including the gap deformation and nail dropping, of a tibia fracture with various fracture sites and fixed with various degrees of prebending of the elastic nails by the finite element method. Furthermore, the contribution of end caps to stability was taken into consideration in the simulation. A tibia model was developed with a transverse fracture at the proximal, middle and distal parts of the diaphysis, and fixed with three degrees of prebending of elastic nails, including those equal to, two times and three times the diameter of the intramedullary canal. The outer diameter of the nail used in the computation was 3.5mm, and the fractured tibia was fixed with two elastic double C-type nails. Furthermore, the proximal end of each nail was set to free or being tied to the surrounding bone by a constraint equation to simulate with or without using end caps. The results indicated that using end caps can prevent the fracture gap from collapsing by stopping the ends of the nails from dropping back in all prebending conditions and fracture patterns, and increasing the prebending of the nails to a degree three times the diameter of the canal reduced the gap shortening and the dropping distance of the nail end in those without using end caps under axial compression and bending. Insufficient prebending of the nails and not using end caps caused the gap to collapse and the nail to drop back at the entry point under loading. Using end caps or increasing the prebending of the nails to three times the diameter of the canal is suggested to stop the nail from dropping back and thus produce a more stable
Stevens, Peter M; Pease, Felicity
Posttraumatic tibial valgus is a recognized complication of proximal tibial metaphyseal fractures in children. There is no consensus regarding management of this malalignment; approaches range from repeated osteotomy to therapeutic nihilism. The authors present 12 patients with an average age at fracture of 4 years 11 months, each of whom who was successfully managed by temporary hemiepiphysiodesis. An additional patient (age 33 years) is included to illustrate the potential long-term outcome of "benign neglect."Using staples or, more recently, a 2-hole plate for guided growth, we have demonstrated correction of posttraumatic tibial valgus by all criteria; including mechanical axis deviation, lateral tibial metaphyseal-diaphyseal angle, tibiofemoral angle, and tibial length. We conclude that hemiepiphysiodesis is a safe and effective method of treatment with a high degree of patient/parent satisfaction. There have been no permanent growth arrests.
Dlimi, F; Mahfoud, M; Berrada, M S; El Bardouni, A; El Yaacoubi, M
Tibiotalar dislocation without associated fracture is a rare injury. We report a case of an unusual open medial ankle dislocation without any associated bony injury. After reduction and debridement under general anaesthesia, capsule suture and ligaments repair were performed. An external fixator was applied for ankle immobilization. After 3 years follow-up, functional results were excellent without signs of instability or degenerative arthritis. Copyright © 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
were found fit for duty after a transtibial amputation (nine of 130) with our cohort of isolated salvaged tibia fractures who either RTD by recovery...outcome data in a military population are only available for patients with a limb amputation ranging from 2.3% to 16.5%.1 Civilian trauma patients with...or amputation . PATIENTS AND METHODS After protocol approval by our Institutional Review Board, we identified battle wounded soldiers with Type III open
Leonov, S V; Pinchuk, P V; Krupin, K N; Panfilov, D A
We have undertaken the mathematical modeling of the process associated with the destruction of the diaphyseal and proximal epiphyseal parts of the tibial bone by means of the finite element analysis. The main emphasis was laid on the elucidation of the topography of force stresses in the model bone. It was shown that loading the upper third of the bone either along its axis or perpendicular to the surface (i.e. in the region formed largely by the cancellous tissue) results in the depressed fracture at the site of the impact. Loading of the mid-third region of the bone (characterized by the predominance of the compact tissue) under the same conditions led to the transverse fracture originating from the side opposite to the impact application site.
Wang, Tie-Jun; Ju, Wei-Na; Qi, Bao-Chang
Anatomical characteristics, such as subcutaneous position and minimal muscle cover, contribute to the complexity of fractures of the distal third of the tibia and fibula. Severe damage to soft tissue and instability ensure high risk of delayed bone union and wound complications such as nonunion, infection, and necrosis. This case report discusses management in a 54-year-old woman who sustained fractures of the distal third of the left tibia and fibula, with damage to overlying soft tissue (swelling and blisters). Plating is accepted as the first choice for this type of fracture as it ensures accurate reduction and rigid fixation, but it increases the risk of complications. Closed fracture of the distal third of the left tibia and fibula (AO: 43-A3). After the swelling was alleviated, the patient underwent closed reduction and fixation with an Acumed fibular nail and minimally invasive plating osteosynthesis (MIPO), ensuring a smaller incision and minimal soft-tissue dissection. At the 1-year follow-up, the patient had recovered well and had regained satisfactory function in the treated limb. The Kofoed score of the left ankle was 95. Based on the experience from this case, the operation can be undertaken safely when the swelling has been alleviated. The minimal invasive technique represents the best approach. Considering the merits and good outcome in this case, we recommend the Acumed fibular nail and MIPO technique for treatment of distal tibial and fibular fractures.
Goett, Scott D; Sinnott, Michael T; Ting, Dennis; Basinger, R Randy; Haut, Roger C; Déjardin, Loïc M
To compare the structural properties of interlocking nails (ILNs) locked with bolts (ILNb) to ILN locked with extended bolts connected with a type-IA external skeletal fixator (ILN-ESF) in a fracture gap model. Experimental study. Synthetic tibial bone substitutes. Custom-made synthetic tibial bone substitutes were implanted with standard ILNs locked with either bolts or extended bolts connected to an external skeletal fixation (ESF). Constructs were tested in torsion, bending, and axial compression (n=4/testing mode). Data, consisting of construct compliance and associated deformation, were compared using t-tests. The ILN-ESF construct compliance and deformation were significantly less than those of the ILNb construct in torsion, bending, and compression (P<.001). Slack was present in the ILNb construct under torsion and bending, but not in the ILN-ESF construct, regardless of testing mode. Substitution of locking bolts with extended bolts connected to an ESF significantly reduced the construct compliance and overall deformation in torsion, bending, and compression. Furthermore, the inherent slack of the ILNb was eliminated by the use of an ESF in torsion and bending. The improvement in structural properties of the ILN-ESF constructs could diminish interfragmentary motion at the fracture site and potentially improve bone healing.
Lee, Yong Seuk; Kim, Min Kyu; Byun, Hae Won; Kim, Sang Bum; Kim, Jin Goo
The purpose of this study was to verify a recently developed picture-archiving and communications system-photoshop method by comparing reliabilities between real-size paper template and the PACS-photoshop methods in preoperative planning of open-wedge high tibial osteotomy. A prospective case series was conducted, including patients with medial osteoarthritis undergoing open-wedge high tibial osteotomy. In the preoperative planning, the picture-archiving and communications system-photoshop method and real-size paper template method were used simultaneously in all patients. Preoperative hip-knee-ankle angle, height, and angle of the osteotomy were evaluated. The reliability of this newly devised method was evaluated, and the consistency between the two methods was also evaluated using intra-class correlation coefficient. Using the picture-archiving and communications system-photoshop method, the mean correction angle and height of osteotomy gap of rater-1 were 11.7° ± 3.6° and 10.7 ± 3.6 mm, respectively. The mean correction angle and height of osteotomy gap of rater-2 were 12.0 ± 2.6 and 10.8 ± 3.6, respectively. The inter- and intra-rater reliabilities of the correction angle were 0.956 ~ 0.979 and 0.980 ~ 0.992, respectively. The inter- and intra-rater reliabilities of the height of the osteotomy gap were 0.968 ~ 0.985 and 0.971 ~ 0.994, respectively (p < 0.001). Using the real-size paper template method, the correction angle and height of the osteotomy gap were 11.5° ± 3.4° and 10.9 ± 3.8 mm, respectively. Using the picture-archiving and communications system-photoshop method, mean values of the correction angle and height of the osteotomy gap were 11.9° ± 3.6° and 10.8 ± 3.6 mm, respectively. Consistency between the two methods by comparing the means of the correction angle and the height of the osteotomy gap were 0.985 and 0.985, respectively (p < 0.001). Use of the picture-archiving and communications system-photoshop method enables direct
Pauchard, Yves; Ivanov, Todor G; McErlain, David D; Milner, Jaques S; Giffin, J Robert; Birmingham, Trevor B; Holdsworth, David W
High-tibial osteotomy (HTO) is a surgical technique aimed at shifting load away from one tibiofemoral compartment, in order the reduce pain and progression of osteoarthritis (OA). Various implants have been designed to stabilize the osteotomy and previous studies have been focused on determining primary stability (a global measure) that these designs provide. It has been shown that the local mechanical environment, characterized by bone strains and segment micromotion, is important in understanding healing and these data are not currently available. Finite element (FE) modeling was utilized to assess the local mechanical environment provided by three different fixation plate designs: short plate with spacer, long plate with spacer and long plate without spacer. Image-based FE models of the knee were constructed from healthy individuals (N = 5) with normal knee alignment. An HTO gap was virtually added without changing the knee alignment and HTO implants were inserted. Subsequently, the local mechanical environment, defined by bone compressive strain and wedge micromotion, was assessed. Furthermore, implant stresses were calculated. Values were computed under vertical compression in zero-degree knee extension with loads set at 1 and 2 times the subject-specific body weight (1 BW, 2 BW). All studied HTO implant designs provide an environment for successful healing at 1 BW and 2 BW loading. Implant von Mises stresses (99th percentile) were below 60 MPa in all experiments, below the material yield strength and significantly lower in long spacer plates. Volume fraction of high compressive strain ( > 3000 microstrain) was below 5% in all experiments and no significant difference between implants was detected. Maximum vertical micromotion between bone segments was below 200 μm in all experiments and significantly larger in the implant without a tooth. Differences between plate designs generally became apparent only at 2 BW loading. Results suggest that
Duchesne, Juan C; Bharmal, Husain M; Dini, Arash A; Islam, Tareq; Schmieg, Robert E; Simmons, Jon D; Wahl, Georgia M; Davis, John A; Krause, Peter; McSwain, Norman E
Open-book pelvic fractures (OBPF) with concomitant intra-abdominal injuries carry a high morbidity and mortality; the significance of associated perineal open wound (OBPF-POW) has not been defined. We hypothesize that the presence of perineal open wounds increases morbidity, mortality, and concomitant use of hospital resources. Patients diagnosed with OBPF over a 5-year period at a Level I trauma center were identified by trauma registry review, and were retrospectively reviewed under an Institutional Review Board-approved protocol. Patients with OBPF without a perineal open wound were compared with those with OBPF-POW. Data collected included patient demographics, injury details, management, and outcomes. A total of 1,635 patients with blunt pelvic fractures were identified, of which 177 (10.8%) had OBPF. OBPF-POW (36/177) significantly increased the use of angioembolization, occurrence of sepsis, pelvic sepsis, ARDS, and multi-organ system failure. Patients with OBPF-POW had an increase of 13 days in length of hospitalization compared with the OBPF group (P < 0.001), with cost of $120,647.30 and $62,952.72 respectively (P < 0.001). Perineal open wounds complicate open-book pelvic fractures with significant increase in hospital resource utilization. Aggressive multidisciplinary evaluation and management is appropriate to detect and prevent complications.
Huang, Ying Chieh; Chao, Ying-Hao; Lien, Fang-Chieh
Tibial tubercle avulsion is an uncommon fracture in physically active adolescents. Sequential avulsion of tibial tubercles is extremely rare. We reported a healthy, active 15-year-old boy who suffered from left tibial tubercle avulsion fracture during a basketball game. He received open reduction and internal fixation with two smooth Kirschner wires and a cannulated screw, with every effort to reduce the plate injury. Long-leg splint was used for protection followed by programmed rehabilitation. He recovered uneventfully and returned to his previous level of activity soon. Another avulsion fracture happened at the right tibial tubercle 3.5 months later when he was playing the basketball. From the encouragement of previous successful treatment, we provided him open reduction and fixation with two small-caliber screws. He recovered uneventfully and returned to his previous level of activity soon. No genu recurvatum or other deformity was happening in our case at the end of 2-year follow-up. No evidence of Osgood-Schlatter disease or osteogenesis imperfecta was found. Sequential avulsion fractures of tibial tubercles are rare. Good functional recovery can often be obtained like our case if we treat it well. To a physically active adolescent, we should never overstate the risk of sequential avulsion of the other leg to postpone the return to an active, functional life.
Thakore, R V; Francois, E L; Nwosu, S K; Attum, B; Whiting, P S; Siuta, M A; Benvenuti, M A; Smith, A K; Shen, M S; Mousavi, I; Obremskey, W T; Sethi, M K
We sought to conduct the largest retrospective study to date of open tibia fractures and describe the incidence of complications and evaluate the potential predictive risk factors for complications. Patients with open tibia fractures treated with reamed intramedullary nail (IMN) across a 10-year period were evaluated. Patient charts were reviewed for demographics, type of open fracture (T), comorbidities, and postoperative complications. A multivariate model was conducted to determine the risk factors for each type of complication. Of the 486 patients with open tibia fractures, 13 % (n = 64) had infections, 12 % (n = 56) had nonunions, and 1 % (n = 7) had amputations. TIII fractures had much higher rates of each complication than TI and TII fractures. Fracture type was the only significant risk factor for both nonunion and infection. Our study found that the Gustilo grade of open tibia fracture is by far the greatest predictor of nonunion and infection.
Busse, Jason W; Bhandari, Mohit; Guyatt, Gordon H; Heels-Ansdell, Diane; Kulkarni, Abhaya V; Mandel, Scott; Sanders, David; Schemitsch, Emil; Swiontkowski, Mark; Tornetta, Paul; Wai, Eugene; Walter, Stephen D
To explore the role of patients' beliefs in their likelihood of recovery from severe physical trauma. We developed and validated an instrument designed to capture the impact of patients' beliefs on functional recovery from injury: the Somatic Pre-Occupation and Coping (SPOC) questionnaire. At 6-weeks postsurgical fixation, we administered the SPOC questionnaire to 359 consecutive patients with operatively managed tibial shaft fractures. We constructed multivariable regression models to explore the association between SPOC scores and functional outcome at 1 year as measured by return to work and Short Form-36 (SF-36) physical component summary and mental component summary scores. In our adjusted multivariable regression models that included preinjury SF-36 scores, SPOC scores at 6 weeks postsurgery accounted for 18% of the variation in SF-36 physical component summary scores and 18% of SF-36 mental component summary scores at 1 year. In both models, 6-week SPOC scores were a far more powerful predictor of functional recovery than age, gender, fracture type, smoking status, or the presence of multitrauma. Our adjusted analysis found that for each 14-point increment in SPOC score at 6 weeks (14 chosen on the basis of half a standard deviation of the mean SPOC score), the odds of returning to work at 1 year decreased by 40% (odds ratio, 0.60; 95% confidence interval, 0.50-0.73). The SPOC questionnaire is a valid measurement of illness beliefs in patients with tibial fracture and is highly predictive of their long-term functional recovery. Future research should explore if these results extend to other trauma populations and if modification of unhelpful illness beliefs is feasible and would result in improved functional outcomes.
Adam, P; Bonnomet, F; Ehlinger, M
Intramedullary nailing is a common method of treating tibial shaft fractures. However, precise control of reduction at the proximal and distal quarters is difficult to achieve. The purpose of this study was to assess the results of plating using locking screws and the feasibility of a minimally-invasive approach. All patients with tibial shaft fracture treated by means of locking plates from January 2004 to October 2006. Thirty-two fractures were treated in 32 patients with a mean age of 43.8 years. Internal fixation with a locking plate and screw construct, using a minimally-invasive or standard approach. Surgical approach, time to weight bearing, complications and their type, time to bone union, alignment in the frontal and sagittal planes on anteroposterior and lateral radiographs. The minimally-invasive approach was performed in 28 cases and immediate full weight bearing allowed in 25 cases. At a mean follow-up of 27 months, two patients had died and two patients were lost to follow-up. The mean time to bone union was 9.1 weeks. Four cases had a complicated course: one infection, one compartment syndrome, one hardware breakage and one pseudarthrosis. Six cases ended up with valgus malunion exceeding 5° in the frontal plane, already present at the time of surgery. Where a minimally-invasive approach can be performed, immediate pain-free weight bearing can be allowed without further displacement at follow-up. The observed rate of malunion underlines the need for adequate reduction and shows that the rationale for success does not solely depend on the plate anatomic design but also on the skills of the operating surgeon. Level I university regional hospital Cohort study. Copyright © 2012. Published by Elsevier Masson SAS.
Ruangsomboon, Pakpoom; Chareancholvanich, Keerati; Harnroongroj, Thos; Pornrattanamaneewong, Chaturong
Medial opening wedge high tibial osteotomy (MOWHTO) is a well-accepted procedure, which has been widely used for pain relief and varus deformity correction in the osteoarthritic (OA) knee, especially in the young patient. However, in the elderly patient, the efficacy of this procedure is still unknown. Therefore, this study aims to evaluate the survivorship of MOWHTO in elderly patients as the primary outcome. The secondary outcome is to evaluate the loss of correction angle that is the common complication after MOWTHO. A retrospective study of 50 elderly patients (≥ 60 years) was conducted to track survivorship of MOWHTO. All patients were diagnosed with varus OA knee and underwent MOWHTO at our institute. The patients who had previous knee surgery or incomplete data were excluded. Medical records and radiographs of eligible patients were reviewed for recruiting the data. Survivorship of MOWHTO was analyzed using Kaplan-Meier curves. The starting point was the time of operation and the end point was the time of subsequent TKA. The loss of correction angle was defined as the change of medial proximal tibial angle (MPTA) between three months and one year post-operatively. The mean age of patients was 66 ± 5.0 years. The majority of patients were female (74%). The mean correction angle was 10.6 ± 3.6 degrees. The union rate of osteotomy site was 100%. In survival analysis, the median follow-up time was 6.0 ± 3.0 years. Two patients required subsequent conversions to TKA. The survivorship of MOWHTO at four years was 95.5% (95%CI, 96.0 to 98.0). For radiographic assessment, the loss of correction angle was 1.0 ± 0.5 degrees at one year post-operatively. This study proved that MOWHTO in patient ≥60 years had good mid-term survivorship with acceptable complications. This procedure can be the alternative option for the treatment of varus OA knee in the elderly.
Moskowitz, Eliza E; Burlew, Clay Cothren; Moore, Ernest E; Pieracci, Fredric M; Fox, Charles J; Campion, Eric M; Lawless, Ryan A; Cohen, Mitchell J
Open pelvic fractures are life-threatening injuries. Preperitoneal pelvic packing (PPP) has been suggested to be ineffective for hemorrhage control in open pelvic fractures. We hypothesize that PPP is effective at hemorrhage control in patients with open pelvic fractures and reduces mortality. Patients undergoing PPP from 2005 to 2015 were analyzed. Patients with open pelvic fractures were defined as direct communication of the bony injury with overlying soft tissue, vagina, or rectum. During the 10-year study, 126 patients underwent PPP; 14 (11%) sustained an open pelvic fracture. After PPP, 1 patient (7%) underwent angioembolization with a documented arterial blush. PPP controlled pelvic hemorrhage in all patients. Overall mortality rate was 7% with one death due to traumatic brain injury. PPP is effective for hemorrhage control in patients with open pelvic fractures. PPP should be used in a standard protocol for hemodynamically unstable patients with pelvic fractures regardless of associated perineal injuries. Copyright © 2017 Elsevier Inc. All rights reserved.
Giordano, Vincenzo; Koch, Hilton Augusto; Mendes, Carlos Henrique; Bergamin, André; de Souza, Felipe Serrão; do Amaral, Ney Pecegueiro
The aim of this study was to evaluate the inter- and intra-observer agreement in the initial diagnosis and classification by means of plain radiographs and CT scans of tibial plateau fractures photographed and sent via WhatsApp Messenger. The increasing popularity of smartphones has driven the development of technology for data transmission and imaging and generated a growing interest in the use of these devices as diagnostic tools. The emergence of WhatsApp Messenger technology, which is available for various platforms used by smartphones, has led to an improvement in the quality and resolution of images sent and received. The images (plain radiographs and CT scans) were obtained from 13 cases of tibial plateau fractures using the iPhone 5 (Apple Inc., Cupertino, CA, USA) and were sent to six observers via the WhatsApp Messenger application. The observers were asked to determine the standard deviation and type of injury, the classification according to the Schatzker and the Luo classifications schemes, and whether the CT scan changed the classification. The six observers independently assessed the images on two separate occasions, 15 days apart. The inter- and intra-observer agreement for both periods of the study ranged from excellent to perfect (0.75<κ<1.0) across all survey questions. When asked if the inclusion of the CT images would change their final X-ray classification (Schatzker or Luo), the inter- and intra-observer agreement was perfect (k=1) on both assessment occasions. We found an excellent inter- and intra-observer agreement in the imaging assessment of tibial plateau fractures sent via WhatsApp Messenger. The authors now propose the systematic use of the application to facilitate faster documentation and obtaining the opinion of an experienced consultant when not on call. Finally, we think the use of the WhatsApp Messenger as an adjuvant tool could be broadened to other clinical centres to assess its viability in other skeletal and non
Flynn, Kelly; Shah, Apurva S; Brusalis, Christopher M; Leddy, Kelly; Flynn, John M
The vast majority of displaced pediatric supracondylar humeral fractures can be treated successfully with closed reduction and percutaneous pinning. The need for open reduction is difficult to determine a priori and is typically due to the failure of closed reduction attempts or persistent limb ischemia. The aims of this study were to determine the prevalence of flexion-type supracondylar humeral fractures, the rate of open reduction for flexion-type fractures, and the predictive impact of ulnar nerve injury on the need for open reduction for flexion-type supracondylar humeral fractures. We developed a database of consecutive pediatric supracondylar humeral fractures treated operatively at a tertiary care pediatric trauma center from 2000 to 2015. Data recorded included age, mechanism of injury, fracture type (open or closed), fracture pattern (flexion-type or extension-type), concomitant skeletal injury, neurovascular injury, treatment, and surgeon. Radiographs of all flexion-type supracondylar humeral fractures were reviewed in order to confirm the classification of the injury pattern. The rate of open reduction for fractures with a flexion-type injury pattern and for such fractures with and without ulnar nerve injury at presentation was assessed. Of 2,783 consecutive pediatric supracondylar humeral fractures treated by surgeons at our center, 95 (3.4%) were flexion-type fractures. Ulnar nerve injury was noted for 10 (10.5%) of the 95 flexion-type fractures. Open injuries were identified at presentation in 3 (3.2%) of the 95 cases. Among closed fractures, 21 (22.8%) of 92 flexion-type fractures required open reduction compared with 50 (1.9%) of 2,647 extension-type fractures (odds ratio [OR] = 15.4; 95% confidence interval [CI] = 8.8 to 27.0; p < 0.001). Among closed flexion-type fractures, open reduction was performed in 6 (60%) of 10 fractures with associated ulnar nerve injury and in 15 (18.3%) of 82 fractures without ulnar nerve injury (OR = 6.7; 95% CI = 1
Slevin, Omer; Ayeni, Olufemi R; Hinterwimmer, Stefan; Tischer, Thomas; Feucht, Matthias J; Hirschmann, Michael T
A variety of bone void filling materials and methods are available in opening medial wedge HTO (OWHTO). The pertinent question revolves around if and when bone void fillers are needed. The primary purpose of this study was to systematically review outcomes and complications after OWHTO with and without the use of bone void fillers. The EMBASE, PubMed\\MEDLINE, Cochrane Library and Google Scholar databases were searched to identify articles that reported OWHTO results using different bone void fillers until March 2016. Only articles reporting the exact bone void filler type, the opening gap size and the fixation method were included. The extracted data included the study design, demographic data, the radiological and clinical results and complication rates. Outcomes were analysed with regard to bone void filler type, and comparison was made between the groups (allograft, autograft, synthetic bone void filler and OWHTO without bone void filling). Twenty-two articles reporting the results of 1421 OWHTO met the inclusion criteria. In total, 647 osteotomies were completed with allogeneic graft as bone void filler, 367 with synthetic materials, 199 with autograft and 208 without any bone void filling material. The maximum opening gap size was similar in all groups with mean of 9.8 mm (range 4-17.5 mm). Locking plate fixation was used in 90 % of the osteotomies that were completed without bone void filler, while all allograft cases and more then 90 % of the autograft cases were done with non-locking systems. The highest rates of non-union (1.1 %) were seen in the synthetic group, compared to 0.5 % in the all the other groups. This systematic review showed no definitive advantages for OWHTO with any bone void filler in terms of union rates and loss of correction. Moreover, the use of autografts or allografts showed more favourable outcomes than synthetic bone substitutes. OWHTO with gaps smaller then 10 mm and rigid fixation might be successfully managed without
Tralman, G; Andrianov, V; Arend, A; Männik, P; Kibur, R T; Nõupuu, K; Uksov, D; Aunapuu, M
The study compares the efficiency of a new bone fixator combining periostal and intramedullary osteosynthesis to bone plating in treatment of tibial fractures in sheep. Experimental osteotomies were performed in the middle third of the left tibia. Animals were divided into two groups: in one group (four animals) combined osteosynthesis (rod-through-plate fixator, RTP fixator) was applied, and in the other group (three animals) bone plating was used. The experiments lasted for 10 weeks during which fracture union was followed by radiography, and the healing process was studied by blood serum markers reflecting bone turnover and by histological and immunohistochemical investigations. In the RTP fixator group, animals started to load body weight on the operated limbs the next day after the surgery, while in the bone plating group, this happened only on the seventh day. In the RTP fixator group, consolidation of fractures was also faster, as demonstrated by radiographical, histological, and immunohistochemical investigations and in part by blood serum markers for bone formation. It can be concluded that application of RTP fixation is more efficient than plate fixation in the treatment of experimental osteotomies of long bones in sheep. © 2012 Blackwell Verlag GmbH.
Tissingh, Elizabeth K; Memarzadeh, Arman; Queally, Joseph; Hull, Peter
Open lower limb fractures are resource intensive injuries. Regardless of the financing model, the cost of treatment is an important consideration for any healthcare provider. Open lower limb fractures treated at our centre were identified over a six-month period. Isolated open femur or tibia fractures were included as well as cases with multiple fractures. Direct inpatient care costs were calculated and income was reviewed for each case according to 'Healthcare Resource Group' (HRG) cost codes. A total of 41 open lower limb fractures (32 patients) were identified. There were isolated open fractures in twenty-five and multiple lower limb open fractures in seven patients. Twenty-three patients (72%) were male and nine were female (28%) with an average age of 40 years (range 10-89 years). The fractures were classified according to Gustilo and Anderson (GA) and divided into two main groups; there were 13 mild and 28 severe open fractures. The median direct cost of inpatient treatment for open lower limb fractures was £19,189 per patient. There was a net gain of £6,288 per fracture in the mild group and a loss of £7,582 in the severe group. The total deficit was £149,545 over the six-month period for this cohort of 41 fractures. Open lower limb fractures are expensive to treat at a cost of approximately £19,200 per patient and associated with a significant loss of income in our MTC. Cost codes should reflect the complex and more expensive treatment of these patients to avoid the inadvertent financial 'penalties' of treating such patients. This study is the first to calculate the direct inpatient treatment costs of open lower limb fractures in a major trauma centre. It highlights the need for cost saving strategies and for appropriate remuneration in MTCs. Copyright © 2016 Elsevier Ltd. All rights reserved.
Giannetti, Silvio; Bizzotto, Nicola; Stancati, Andrea; Santucci, Attilio
The purpose of our study was to compare the outcome after minimally invasive reconstruction and internal fixation with and without the use of pre- and intra-operative real size 3D printing for patients with displaced tibial plateau fractures (TPFs). We prospectively followed up 40 consecutive adult patients with closed TPF who underwent surgical treatment of reconstruction of the tibial plateau with the use of minimally invasive fixation. Sixteen patients (group 1) were operated using a pre-operative and intra-operative real size 3D-model, while 24 patients (group 2) were operated without 3D-model printing, but using only pre-operative and intra-operative 3D Tc-scan images. The mean operating time was 148.2±15.9min for group 1 and 174.5±22.2min for group 2 (p=0.041). In addition, the mean intraoperative blood loss was less in group 1 (520mL) than in group 2 (546mL) (p=0.534). After discharge, all patients were followed up at 6 weeks, 12 weeks, 6 months, 1year and then every year post surgically and radiographic evaluation was carried out each time using clinical and radiological Rasmussen's score, with no significant differences between the two groups. Two patients (group 2) developed infection which resolved within 3 weeks after usage of antibiotics. Neither superficial nor deep infections were present in group 1. In all patients, no non-union occurred. No intraoperative, perioperative, or postoperative complications, such as loss of valgus correction, bone fractures, or metallic plate failures were detected at follow-up. In patients operated with the use of 3D-model printing, we found a significant reduction in surgical time. Moreover, the technique without a 3D-model increased the patient's and the surgeon's exposure to radiation. Copyright © 2016 Elsevier Ltd. All rights reserved.
Okál, F; Hart, R; Komzák, M
When a larger opening of high-tibial osteotomy is necessary to achieve good correction of the lower extremity axis, partial release of the attachments of the medial stabilisers of the knee may be required. The aim of the study was to ascertain, in cadaver specimens, the effect of loosening the medial knee stabilisers on the magnitude of correction in medial opening-wedge high-tibial valgus osteotomy. Thirty-eight knees obtained from cadavers of Caucasian race were dissected. Medial opening-wedge high-tibial valgus osteotomy was performed using a dynamic distractor, constructed by us, with a dynamometer to ensure constant force action. Using a kinematic navigation system, the lower leg axis was studied at opening-wedge osteotomy under constant forces of 100 N and 150 N. The change in its angulation was recorded after each step in releasing the medial stabilisers whose structures were gradually made loose, under constant action of the given force, in the following order: superficial portion of the medial collateral ligament, tendons of the gracilis, semitendinosus and sartorius muscles. The results were statistically analysed using descriptive statistical methods and the two-sample paired t-test with the level of statistical significance set at p < 0.05. Loosening of the medial stabilisers one by one under a constant load led to a statistically significant change in alignment. The most significant change in angulation, both in clinical and statistical terms, was that of 3.4° occurring after the superficial portion of the medial collateral ligament was made loose under a constant force of 100 N applied to osteotomy. Thus, this loosening contributed by 62% to an overall change of 5.5° in the lower extremity mechanical axis, as compared with the condition not allowing for loosening of the stabilisers. Under a load of 150 N applied to osteotomy, loosening of the medial collateral ligament resulted in a change by 4.1°, which accounted for 56% of an overall change of 7
Abbo, Olivier; Accadbled, Frank; Laffosse, Jean-Michel; De Gauzy, Jérome Sales
Traumatic osteoarticular or ligament defect of the tibial medial malleolus is a rare entity in children. Associated lesions may include soft tissue and joint defect, subsequent instability of the ankle, and growth arrest. We report here, the case of an 11-year-old boy, a victim of a severe trauma to the ankle, managed by an original technique. It combined a reconstruction by a composite iliac crest and gluteal fascia graft, an anticipatory Langenskiold procedure, and a serratus anterior muscle flap. This original technique proved to be a suitable alternative in this type of trauma.
Beltran, Michael J; Collinge, Cory A
To determine the clinical and functional outcomes of high-grade (types II and III) open calcaneus fractures managed with a protocol of modern wound care, open reduction via the medial hindfoot wound, and percutaneous screw fixation. Retrospective clinical series of consecutively treated patients. Regional trauma center (level 2). Seventeen consecutive patients with open type II and III calcaneus fractures treated with fracture repair by a single surgeon. Soft tissue debridement and modern wound care, reduction of calcaneus fractures through the open medial wound, and percutaneous screw fixation. Patient demographics and injury data, radiographic analyses, complications of treatment, and hindfoot outcomes assessed with American Orthopaedic Foot and Ankle Surgeon and Maryland Foot Scores and general health with the Short Form 36 measurement at a minimum of 12 months post injury. Seventeen patients were available for follow-up at >12 months, with 15 completing all outcome measures. Four fractures were graded as type II, 9 as type IIIA, and 4 as type IIIB. There was 1 deep infection, and 1 wound dehiscence, both in type III open injuries; both were successfully treated with local wound care, delayed closure, and appropriate antibiotics. Overall, 7 of 17 (41%) patients required secondary surgical procedures, including 4 hindfoot fusions (23.5%). The average American Orthopaedic Foot and Ankle Surgeon score was 77 (range, 32-95), and the Maryland Foot Score was 64 (range, 16-93). The physical and mental components of the Short Form 36 averaged 44.4 and 49.1, respectively. Limb-threatening catastrophic complications are uncommon for high-grade open calcaneus fractures treated with modern soft-tissue care, fracture reduction using the medial open fracture wound, and percutaneously placed screw fixation. Limb and whole body functional outcomes are comparable to previously published reports of both closed and open calcaneus fractures. Therapeutic Level IV. See Instructions
Court-Brown, Charles M; Honeyman, Calum S; Clement, Nick D; Hamilton, Stuart A; McQueen, Margaret M
A study was undertaken to determine the requirement for primary plastic surgery in the treatment of open fractures. We reviewed 3297 consecutive open fractures in a 22-year period in a defined population. Analysis showed that 12.6% of patients required primary plastic surgery with 5.6% being treated with split skin grafting and 7.2% with a flap. Only 3.5% of open upper limb fractures required primary plastic surgery compared to 27.9% of open lower limb fractures. The fractures that required most primary plastic surgery were those of the femoral diaphysis and all fractures between the proximal tibia and the midfoot. The incidence of open fractures that require primary plastic surgery was 28/10(6)/year. The incidence in open upper and lower limb fractures was 5.3/10(6)/year and 22.7/10(6)/year respectively. Using these figures it is possible to estimate the numbers of open fractures that will require primary plastic surgery each year in the United Kingdom. Copyright © 2015 Elsevier Ltd. All rights reserved.
Ivarsson, Magnus; Bengtson, Stefan; Skogby, Henrik; Belivanova, Veneta; Marone, Federica
The deep subseafloor crust is one of the few great frontiers of unknown biology on Earth and, still today, the notion of the deep biosphere is commonly based on the fossil record. Interpretation of palaeobiological information is thus central in the exploration of this hidden biosphere and, for each new discovery, criteria used to establish biogenicity are challenged and need careful consideration. In this paper networks of fossilized filamentous structures are for the first time described in open fractures of subseafloor basalts collected at the Emperor Seamounts, Pacific Ocean. These structures have been investigated with optical microscopy, environmental scanning electron microscope, energy dispersive spectrometer, X-ray powder diffraction as well as synchrotron-radiation X-ray tomographic microscopy, and interpreted as fossilized fungal mycelia. Morphological features such as hyphae, yeast-like growth and sclerotia were observed. The fossilized fungi are mineralized by montmorillonite, a process that probably began while the fungi were alive. It seems plausible that the fungi produced mucilaginous polysaccharides and/or extracellular polymeric substances that attracted minerals or clay particles, resulting in complete fossilization by montmorillonite. The findings are in agreement with previous observations of fossilized fungi in subseafloor basalts and establish fungi as regular inhabitants of such settings. They further show that fossilized microorganisms are not restricted to pore spaces filled by secondary mineralizations but can be found in open pore spaces as well. This challenges standard protocols for establishing biogenicity and calls for extra care in data interpretation.
Liu, Lei; Tan, Gang; Luan, Fujun; Tang, Xin; Kang, Pengde; Tu, Chongqi; Pei, Fuxing
The purpose of this study was to review the results of external fixation combined with vacuum sealing drainage (VSD) to treat patients who sustained tibial and fibular fractures in the Wenchuan earthquake. We retrospectively analysed 179 cases (of which 85 were classified as Gustilo grade III) of open comminuted fracture of the tibia and fibula caused by the Wenchuan earthquake. The patients were followed up for an average of 15 months; detailed records were kept on their function and recovery. After caring for the life-threatening injuries; fractures were treated by external fixation, with VSD used on the surface or in the cavity of the wound after debridement. Antibiotics were administered on the basis of drug sensitivity test results. After the infection had been controlled and healthy granulation tissue had developed, the patients underwent secondary suture, free skin grafting, or skin flap transfer. Good results can be achieved when external fixation combined with vacuum sealing drainage were used to treat open comminuted fractures of tibia and fibula in the Wenchuan earthquake.
Couture, Christopher J.; Karlson, Kristine A.
Tibial stress injuries, commonly called shin splints, often result when bone remodeling processes adopt inadequately to repetitive stress. Physicians who are caring for athletic patients must have a thorough understanding of this continuum of injuries, including medial tibial stress syndrome and tibial stress fractures, because there are…
Wu, Lingfeng; Lin, Jun; Jin, Zhicheng; Cai, Xiaobin; Gao, Weiyang
High tibial osteotomy (HTO) has been widely used for clinical treatment of osteoarthritis of the medial compartment of the knee, and both opening-wedge and closing-wedge HTO are the most commonly used methods. However, it remains unclear which technique has better clinical and radiological outcomes in practice. To systematically evaluate this issue, we conducted a comprehensive meta-analysis by pooling all available data for the opening-wedge HTO and closing-wedge HTO techniques from the electronic databases including PubMed, Embase, Wed of Science and Cochrane Library. A total of 22 studies encompassing 2582 cases were finally enrolled in the meta-analysis. There was no significant difference regarding surgery time, duration of hospitalization, knee pain VAS, Lysholm score and HSS knee score (clinical outcomes) between the opening-wedge and closing-wedge HTO groups (P > 0.05). However, the opening-wedge HTO group showed wider range of motion than the closing-wedge HTO group (P = 0.003). Moreover, as for Hip-Knee-Ankle angle and mean angle of correction, no significant difference was observed between the opening-wedge and closing-wedge HTO groups (P > 0.05), while the opening-wedge HTO group showed greater posterior tibial slope angle (P < 0.001) and lesser patellar height than the closing-wedge HTO group (P < 0.001). On light of the above analysis, we believe that individualized surgical approach should be introduced based on the clinical characteristics of each patient. PMID:28182736
Xu, Chun; Silder, Amy; Zhang, Ju; Reifman, Jaques; Unnikrishnan, Ginu
Load carriage is associated with musculoskeletal injuries, such as stress fractures, during military basic combat training. By investigating the influence of load carriage during exercises on the kinematics and kinetics of the body and on the biomechanical responses of bones, such as the tibia, we can quantify the role of load carriage on bone health. We conducted a cross-sectional study using an integrated musculoskeletal-finite-element model to analyze how the amount of load carriage in women affected the kinematics and kinetics of the body, as well as the tibial mechanical stress during running. We also compared the biomechanics of walking (studied previously) and running under various load-carriage conditions. We observed substantial changes in both hip kinematics and kinetics during running when subjects carried a load. Relative to those observed during running without load, the joint reaction forces at the hip increased by an average of 49.1% body weight when subjects carried a load that was 30% of their body weight (ankle, 4.8%; knee, 20.6%). These results indicate that the hip extensor muscles in women are the main power generators when running with load carriage. When comparing running with walking, finite element analysis revealed that the peak tibial stress during running (tension, 90.6 MPa; compression, 136.2 MPa) was more than three times as great as that during walking (tension, 24.1 MPa; compression, 40.3 MPa), whereas the cumulative stress within one stride did not differ substantially between running (15.2 MPa · s) and walking (13.6 MPa · s). Our findings highlight the critical role of hip extensor muscles and their potential injury in women when running with load carriage. More importantly, our results underscore the need to incorporate the cumulative effect of mechanical stress when evaluating injury risk under various exercise conditions. The results from our study help to elucidate the mechanisms of stress fracture in women.
Forman, Jordanna M; Urruela, Adriana M; Egol, Kenneth A
The purpose of this retrospective chart and radiographic review is to describe an effective reduction technique during intramedullary nailing of distal metaphyseal tibia fractures with the use of a pointed percutaneous clamp. Between 2007 and 2010, 100 patients who sustained 102 tibia fractures were definitively treated with an intramedullary nail at one of two medical centers. Diaphyseal fractures and injuries with an associated disruption of the distal tibiofibular joint were excluded from our study. A total of 27 patients with 27 distal metaphyseal tibia fractures (OTA types 42-A, 43-A, and 43-B) were included. All 27 patients underwent IM nailing of their fractures with anatomic reduction achieved using a percutaneously placed pointed reduction clamp prior to insertion of the IM implant. Fracture alignment and angular deformity was assessed using goniometric measurement functions on the PACS system (GE, Waukeshau, WI) obtained from preoperative and postoperative anteroposterior and lateral images for all subjects. Malalignment was defined as more than 5 degrees of angulation in any plane. Fourteen of the fractures were classified as OTA 42-A, 9 were OTA 43-A, and 4 were OTA 43-B. Analysis of post-closed reduction, preoperative anteroposterior radiographs revealed a mean of 7.9 degrees of coronal plane (range: 0.9 degrees-26 degrees) angulation. Post closed reduction preoperative lateral radiographs revealed a mean of 6.8 degrees sagittal plane (range: 0 degrees-24.6 degrees) angulation. Postoperative anteroposterior and lateral radiographs showed the distal segment returned to its anatomical alignment with a mean angulation of 0.5 degrees (range, 0 degrees-3.5 degrees) and 0.7 degrees (range, 0 degrees-4.2 degrees) of varus/ valgus and apex anterior/posterior angulation, respectively. These results showed an acceptable postopertative alignment in all 27 distal third fractures. No intra-operative or postoperative complications were noted in the study group. This
Guthrie, J W; Kalff, S
To evaluate the clinical and radiographic outcomes following surgical stabilisation of ilial fractures in dogs and cats using a laterally applied Synthes TPLO locking compression plate. Medical records and radiographs of seven dogs and two cats which had undergone surgical repair of an ilial body fracture with a TPLO locking compression plate were reviewed. Long-term clinical follow-up was obtained from an owner or referring veterinarian questionnaire. Fracture reduction was anatomic in six of nine ilia and near-anatomic in three of nine. All but one fracture achieved osseous union by 6 weeks after surgery. No screw loosening or implant-related complications occurred in any patient. There was pelvic canal narrowing in six of nine patients (median reduction in pelvic canal diameter was 4·9%). No intraoperative or postoperative complications were reported. Lateral plating of canine and feline ilial fractures with a Synthes TPLO locking compression plate was associated with a low complication rate and satisfactory radiographic and clinical outcomes in this small case series. © 2017 British Small Animal Veterinary Association.
Suero, Eduardo M; Hawi, Nael; Westphal, Ralf; Sabbagh, Yaman; Citak, Musa; Wahl, Friedrich M; Krettek, Christian; Liodakis, Emmanouil
Intraoperative fracture of the lateral cortex fractures of the tibia is a potential complication of high tibial osteotomy (HTO), which may result in inadequate rotational alignment of the distal tibia. Our aim was to determine how rotational malalignment of the distal tibial segment distal would affect intraarticular contact pressure distribution in the knee and ankle joints. A medial, L-shaped opening-wedge HTO was performed on seven human lower body specimens. A stainless steel device with integrated load cell was used to axially load the leg. Pressure-sensitive sensors were used to measure intraarticular contact pressures. Intraoperative changes in alignment were monitored in real time using computer navigation. Measurements were performed in the native knee alignment, after 10° and 15° of alignment correction and with the distal tibia fixed at 15° of external rotation. Moderate-to-large alignment changes after medial opening-wedge HTO resulted in a shift in intraarticular contact pressures from the medial compartment of the knee towards the lateral compartment. However, fixation of the distal tibial segment at 15° of external rotation neutralized this intended beneficial effect. In the ankle, external rotation of the distal tibia also caused a reduction in contact pressures and tibiotalar contact area. Malrotation of the distal tibial fragment negates the intended effect of offloading the diseased compartment of the knee, with the contact pressures remaining similar to those of the native knee. Furthermore, malrotation leads to abnormal ankle contact pressures. Care should be taken to ensure appropriate rotational alignment of the distal tibial segment during intraoperative fixation of HTO procedures.
Lee, Qi; Zeng, Bing-Fang; Luo, Cong-Feng; Wang, Jin-Wu; Lu, Nan-Ji
To assess the method and results of applying a backstroke technique, we treated 43 patients with tibial shaft fracture using unreamed tibial nails (UTN). Of these patients, 27 suffered a closed fracture and 16 an open fracture. After the operation, the effect of treatment was evaluated: 42 of 43 cases were followed up from four to 18 months, averaging 13.6 months. The four-month and 12-month healing rates of open fracture were 54.6 and 80.9%, respectively, the former of which is significantly higher than the average rate of the AO/ASIF multicentre study. Our results indicate that applying a backstroke technique in treating tibial shaft fracture with UTN can improve the healing rate and reduce complications.
Osti, Michael; Gohm, Alexander; Schlick, Bernd; Benedetto, Karl Peter
Medial open-wedge high tibial osteotomy (HTO) with spacer plates is recommended to correct varus malalignment of the knee with symptomatic overload of the medial compartment. Fifty-five knees in 50 patients were assessed. Intra- and post-operative complications were recorded, and Tegner, Lysholm and IKDC scores were used to evaluate functional results. Radiological parameters consisted of medial proximal tibial angle (aMPTA), femorotibial angle (aFTA), posterior proximal tibial angle, lateral distal femur angle, mechanical axis deviation (MAD) and osteoarthritis score (Jäger and Wirth). Duration of follow-up was 5.0 ± 1.4 years. Overall and implant-related complication rates were 27.3 and 10.9 %, respectively. No statistical association could be detected between overall and implant-related complication rates and age, gender, wedge size, angle of correction or body mass index. Mean improvement in Lysholm score was 26.8. Overall IKDC scores at follow-up were A25, B26, C2 and D2. Post-operative correction of MPTA and FTA averaged to 89.6° and 173° and to 89° and 173.5° at follow-up, respectively. Initial MAD of 21.8 mm was corrected to 11.8 mm at follow-up. Osteoarthritis score increased from 1.4 ± 0.9 to 1.9 ± 0.9 points. HTO with spacer plates improves knee function and is an effective procedure in selected patients. Overall and implant-related complication rates should be considered and seem to be lower with a smaller angle of correction corresponding to incipient osteoarthritis and less varus deformity. Retrospective case series, Level IV.
Hannigan, Geoffrey D.; Pulos, Nicholas; Grice, Elizabeth A.; Mehta, Samir
Significance: Open fractures are fractures in which the bone has violated the skin and soft tissue. Because of their severity, open fractures are associated with complications that can result in increased lengths of hospital stays, multiple operative interventions, and even amputation. One of the factors thought to influence the extent of these complications is exposure and contamination of the open fracture with environmental microorganisms, potentially those that are pathogenic in nature. Recent Advances: Current open fracture care aims to prevent infection by wound classification, prophylactic antibiotic administration, debridement and irrigation, and stable fracture fixation. Critical Issues: Despite these established treatment paradigms, infections and infection-related complications remain a significant clinical burden. To address this, improvements need to be made in our ability to detect bacterial infections, effectively remove wound contamination, eradicate infections, and treat and prevent biofilm formation associated with fracture fixation hardware. Future Directions: Current research is addressing these critical issues. While culture methods are of limited value, culture-independent molecular techniques are being developed to provide informative detection of bacterial contamination and infection. Other advanced contamination- and infection-detecting techniques are also being investigated. New hardware-coating methods are being developed to minimize the risk of biofilm formation in wounds, and immune stimulation techniques are being developed to prevent open fracture infections. PMID:25566415
Fuchs, M; Burchhardt, H; Dresing, K; Radebold, T; Stürmer, K M
Surgical treatment of calcaneal fractures is demanding due to the poor musculocutaneous coverage. Infection with osteitis is a severe complication with open fractures. The appearance of osteitis requires aggressive surgical treatment including amputation in case of persistence, leading to considerable invalidism. We report the case of an 37-year-old mason with an grade III open calcaneal fracture caused by a fall. Osteitis appeared after primary osteosynthesis with open reduction and eventually--after several revisions--required a calcanectomy. By preservation of the forefoot and midfoot and thanks to sufficient orthosis treatment the patient was able to return to his profession after eight months.
Early infection after open reduction and internal fixation (ORIF) of a limb bone is defined as bacteriologically documented, deep and/or superficial surgical-site infection (SSI) diagnosed within 6months after the surgical procedure. This interval is arbitrarily considered sufficient to obtain fracture healing. The treatment of early infection after ORIF should be decided by a multidisciplinary team. The principles are the same as for revision arthroplasty. Superficial SSIs should be differentiated from deep SSIs, based on the results of bacteriological specimens collected using flawless technique. A turning point in the local microbial ecology occurs around the third or fourth week, when a biofilm develops around metallic implants. This biofilm protects the bacteria. The treatment relies on both non-operative and operative measures, which are selected based on the time to occurrence of the infection, condition of the soft tissues, and stage of bone healing. Both the surgical strategy and the antibiotic regimen should be determined during a multidisciplinary discussion. When treating superficial SSIs after ORIF, soft-tissue management is the main challenge. The treatment differs according to whether the hardware is covered or exposed. Defects in the skin and/or fascia can be managed using reliable reconstructive surgery techniques, either immediately or after a brief period of vacuum-assisted closure. In deep SSIs, deciding whether to leave or to remove the hardware is difficult. If the hardware is removed, the fracture site can be stabilised provisionally using either external fixation or a cement rod. Once infection control is achieved, several measures can be taken to stimulate bone healing before the end of the classical 6-month interval. If the hardware was removed, then internal fixation must be performed once the infection is eradicated. Copyright © 2016. Published by Elsevier Masson SAS.
Wong, Chin-Ho; Daniel, Rollin K
Closed reduction and splinting are generally recommended in the acute management of nasal fractures. Although open reduction is recommended for more severe nasal fractures, immediate functional and cosmetic open rhinoplasty following nasal fractures has not been described for Asian noses. The authors document their experiences with combining open reduction of acute nasal fractures with simultaneous cosmetic correction of preexisting aesthetic concerns in an Asian population. Twenty-five Asian patients underwent primary functional and cosmetic open rhinoplasty immediately following acute nasal fracture. Grafts consisted of autologous material, including septum, concha, rib, and deep temporal fascia. Prior to opening the nose, anatomical reduction of the bony vault fractures was performed. Spreader grafts were used to stabilize the fractured or dislocated dorsal septum as well as to straighten the nose. Aesthetic refinement of the nose included lengthening, refining the tip, and increasing tip projection and was performed according to the patients' aesthetic desires. Patient satisfaction was subjectively reported on a 1 to 10 scale. Mean follow-up was 17 months (range, 10-24 months). Twenty-three patients rated the results of their procedures as 7 or higher. Functionally, all patients were breathing as well or better postoperatively compared with their preinjury functional state. One patient (4%) underwent a secondary filler procedure for a slight dorsal irregularity. Immediate cosmetic and functional open rhinoplasty is safe, predictable, and effective in Asian patients. 4.
Boersma, Quinten; Hardebol, Nico; Barnhoorn, Auke; Bertotti, Giovanni; Drury, Martyn
Orthogonal fracture networks (ladder-like networks) are arrangements that are commonly observed in outcrop studies. They form a particularly dense and well connected network which can play an important role in the effective permeability of tight hydrocarbon or geothermal reservoirs. One issue is the extent to which both the long systematic and smaller cross fractures can be simultaneously critically stressed under a given stress condition. Fractures in an orthogonal network form by opening mode-I displacements in which the main component is separation of the two fracture walls. This opening is driven by effective tensile stresses as the smallest principle stress acting perpendicular to the fracture wall, which accords with linear elastic fracture mechanics. What has been well recognized in previous field and modelling studies is how both the systematic fractures and perpendicular cross fractures require the minimum principle stress to act perpendicular to the fracture wall. Thus, these networks either require a rotation of the regional stress field or local perturbations in stress field. Using a mechanical finite element modelling software, a geological case of layer perpendicular systematic mode I opening fractures is generated. New in our study is that we not only address tensile stresses at the boundary, but also address models using pore fluid pressure. The local stress in between systematic fractures is then assessed in order to derive the probability and orientation of micro crack propagation using the theory of sub critical crack growth and Griffith's theory. Under effective tensile conditions, the results indicate that in between critically spaced systematic fractures, local effective tensile stresses flip. Therefore the orientation of the least principle stress will rotate 90°, hence an orthogonal fracture is more likely to form. Our new findings for models with pore fluid pressures instead of boundary tension show that the magnitude of effective tension
01 JUN 2014 2. REPORT TYPE N/A 3. DATES COVERED - 4. TITLE AND SUBTITLE A versatile model of open-fracture infection: a contaminated ...institution’s experi- ence with a rat- contaminated open femur fracture model. This is a versatile, reproducible model for testing interven- tions in...with 30 mg of sterile bovine collagen soaked with a specified amount of Staphylococcus aureus (S. aureus) in 0.5 ml of saline. The (Xenogen 36
Larsen, P; Koelner-Augustson, L; Elsoe, R; Petruskevicius, J; Rasmussen, S
The objective of the present study was to evaluate the relationship between clinical outcome and time of day of surgery and experience level of the surgeon. Secondly, we examined the relationship between the length of hospital stay and the time of day of surgery. This retrospective cross-sectional cohort design study included patients treated with intramedullary nailing at Aalborg University Hospital from 1998 to 2008 after tibial shaft fractures (N = 294). At follow-up, the participants completed the Knee Injury and Osteoarthritis Outcome Score (KOOS). Age, sex, complications, length of hospital stay, start time of surgery, and education level of surgeons were recorded. The long-term analysis of the KOOS assessment shows no significant association between time of day of surgery and the level of surgeon experience. There was no difference in complication rates between time of day of surgery and the level of surgeon experience. The secondary outcome analysis showed an estimated increased risk of 25 % (p = 0.001), for a longer length of hospital stay when operated by a trainee at night-hours compared to day-hours, and an estimated increased risk of 17 % (p = 0.002) for longer length of stay, when operated at day-hours by a trauma surgeon compared to a trainee. Complication rates and KOOS outcome after surgery with intramedullary nailing were not influenced by time of day of surgery and experience level of the surgeon. The lengths of hospital stay increase significantly when surgery is performed at night by trainee surgeons, but not when performed by trauma surgeons.
Gulabi, Deniz; Erdem, Mehmet; Bulut, Guven; Avci, Cem Coskun; Asci, Murat
Both the isolated distal femoral epiphysiolysis and the isolated proximal tibial epiphysiolysis are the least common epiphyseal injuries. Even though they are uncommon, they have a high incidence rate of complications. We present a case with Gustilo-Anderson grade 3b open and Salter-Harris type 1 epiphysiolysis of the distal femur and proximal tibia caused by a farm machinery accident. The patient was a 10-year-old boy, treated by open reduction and internal fixation. Although distal femoral and proximal tibial growth plate injuries are rarely seen benign fractures, their management requires meticulous care. Anatomic reduction is important, especially to minimize the risk of growth arrest and the development of degenerative arthritis. However, there is a high incidence of growth arrest and neurovascular injury with these type of fractures.
Introduction Both the isolated distal femoral epiphysiolysis and the isolated proximal tibial epiphysiolysis are the least common epiphyseal injuries. Even though they are uncommon, they have a high incidence rate of complications. Case presentation We present a case with Gustilo-Anderson grade 3b open and Salter-Harris type 1 epiphysiolysis of the distal femur and proximal tibia caused by a farm machinery accident. The patient was a 10-year-old boy, treated by open reduction and internal fixation. Conclusion Although distal femoral and proximal tibial growth plate injuries are rarely seen benign fractures, their management requires meticulous care. Anatomic reduction is important, especially to minimize the risk of growth arrest and the development of degenerative arthritis. However, there is a high incidence of growth arrest and neurovascular injury with these type of fractures. PMID:23724954
Liu, Zhong; Xu, Hong; Zhang, Zhao; Teng, Yunsheng; Wu, Meng; Tao, Shenglin
To explore the effectiveness of staged treatment of open Pilon fracture combined with soft tissue defect. Between June 2007 and December 2012, 18 cases of open Pilon fracture combined with soft tissue defect were treated. There were 14 males and 4 females with an average age of 35 years (range, 19-55 years). The causes of injury included falling from height in 12 cases, traffic accident in 4 cases, and crushing by machine in 2 cases. According to AO classification, 1 case was classified as type B2 fracture, 3 cases as type B3 fracture, 5 cases as type C1 fracture, 5 cases as type C2 fracture, and 4 cases as type C3 fracture. Sixteen cases accompanied by fibular fracture (14 cases of simple fibular fracture and 2 cases of communicated fibular fracture). According to Gustilo classification, the soft tissue injuries were all type IIIB. In first stage, debridement and vaccum sealing drainage combined with external fixation were performed; open reduction and internal fixation of simple fibular fracture were used. In second stage, open reduction and internal fixation of Pilon fracture and communicated fibular fracture were performed, and the flaps of 6 cm x 5 cm to 18 cm x 14 cm were applied to repair soft tissue defect at the same time. The donor site was repaired by skin graft. Partial necrosis occurred in 2 flaps, the other 16 flaps survived completely. The incisions of donor sites healed by first intention, the skin graft survived completely. The average follow-up interval was 12 months (range, 6-24 months). The X-ray films showed that the bone healing time ranged from 5 to 8 months (mean, 6 months). No internal fixation failure was found. At last follow-up, the average range of motion of the ankle joint was 37 degrees (range, 26-57 degrees). According to the American Orthopedic Foot and Ankle Society (AOFAS) scale, the average score was 80.2 (range, 72-86). Traumatic arthritis occurred in 2 cases (11%). The staged treatment has the advantages of accurate evaluation
Kraemer, Bruce A; Geiger, Scott E; Deigni, Oliver A; Watson, John Tracy
Open wounds of the distal third of the leg and foot with exposed bone, fractures, and hardware are challenging wounds for which to achieve stable coverage. The orthopedic advances in lower extremity fracture management over the last 30 years have allowed a rethinking of the standard operative approach to close these complex wounds. The ability of extracellular matrix (ECM) products to facilitate constructive remodeling of a wound seemed a reasonable approach for treatment, especially in patients who are often poor surgical candidates for more advanced reconstructive procedures. The authors reviewed 9 patients with 11 open fractures of the leg, ankle, or foot treated with a newer ECM wound healing device to total closure. The clinical course and patient management are reviewed. The authors conclude that newer ECM products can provide a reasonable method of management for patients who have wounds with exposed hardware, distal leg wounds, and open foot fractures compared to prolonged negative pressure wound therapy or complex reconstructive operative procedures.
Schuster, Philipp; Geßlein, Markus; Schlumberger, Michael; Mayer, Philipp; Mayr, Raul; Oremek, Damian; Frank, Sebastian; Schulz-Jahrsdörfer, Martin; Richter, Jörg
High tibial osteotomy (HTO) is a widely used treatment option for medial osteoarthritis and varus malalignment, especially in young patients with early osteoarthritis. Limited outcome data are available for this procedure in severe osteoarthritis, and no long-term data are available using newer implants. To determine survivorship and functional results of medial open-wedge HTO combined with a chondral resurfacing (CR) procedure (abrasion plus microfracture) in severe medial osteoarthritis (Kellgren-Lawrence grade 3 and 4) and varus malalignment. Furthermore, factors that potentially influence the outcome were analyzed. Case series; Level of evidence, 4. From September 2005 to December 2008, all cases of HTO (fixation with an angular-stable internal fixator) combined with CR were prospectively surveyed with regard to survival (Kaplan-Meier-method, not requiring arthroplasty) and functional outcome (subjective International Knee Documentation Committee [IKDC] score). Cartilage regeneration at the time of hardware removal, tibial bone varus angle (TBVA), pre- and postoperative mechanical medial proximal tibial angle (MPTA), and postoperative alignment were analyzed with regard to the result. Seventy-nine knees were included (73 patients; mean age 50.9 ± 7.6 years). The follow-up rate was 90% at 10.0 ± 1.2 years (range, 8.3-12.1 years). Pre- and postoperative mechanical tibiofemoral axis were 9.6° ± 3.0° of varus and 0.6° ± 2.7° of valgus, respectively. Survival rate was 81.7% (95% CI, 72.5%-90.9%) at 10 years. Subjective IKDC score significantly improved from 44 ± 11 preoperatively to 70 ± 13 at one, 66 ± 15 at three, 66 ± 15 at five, and 65 ± 17 at ten years ( P < .001 at any point of follow-up). Poor cartilage regeneration and low preoperative IKDC score (<40) were associated with decreased survival. High preoperative TBVA was associated with better and an overcorrected MPTA (>95°) with inferior functional outcome at final follow-up, respectively. Even
Kortram, Kirsten; Bezstarosti, Hans; Metsemakers, Willem-Jan; Raschke, Michael J; Van Lieshout, Esther M M; Verhofstad, Michael H J
The purpose of this study was to identify risk factors for the development of infection after open fracture fixation. A comprehensive search in all scientific literature of the last 30 years was performed in order to identify patient-, trauma-, diagnosis- and treatment-related risk factors. Studies were included when infectious complications were assessed in light of one or more risk factors. A meta-analysis was performed. Risk ratios (RR) or risk differences (RD) with 95% confidence intervals were calculated. A total of 116 manuscripts were included. Male gender (RR 1.42), diabetes mellitus (DM) (RR 1.72), smoking (RR1.29), a lower extremity fracture (RR 1.94), Gustilo-Anderson grade III open fracture (RR 3.01), contaminated fracture (RR 7.85) and polytrauma patients (RR 1.49) were identified as statistically significant risk factors for the development of infectious complications. Of the treatment-related risk factors, only pulsatile lavage was associated with a higher infectious complication rate (RR 2.70). A number of risk factors for the development of infections after open fractures have been identified in the available literature. These factors should still be tested for independence in a multivariable model. Prospective, observational studies are needed to identify and quantify individual risk factors for infection after open fracture fixation.
Shibuya, Naohiro; Liu, George T; Davis, Matthew L; Grossman, Jordan P; Jupiter, Daniel C
A limited number of studies have described the epidemiology of open fractures, and the epidemiology of open ankle fractures is not an exception. Therefore, the risk factors associated with open ankle fractures have not been extensively evaluated. The frequencies and proportions of open ankle fractures among all the recorded malleolar fractures in the US National Trauma Data Bank data set from January 2007 to December 2011 were analyzed. Clinically relevant variables captured in the data set were also used to evaluate the risk factors associated with open ankle fractures, adjusting for other covariates. The entire cohort was further subdivided into "lower" and "higher" energy trauma groups and the same analysis performed for each group separately. We found that a body mass index of >40 kg/m(2) and farm location were risk factors for open ankle fractures and impaired sensorium was protective against open ankle fractures. In the "lower energy" group, male gender, alcohol use, peripheral vascular disease, other injuries, and injury occurring at a farm location were risk factors for open fractures. In the "higher energy" group, female gender, work-related injury, and injury at a farm or industry location demonstrated statistically significantly associations with open fractures. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Zhu, Hongyi; Li, Xingwei; Zheng, Xianyou
Aims . In this work, the main objectives were to investigate the clinical characteristics and bacterial spectrum present in open fractures contaminated by seawater. Methods . We conducted a retrospective cohort study and included all patients with open fractures from 1st January, 2012, to 31st December, 2015, in our hospital. Patients were grouped based on the presence of seawater contamination in wounds. We compared the infection rate, bacterial spectrum, and antibiotic resistance between the two groups. Results . We totally included 1337 cases of open fracture. Wounds from 107 cases (8.0%) were contaminated by seawater. The wound infection rate of seawater-contaminated group was significantly higher in patients with Gustilo-Anderson Type II and Type III open fractures. The bacterial spectrum from seawater-contaminated wounds was remarkably different from that of the remaining. Antibiotic sensitivity tests revealed that more than 90% of infecting pathogens in seawater-contaminated wounds were sensitive to levofloxacin and ciprofloxacin. Conclusion . Cephalosporin in combination with quinolone was recommended in the early-stage management of open fractures contaminated by seawater.
Tiemdjo, H G; Coulibaly, T; Touré, A A
Open tibiofibular fractures resulting from domestic animal bites are exceptional. We report two such cases, in patients of 11 and 13 years of age, and discuss the etiological, pathogenic, anatomic, and clinical aspects of these injuries. These were type III fractures according to the Cauchoix and Duparc classification. The fractures were treated with emergency wound care, wound dressing, and conservative orthopaedic treatment using a long leg cast for immobilization. Preventive parenteral antibiotics were also given. Evolution was favorable in both cases and the patients returned to their normal activities with no substantial disability. 2009 Elsevier Masson SAS. All rights reserved.
Niezen, E T; Stuive, I; Post, W J; Bos, R R M; Dijkstra, P U
The aim of this retrospective study was to assess recovery of mouth opening after closed treatment of fractures of the mandibular condyle, and analyse which characteristics might influence recovery. We measured mouth opening in 142 patients (mean (SD) age 30 (14) years, 96 of whom were male) during follow-up at 3, 6, 13, 26, and 52 weeks after the injury. Fractures were assessed on radiographs. Data were analysed using a multilevel analysis. Half the fractures were of the low condylar neck (n=71). Thirty-seven patients had bilateral condylar fractures, 29 had dislocated fractures, and in 80 the fracture was displaced. One or more additional mandibular fractures were present in 68. During follow-up mean (SD) mouth opening increased to: 33.6 (9.6) at 3 weeks, 40.1 (10.0) at 6 weeks, 45.1 (9.6) at 13 weeks, 49.8 (9.5) at 26 weeks, and 52.6 (7.5) at 52 weeks. Older age, female sex, displaced fracture, bilateral fractures, additional mandibular fractures, and the interaction between follow-up time and additional mandibular fractures, were predictors of a less favourable recovery of mouth opening. Clinicians can use the results of this study to predict recovery of mouth opening after closed treatment of fractures of the mandibular condyle at first consultation. Copyright © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Shiju, Muhammed; Rastogi, Sanjay; Gupta, Prashant; Kukreja, Sumedha; Thomas, Roy; Bhugra, Amit Kumar; Parvatha Reddy, Mahendra; Choudhury, Rupshikha
The aim of this prospective randomized controlled study was to evaluate the superiority of open method of treatment of mandibular condylar fracture over closed method of treatment by comparing them. Out of a total of 50 randomized patients fractures of the mandibular condylar process completed the study and were evaluated. All fractures were displaced, being either angulated between 10° and 45°. The follow-up examinations 1st day, 2nd day, 1st week, 2nd week, 6th week, and 6 months following treatment included clinical evaluation of functional and subjective parameters including visual analogue scale for pain and the interincisal mouth opening, malocclusion, deviation of mouth, range of motion, radiographic measurements were done. No significant difference was found between the two groups in the maximal interincisal opening, range of movements and TMJ pain. However statistically significant difference was seen in the anatomic reduction of condyle, shortening of ascending ramus, occlusal status and deviation on mouth opening on immediate postoperative phase. Both treatment options for condylar fractures of the mandible yielded acceptable results. However, a statistically significant difference was seen in the anatomic reduction of the condyle and there was no deviation on maximum mouth opening in patients treated with open reduction and internal fixation which suggests its superiority over closed method. Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
CHENG, QIAN; ZHANG, XIAO-FEI; DI, DONG-HUA; ZHAO, GUO-YANG; CUI, XUE-WEN
Contaminating bacteria are only found on wound surfaces in the initial stages of open fractures; therefore, effective debridement is critical for bacterial infection prevention and the reduction of inflammatory reactions. Various irrigation solutions are currently being used; however, a comprehensive study on their efficacy is lacking. In the present study, a comparison of the effects of normal saline, iodophor and hydrogen peroxide as the irrigation solutions for debridement of open femur fractures in rat models was conducted. It was revealed that all three solutions were comparably effective in bacterial removal while normal saline was superior in minimizing adverse wound inflammation; therefore, the use of normal saline for routine debridement is recommended in the early-stage treatment of open fractures in the trauma clinic and in relief fieldwork. PMID:26136863
Mafi, Pouya; Stanley, James; Hindocha, Sandip; Mafi, Reza
Pilon fractures are complex and difficult-to-treat fractures of the lower extremity that account for about 1% of all lower extremity fractures and up to 10% of tibial fractures. The injury is caused by high energy axial load either from motor vehicle accidents or a fall from height. The treatment of these fractures has caused controversy among surgeons due to mixed outcomes. Here we report a case of pilon fracture in a 45 year old male patient who has sustained the injury as a result of a fall from a height of approximately 12 feet. We describe why it is absolutely crucial that the patient is treated with external fixation initially and evaluate its merits and drawbacks as well as ways to minimize the complications associated with external fixation of open intra-articular distal tibial fractures.
Bond, C. E.; Wightman, R.; Ringrose, P. S.
Carbon mitigation through the geological storage of carbon dioxide is dependent on the ability of geological formations to store CO2 trapping it within a geological storage complex. Secure long-term containment needs to be demonstrated, due to both political and social drivers, meaning that this containment must be verifiable over periods of 100-105 years. The effectiveness of sub-surface geological storage systems is dependent on trapping CO2 within a volume of rock and is reliant on the integrity of the surrounding rocks, including their chemical and physical properties, to inhibit migration to the surface. Oil and gas reservoir production data, and field evidence show that fracture networks have the potential to act as focused pathways for fluid movement. Fracture networks can allow large volumes of fluid to migrate to the surface within the time scales of interest. In this paper we demonstrate the importance of predicting the effects of fracture networks in storage, using a case study from the In Salah CO2 storage site, and show how the fracture permeability is closely controlled by the stress regime that determines the open fracture network. Our workflow combines well data of imaged fractures, with a discrete fracture network (DFN) model of tectonically induced fractures, within the horizon of interest. The modelled and observed fractures have been compared and combined with present day stress data to predict the open fracture network and its implications for anisotropic movement of CO2 in the sub-surface. The created fracture network model has been used to calculate the 2D permeability tensor for the reservoir for two scenarios: 1) a model in which all fractures are permeable, based on the whole DFN model and 2) those fractures determined to be in dilatational failure under the present day stress regime, a sub-set of the DFN. The resulting permeability anisotropy tensors show distinct anisotropies for the predicted CO2 movement within the reservoir. These
Schenker, Mara L; Ahn, Jaimo; Donegan, Derek; Mehta, Samir; Baldwin, Keith D
The aim of this study was to evaluate the additional cost associated with performing after-hours operative debridement of open fractures within 6 hours of injury. The economic model is based on population estimates obtained from the National Trauma Database and the National Inpatient Sample on the number of open tibia fractures that occur annually in the United States and the number that present after-hours (between 6 PM and 2 AM) that undergo operative debridement within 6 hours. This model estimates incremental cost for after-hours surgery based on overtime wages for on-call personnel (nurses and surgical technicians) required to staff after-hours cases as published by the US Department of Labor and data from our own institution. As many level 1 hospitals are capable of performing after-hours cases without additional cost, a sensitivity analysis was performed to determine the effect of designated level of care of the trauma hospital. A total of 17,414 open tibia fractures were recorded in the National Inpatient Sample for 2009, and an estimated 7485 open tibia fractures presented after-hours, 4242 of which underwent operative debridement within 6 hours of presentation. Based on wage statistics from the US Department of Labor and our own institution, the estimated total additional cost for after-hours operative debridement of open tibia fractures within 6 hours is from $2,210,895 to $4,046,648 annually, respectively. For level 2 hospitals and below, the cost of performing after-hours operative debridement of open tibia fractures is calculated as from $1,532,980 to $2,805,846 annually. The data indicated an increased overall financial cost of performing after-hours operative debridement of open tibia fractures. Given that there is minimal documented benefit to this practice, and with increased pressure to practice cost containment, elective delay of operative debridement of open fractures and/or transfer to a higher level of care trauma hospital may be an
Briem, Kristin; Ramsey, Dan K; Newcomb, William; Rudolph, Katherine S; Snyder-Mackler, Lynn
The goal of opening wedge high tibial osteotomy (HTO) is to reduce excessive loading on the medial compartment of the knee by correcting varus deformity, thereby reducing pain and improving function. Although surgical outcome is reportedly poor in cases of under- or overcorrection, the recommended alignment varies. The aim of this study was to investigate the effect of the degree of frontal plane knee alignment following open wedge HTO surgery on muscle co-contraction, joint moments, and self-reported functional outcome. Sixteen patients with medial compartment osteoarthritis (OA), who were scheduled for an opening wedge osteotomy, were recruited for participation in the study. Data were collected using an optoeletric motion analysis system and varus and valgus angulations of the knee were measured, using standing, long cassette, radiographs of the lower extremities. Results showed that physical function improved significantly overall (p < 0.001). However, those subjects whose knee alignment was further away from the group's postoperative mean tended to improve less in their Knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS) scores than those closer to the mean (p = 0.07). They also had higher medial and lateral co-contractions and higher adduction moments one year after surgery (p
Lee, Hyun Il; Park, Dongjun; Cho, Jinho
To identify the structural integrity of the healing site after medial open wedge high tibial osteotomy (MOWHTO) in patients with a posterior root tear of the medial meniscus (PRTMM) and chondral lesion by second-look arthroscopy and to determine the clinical and radiological findings. From August 2010 to June 2016, 52 consecutive patients underwent MOWHTO and arthroscopic examination without a chondral resurfacing procedure and meniscal treatment for PRTMM. Twenty-four patients were available for second-look arthroscopic evaluation. The mean follow-up period was 19.5 months (range, 5 to 46 months). Clinical evaluation was based on the Lysholm knee scores and Hospital for Special Surgery (HSS) scores. There were 5 lax healing, 6 scar tissue, 13 failed healing of PRTMM. Definite change of chondral lesion was not observed. The Kellgren-Lawrence grade did not improve according to the follow-up plain radiograph. The mean Lysholm score improved from 34.7 preoperatively to 77.1 at the last follow-up, and the mean HSS score significantly increased from 36.5 to 82.4. This study revealed a low rate of healing potency of PRTMM and chondral lesion after MOWHTO without any attempt for meniscal treatment or chondral resurfacing. The cartilage and healing status of PRTMM was not associated with improved clinical outcomes and radiological findings.
Berlusconi, M; Busnelli, L; Chiodini, F; Portinaro, N
The role of stabilisation of the fibula in distal two-bone fractures of the leg is controversial. Some studies indicate the need for fibular stabilisation in 43 AO fractures, but few studies consider the role of the fibula in 42 AO fractures. The aim of the current paper is to explain the role of stabilisation of the fibula in 42 AO fractures, correlating the rates of healing and non-union between patients with and without fibula fixation. A total of 60 patients with 42 AO (distal) shaft fracture of the tibia with associated fracture of the fibula were selected. Patients were divided into two groups according to whether or not the fibula was fixed: Group I (n=26) comprised patients who had their fibula fixed while Group II (n=34) comprised patients who did not. The fibular fracture was classified according to the AO and related to the level of the tibial fracture. Other parameters examined were the union rate of the two groups correlated to the fracture pattern and position of the fibular fracture; the demographic data, such as age and gender; the presence of an open fracture, and the type of tibial fixation device used (nail or plate). None of the parameters considered (open injury, AO classification, device used and level of the fibular fracture relative to the tibial) were shown to have an influence on the development of a non-union. This study showed a higher non-union rate when the fracture of the tibia and fibula were at the same level, the tibia was fixed with a bridging plate and the fibula left untouched. For this reason, we recommend fibular fixation in all 42 distal fractures when both fractures lie on the same plane and the tibial fracture is relatively stabilised. Copyright © 2013 Elsevier Ltd. All rights reserved.
Singh, D; Garg, R; Bassi, J L; Tripathi, S K
Open grade III fractures of femur are a challenging therapeutic problem as most of them are associated with multiple trauma. Method used for skeletal stabilization of these fractures should limit further soft tissue damage, bacterial spread and morbidity in addition to its ease of application, providing mechanical support and restoring normal alignment. Forty-six patients with open grade III fractures of femoral shaft were included in the study. There were 10 grade IIIA, 34 grade IIIB and two grade IIIC fractures that were treated with early reamed intramedullary nailing with adequate management of soft tissue. Patients were reviewed retrospectively. Mean time of union was 27 weeks. Infection rate was 4% and non-union rate was 9%. There were two cases (4%) with limb shortening. No case of angular or rotational deformity was noted. Early reamed intramedullary nailing for open grade III fractures of femoral shaft, after giving due respect to the soft tissue injury, gives satisfactory results with proper alignment, good range of motion, short rehabilitation period and low infection rate. Level IV. Retrospective therapeutic study. Copyright © 2011 Elsevier Masson SAS. All rights reserved.
Scolaro, John A; Roberts, Zachary V; Benirschke, Stephen K; Barei, David P
Simultaneous ipsilateral fractures of the calcaneus and fibula are the result of high-energy injuries. Open surgical treatment of both fractures can be performed with incisions based on the described blood supply of the lower extremity. A retrospective review for all patients with ipsilateral fractures of the calcaneus and fibula was performed over an eight-year period. Thirty-eight patients were identified. Eleven patients (28.9%) were treated with open reduction and internal fixation through two separate incisions. Average follow-up was 48.8 weeks. Two patients (18.1%) required a secondary procedure. Three patients (27.2%) developed incisional cellulitis that resolved with oral antibiotics and one patient required local wound care. All fractures united. Ipsilateral fractures of the calcaneus and fibula require open reduction and internal fixation when closed or percutaneous treatment is not appropriate. We describe an operative approach based on the angiosomes of the lower extremity that allows for treatment of these complex injuries and report the associated complications. Copyright © 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Lindsey, Brock A; Clovis, Nina B; Smith, E Suzanne; Salihu, Sydha; Hubbard, David F
Infection is an everyday problem in orthopaedics and is quite common in open fracture management. To study this process and provide a basis to prevent infection, we developed a model that includes trauma (blunt fracture in the fashion of Bonnarens and Einhorn), surgical stabilization (standardized intramedullary K-wire fixation), and infection (Staphylococcus aureus inoculum). In this two-part study, we found that 10(2) colony-forming units of inoculum produced an optimal infection rate of 90-100%, which substantially challenged the immune system without overwhelming sepsis. We hypothesized that, in traumatic fractures, there is a specific immunological response that may lead to an increased rate of infection. In Part 2, we demonstrated immunosuppression (decreased Interleukin-12 levels) at days 6, 10, and 12 after fracture fixation versus nonfractured control groups (p < 0.05). This study describes a rat model of femur factures with osteomyelitis that allows investigation of posttraumatic immunosuppression.
Bevevino, Adam J; Dickens, Jonathan F; Potter, Benjamin K; Dworak, Theodora; Gordon, Wade; Forsberg, Jonathan A
Open calcaneus fractures can be limb threatening and almost universally result in some measure of long-term disability. A major goal of initial management in patients with these injuries is setting appropriate expectations and discussing the likelihood of limb salvage, yet there are few tools that assist in predicting the outcome of this difficult fracture pattern. We developed two decision support tools, an artificial neural network and a logistic regression model, based on presenting data from severe combat-related open calcaneus fractures. We then determined which model more accurately estimated the likelihood of amputation and which was better suited for clinical use. Injury-specific data were collected from wounded active-duty service members who sustained combat-related open calcaneus fractures between 2003 and 2012. One-hundred fifty-five open calcaneus fractures met inclusion criteria. Median followup was 3.5 years (interquartile range: 1.5, 5.1 years), and amputation rate was 44%. We developed an artificial neural network designed to estimate the likelihood of amputation, using information available on presentation. For comparison, a conventional logistic regression model was developed with variables identified on univariate analysis. We determined which model more accurately estimated the likelihood of amputation using receiver operating characteristic analysis. Decision curve analysis was then performed to determine each model's clinical utility. An artificial neural network that contained eight presenting features resulted in smaller error. The eight features that contributed to the most predictive model were American Society of Anesthesiologist grade, plantar sensation, fracture treatment before arrival, Gustilo-Anderson fracture type, Sanders fracture classification, vascular injury, male sex, and dismounted blast mechanism. The artificial neural network was 30% more accurate, with an area under the curve of 0.8 (compared to 0.65 for logistic
Thomason, Katherine; Ramesh, Ashwanth; McGoldrick, Niall; Cove, Richard; Walsh, James C; Stephens, Michael M
Primary ankle arthrodesis used to treat a neglected open ankle fracture dislocation is a unique decision. A 63-year-old man presented to the emergency department with a 5-day-old open fracture dislocation of his right ankle. After thorough soft tissue debridement, primary arthrodesis of the tibiotalar joint was performed using initial Kirschner wire fixation and an external fixator. Definitive soft tissue coverage was later achieved using a latissimus dorsi free flap. The fusion was consolidated to salvage the limb from amputation. The use of primary arthrodesis to treat a compound ankle fracture dislocation has not been previously described. Copyright © 2014 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Malhotra, Ajai Kumar; Goldberg, Stephanie; Graham, Jeffery; Malhotra, Nancy R; Willis, Mark C; Mounasamy, Varatharaj; Guilford, Kelly; Duane, Therese M; Aboutanos, Michel B; Mayglothling, Julie; Ivatury, Rao R
Early (<8 hours) operative debridement and irrigation (D&I) of open fractures are considered essential to reduce the risk of deep infection. With the advent of powerful antimicrobials, this axiom has been challenged. The current study evaluates the rates of deep infections of open fractures in relation to the time to the first D&I. A list of all blunt open fractures during a 6-year period was obtained from the trauma registry. Patients were evaluated for age, Injury Severity Score (ISS), physiologic derangement (systolic blood pressure, lactate, Revised Trauma Score [RTS]), and fracture type (Gustilo). Time to the first D&I was calculated. All patients received appropriate prophylactic antimicrobials. Infection rates were calculated and correlated to the time to the first D&I (<8 hours vs. >8 hours). Regression analysis was performed to identify independent predictors of infection. During the 72-month study period, 404 patients met entry criteria, with 415 open extremity fractures (upper, 129; lower, 287). Early (<8 hours) and delayed (>8 hours) groups were well matched, although the age was lower and ISS was higher in the group with greater than 8 hours. The rates of infection were 35 (11%) of 328 (<8 hour) and 17 (19%) of 87 (>8 hours) (p < 0.05). When fractures were subgrouped by extremity, for the lower extremity, both a delay of greater than 8 hours and higher Gustilo type correlated with the development of infection. In the upper extremity, only higher Gustilo type correlated, and a delay to the first D&I did not increase the incidence of infection. Regression analysis revealed that higher ISS (odd ratio [OR], 1.052; 95% confidence interval [CI], 1.019-1.086), Gustilo grade, and a delay of greater than 8 hours (OR, 2.035; 95% CI, 1.022-4.054) were independent predictors of infection for the all-extremity model. Separate models for upper and lower extremities showed that the same three parameters were independent predictors for the lower extremity (ISS: OR, 1
Assessment of bone healing on tibial fractures treated with wire osteosynthesis associated or not with infrared laser light and biphasic ceramic bone graft (HATCP) and guided bone regeneration (GBR): Raman spectroscopy study
Bastos de Carvalho, Fabíola; Aciole, Gilberth Tadeu S.; Aciole, Jouber Mateus S.; Silveira, Landulfo, Jr.; Nunes dos Santos, Jean; Pinheiro, Antônio L. B.
The aim of this study was to evaluate, through Raman spectroscopy, the repair of complete tibial fracture in rabbits fixed with wire osteosynthesis - WO, treated or not with infrared laser light (λ 780nm, 50mW, CW) associated or not to the use of HATCP and GBR. Surgical fractures were created under general anesthesia (Ketamine 0.4ml/Kg IP and Xilazine 0.2ml/Kg IP), on the tibia of 15 rabbits that were divided into 5 groups and maintained on individual cages, at day/night cycle, fed with solid laboratory pelted diet and had water ad libidum. On groups II, III, IV and V the fracture was fixed with WO. Animals of groups III and V were grafted with hydroxyapatite + GBR technique. Animals of groups IV and V were irradiated at every other day during two weeks (16J/cm2, 4 x 4J/cm2). Observation time was that of 30 days. After animal death the specimens were kept in liquid nitrogen for further analysis by Raman spectroscopy. Raman spectroscopy showed significant differences between groups (p<0.001). It is concluded that IR laser light was able to accelerate fracture healing and the association with HATCP and GBR resulted on increased deposition of calcium hydroxyapatite.
Raj, Manish; Kumar, Sunil; Singh, Pulkesh; Kumar, Dinesh; Singh, Jasveer; Deep, Akash
Introduction Management of compound grade III fractures of both bone leg includes external stabilization for long period, followed by various soft tissue coverage procedures. Primary interlocking of tibia had been also done with variable results. External fixation for long time without any bone loss often leads to infected nonunion, loss of reduction, pin tract infection and failure of fixation, primary interlocking in compound grade III fractures had shown high medullary infection rate. We managed all cases of compound grade III A/B fractures with primary external fixation, simultaneous wound management using vacuum assisted closure (VAC) followed by early conversion to interlocking within 2 weeks of fixator application. Aim To determine the effectiveness of vacuum assisted closure (VAC) for the early conversion of external fixator to definitive interlocking in open fractures of the both bone leg. Materials and Methods In current study we selected 84 cases of compound grade IIIA/B diaphyseal fractures of both bone leg during period of May 2010 to September 2013. We managed these cases by immediate debridement and application of external fixation followed by repeated debridement, application of vacuum assisted closure (VAC) and conversion to interlocking within two weeks. Results Out of 84 cases union was achieved in 80(95%) of cases with definitive tibial interlocking. Excellent to good result were obtained in 77(91.8%) of cases and fair to poor result seen in rest of 7(8.2%) of cases according to modified Ketenjian’s criteria. 5 out of these 7 poor result group cases were from Compound Grade III B group to start with. Deep infection rate in our series were 7% i.e. total 6 cases and 4 out of these were from compound Grade III B group to start with. Conclusion Vacuum assisted closure (VAC) give a good help for rapid closure of the wound and help in early conversion to definitive intramedullary nailing. Reamed nail could well be used in compound grade IIIA
Gill, Simrat Pal Singh; Raj, Manish; Kumar, Sunil; Singh, Pulkesh; Kumar, Dinesh; Singh, Jasveer; Deep, Akash
Management of compound grade III fractures of both bone leg includes external stabilization for long period, followed by various soft tissue coverage procedures. Primary interlocking of tibia had been also done with variable results. External fixation for long time without any bone loss often leads to infected nonunion, loss of reduction, pin tract infection and failure of fixation, primary interlocking in compound grade III fractures had shown high medullary infection rate. We managed all cases of compound grade III A/B fractures with primary external fixation, simultaneous wound management using vacuum assisted closure (VAC) followed by early conversion to interlocking within 2 weeks of fixator application. To determine the effectiveness of vacuum assisted closure (VAC) for the early conversion of external fixator to definitive interlocking in open fractures of the both bone leg. In current study we selected 84 cases of compound grade IIIA/B diaphyseal fractures of both bone leg during period of May 2010 to September 2013. We managed these cases by immediate debridement and application of external fixation followed by repeated debridement, application of vacuum assisted closure (VAC) and conversion to interlocking within two weeks. Out of 84 cases union was achieved in 80(95%) of cases with definitive tibial interlocking. Excellent to good result were obtained in 77(91.8%) of cases and fair to poor result seen in rest of 7(8.2%) of cases according to modified Ketenjian's criteria. 5 out of these 7 poor result group cases were from Compound Grade III B group to start with. Deep infection rate in our series were 7% i.e. total 6 cases and 4 out of these were from compound Grade III B group to start with. Vacuum assisted closure (VAC) give a good help for rapid closure of the wound and help in early conversion to definitive intramedullary nailing. Reamed nail could well be used in compound grade IIIA/B fractures without increasing the risk of infection. It gives
Petrisor, Brad; Jeray, Kyle; Schemitsch, Emil; Hanson, Beate; Sprague, Sheila; Sanders, David; Bhandari, Mohit
Background Although surgeons acknowledge the importance of irrigating open fracture wounds, the choice of irrigating fluid and delivery pressure remains controversial. Our objective was to clarify current opinion with regard to the irrigation of open fracture wounds. Methods We used a cross-sectional survey and a sample-to-redundancy strategy to examine surgeons' preferences in the initial management of open fracture wounds. We mailed this survey to members of the Canadian Orthopaedic Association and delivered it to attendees of an international fracture course (AO, Davos, Switzerland). Results Of the 1,764 surgeons who received the questionnaire, 984 (55.8%) responded. In the management of open wounds, the majority of surgeons surveyed, 676 (70.5%), favoured normal saline alone. Bacitracin solution was used routinely by only 161 surgeons (16.8%). The majority of surgeons, 695 (71%) used low pressures when delivering the irrigating solution to the wound. There was, however considerable variation in what pressures constituted high versus low pressure lavage. The overwhelming majority of surgeons, 889 (94.2%), reported they would change their practice if a large randomized controlled trial showed a clear benefit of an irrigating solution – especially if it was different from the solution they used. Conclusion The majority of surgeons favour both normal saline and low pressure lavage for the initial management of open fracture wounds. However, opinions varied as regards the comparative efficacy of different solutions, the use of additives and high versus low pressure. Surgeons have expressed considerable support for a trial evaluating both irrigating solutions and pressures. PMID:18215287
Osti, Michael; Gohm, Alexander; Benedetto, Karl Peter
The present study evaluates the clinical and radiological outcome following open reconstruction of avulsion fractures of the anterior glenoid rim in traumatic shoulder dislocation. A total of 20 patients (mean age 49.4 years) were treated with open reduction and cannulated screw fixation. Eighteen patients were available for clinical and radiological follow-up after 3.1 (2.0-6.5) years. The average Constant Score was 78 and the average Rowe Score was 90 points. Documented complications were implant failure in one and neurological dysfunction in one patient. Radiographs revealed the bony fragment located in an unimproved displaced position in one patient and a progress in osteoarthritic changes in three patients. No recurrent subluxation or dislocation was observed. Open reconstruction of glenoid rim fractures is a valuable procedure regarding medium-term subjective and objective outcome measures. Recurrent dislocation, glenoid defects and early onset of osteoarthritic degeneration can be avoided.
Ng, Alan; Barnes, Esther S
The management of complications resulting from the open reduction and internal fixation of ankle fractures is discussed in detail. The initial radiographic findings of the most common postsurgical complications of ankle fracture reduction are briefly discussed, namely lateral, medial, and posterior malleolar malunion or nonunion, syndesmotic widening, degenerative changes, and septic arthritis with or without concomitant osteomyelitis. Emphasis is placed on the management of these complications, with a review of the treatment options proposed in the literature, a detailed discussion of the authors' recommendations, and an inclusion of different case presentations.
Yang, Minghui; Zhu, Shiwen; Gao, Zhiqiang; An, Guisheng
To explore the clinical outcomes of open distal radius fractures managed with bridging external fixator and Kirschner-wire. Retrospective reviews were conducted for 9 patients with open distal radius fractures managed with bridging external fixator and Kirschner-wire between October 2009 and October 2010. There were 6 females and 3 males with a mean age at injury of 60.0 (17-79) years. The mechanisms were fall from standing height (n = 5), fall from height >2 meters (n = 1) and traffic accident (n = 2). The average time from injury to operation was 7.2 (4-9) hours. According to the Gustilo and Anderson classification, the grades were I (n = 2),II (n = 3) and IIIA (n = 4). Two patients had additional injuries in other areas.Four patients had associated tendon, nerve or artery injury around wrist.One patient had ipsilateral forearm compartment syndrome. The clinical and radiological outcomes were followed. According to the AO/OTA classification, there were A2 (n = 1),A3 (n = 4) and C3 (n = 4).Seven patients had distal ulnar fractures and 4 suffered a dislocation of DRUJ (distal radial ulnar joint). All distal radius fractures were fixed with bridging external fixator and Kirschner-wire. Percutaneous pin fixation of DRUJ was performed in 4 patients because of instability of radial or ulnar fractures.Nine patients were followed up for an average period of 2.8 (1.9-3.5) years. According to the modified Green and O'Brien score, the clinical outcome at the time of final follow-up was graded as excellent (n = 2), good (n = 4), fair (n = 1) and poor (n = 2). All fractures were healed. The complications included fixation failure and revision (n = 1), fixator pin site infection (n = 2) and Kirschner-wire loosening (n = 5). The outcomes of open distal radius fractures managed with bridging external fixator and Kirschner-wire are unsatisfactory. And this fixation method may not be optimal for all open distal radius fractures.
Lee, O-Sung; Ahn, Soyeon; Lee, Yong Seuk
The aim of this meta-analysis was to compare the effects of closing-wedge (CW) and opening-wedge (OW) high tibial osteotomies (HTOs) on the change in leg length. Our hypotheses were that leg length will increase after OW HTO and decrease after CW HTO, and the magnitude of the change in leg length would be negligible in both techniques. Multiple databases including MEDLINE, Embase, and Cochrane were searched for studies comparing the change in leg length after HTO with that before HTO. After testing for publication bias and heterogeneity, we aggregated variables by using the random-effects model. The weighted mean differences of leg length were estimated before and after OW and CW HTOs with 95% confidence intervals (CIs). Four studies that analyzed 127 OW HTOs and 175 CW HTOs were included in this meta-analysis. Leg length increased by 6.96 mm after OW HTO (95% CI: -3.43 to 17.36) and decreased by 1.95 mm after CW HTO (95% CI: -10.89 to 7). Additionally, the change in leg length after OW HTO had a positive correlation with the degree of correction. The leg length increased after OW HTO, and the increase was sufficiently large to cause clinical concerns. The change in leg length after CW HTO was negligible despite the decrease in length. Therefore, CW HTO seems to be a better treatment option than OW HTO if a large correction is required. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Twardosz, Wojciech; Tondel, Wieslaw; Olewicz-Gawlik, Anna; Hrycaj, Pawel
The results of operative treatment of two groups of patients with articular fractures of the calcaneus were evaluated. Twenty-three cases were treated surgically using a standard reconstruction procedure. In the second group of 19 patients a large bone distractor was used; it held the soft tissue flap retracted, while aiding in articular and tuberosity fragment reduction and increasing visualisation by distraction of the posterior talocalcaneal joint. After a year, the anatomical and functional results, together with the operative time, were evaluated. All fractures healed with good or very good anatomical results. All cases, except those with complications (n = 3), achieved good (n = 28) or very good (n = 11) functional scoring. The distractor group had significantly shorter operative times, and less manpower was needed during surgery. We conclude that the large bone distractor is a useful tool in open reconstruction of articular calcaneal fractures. PMID:19404639
Ho, Susan Yu-Chen; Liao, Han-Tsung; Chen, Chih-Hao; Chen, Yi-Chieh; Chen, Yu-Ray; Chen, Chien-Tzung
Bilateral mandibular condylar fractures accounts for 24% to 33% of condylar fractures but the indications of open reduction of bilateral condylar fracture are still controversial. It is generally accepted that displaced subcondylar fractures are indicated for open reduction, but the proper treatment of condylar head fractures are still variable. This retrospective study compares the radiographical and functional outcomes of bilateral condylar head fractures between open and closed reduction groups. From February 1994 to June 2012, a total of 85 patients with bilateral condylar head fractures were retrospectively reviewed. Among this group, 41 cases underwent open reductions while the other 44 cases had closed reductions. Only adult patients with adequate follow-up and complete radiographic study were included in this study: consisting of 20 patients in the open group and 18 patients in the closed group.The subjective symptoms including temporomandibular joints (TMJ) symptoms, complications or adverse sequelae, and functional results, such as maximal mouth opening, were recorded. The outcome of patient's satisfaction was individually assessed by an independent reviewer. The computed tomographic results after treatment were evaluated between both groups. The mean follow-up period was 25.5±13.3 months. The open reduction group had better postoperative chewing functions, less malocclusion rates, less degree of TMJ pain (p=0.046), better radiographic outcome (p=0.036), and an overall satisfaction rate (p=0.039).There were 4 cases of failure in the closed reduction group. Subsequent open reduction (n=2) and redo closed reduction with intermaxillary fixation (n=2) were performed. Eleven patients in the close reduction group presented persistent malocclusion through objective evaluation. The subsequent treatment included further orthognathic surgery (n=1) and orthodontic treatment (n=7). Three of the patients refused further treatment. Open reduction for bilateral
Zoghbi, Yasmina; Gerth, David J; Tashiro, Jun; Lee, Albert; Thaller, Seth R
Maxillary fractures are frequently managed depending on the surgeon's preferences, nature of the injury, presence of associated injuries, and comorbidities. Current literature advocates open reduction with plating versus closed techniques. However, data defining associated costs and complications comparing the 2 approaches remains lacking. National Inpatient Sample (2006-2011) was examined for patients undergoing closed or open (76.73-76.74) reduction of maxillary fractures. Treatment-related complications were regarded as re-exploration of surgical site, hemorrhage, hematoma, seroma, wound infection, and dehiscence. Overall, 22,157 patients were identified. There were 18,874 closed and 3283 open procedures. Median age was 35 (interquartile range 27). Median length of stay (LOS) was 4 days. Median total charges were reported as 51486.80 USD. Males comprised 77% of the cohort. 68% of patients were Caucasian. Private payer/HMO accounted for the largest source of health care coverage (43.5%). On risk-adjusted multivariate analysis, there was no difference in surgical approach regarding incidence of postoperative complications. Males (2.73), nonprivate insurer payer (P = 0.002), South region (2.49), and transferred patients (2.55) had higher incidence of complications. Presence of chronic pulmonary disease (2.87) and coagulopathy (6.62) also increased risk of complications. Length of stay was shorter for open reduction (0.68) versus closed. Total charges were also less for open approach (0.37). While surgical approach did not affect complications, open approach favorably affected LOS and total charges. Future studies should focus on comorbidities, demographics, and associated injuries in relation to resource utilization for maxillary fractures. In current economic environment, such information might further dictate management options.
Qi, Yong; Sun, Hong-Tao; Fan, Yue-Guang; Li, Fei-Meng; Lin, Zhou-Sheng
The presence of large segmental defects of the diaphyseal bone is challenging for orthopedic surgeons. Free vascularized fibular grafting (FVFG) is considered to be a reliable reconstructive procedure. Stress fractures are a common complication following this surgery, and hypertrophy is the main physiological change of the grafted fibula. The exact mechanism of hypertrophy is not completely known. To the best of our knowledge, no studies have examined the possible relationship between stress fractures and hypertrophy. We herein report three cases of patients underwent FVFG. Two of them developed stress fractures and significant hypertrophy, while the remaining patient developed neither stress fractures nor significant hypertrophy. This phenomenon indicates that a relationship may exist between stress fractures and hypertrophy of the grafted fibula, specifically, that the presence of a stress fracture may initiate the process of hypertrophy.
Bürkner, A; Simmen, H P
Though the injury patterns of the lower extremities in skiing have changed since 1970, tibial fractures remain daily work of hospitals near ski slopes. A lot of medical studies have analysed the relevance of well adjusted bindings of the common lesions of the knee joint ligaments. However the influence of the flexibility of the ski boot and the injury pattern has been neglected. 49 tibial fractures have been analysed in a hospital near a large ski resort in the alpes. All fractures occurred during alpine skiing. The type of the fracture, according to the AO-classification and the injury pattern have been documented. Also demographic data, ski experience and specification concerning the ski boot have been questioned. The type of the ski boot and the grade of flexibility, have been documented if possible. It has also been recorded whether the binding opened. In contrast to other studies our patients are represented in widely spread age-groups with a large share of elderly and experienced persons. Young or unexperienced sportsmen suffer primarily from fractures of the tibial diaphysis. With increasing skiing experience the injury pattern is widening on the whole leg. 62 % of all fractures are caused by rotation traumas. Compression, dorsal forces and direct collisions are the other causes. In 59 % of all accidents the binding failed to open. There is an increased risk of complex fractures in the proximal or distal epiphysis if the binding has not opened. 23 % of all fractures occurred with rented ski boots. Only 16 % of all ski boots are labelled with a flexibility index. There is no standardized value for the flexibility of ski boots. The trend can be derived that rigid ski boots with a high flexibility index cause above all fractures of the diaphysis. 10 % of all fractures happened to patients wearing "snowblades". These short skis without safety bindings contributed a considerable share to tibial fractures, even though there is no big leverage. Tibial fractures are
Ni, Yulong; Gao, Shunhong; Zhang, Jingyu; Dong, Huishuang; Zhang, Yunpeng; Fu, Jiansong
To investigate the effectiveness of tibial periosteal flap pedicled with intermuscular branch of posterior tibial vessels combined with autologous bone graft in the treatment of tibial bone defects. Between January 2007 and December 2013, 19 cases of traumatic tibia bone and soft tissue defects were treated. There were 14 males and 5 females, aged from 18 to 49 years (mean, 28 years). The tibial fracture site located at the middle tibia in 6 cases and at the distal tibia in 13 cases. According to Gustilo type, 4 cases were rated as type III A, 14 cases as type III B, and 1 case as type III C (injury of anterior tibial artery). The length of bone defect ranged from 4.3 to 8.5 cm (mean, 6.3 cm). The soft tissue defects ranged from 8 cm x 5 cm to 17 cm x 9 cm. The time from injury to operation was 3 to 8 hours (mean, 4 hours). One-stage operation included debridement, external fixation, and vacuum sealing drainage. After formation of granulation tissue, the fresh wound was repaired with sural neurovascular flap or posterior tibial artery perforator flap. The flap size ranged from 10 cmx6 cm to 19 cm x 11 cm. In two-stage operation, tibial periosteal flap pedicled with intermuscular branch of posterior tibial vessels combined with autologous bone graft was used to repair tibial defect. The periosteal flap ranged from 6.5 cm x 4.0 cm to 9.0 cm x 5.0 cm; bone graft ranged from 4.5 to 9.0 cm in length. External fixation was changed to internal fixation. All flaps survived with soft texture, and no ulcer and infection occurred. All incisions healed by the first intention. All patients were followed up 18-40 months (mean, between normal and affected sides.The function of the knee an ankle joint was good without infection, malunion, and equinus. According to the Johner standard at last follow-up, the results were excellent in 15 cases, good in 3 cases, and fair in 1 case, with an excellent and good rate of 94.7%. Tibial periosteal flap pedicled with intermuscular branch of
Asad, Waleed A; Younis, Manaf H S; Ahmed, Abdulaziz F; Ibrahim, Talal
Distal tibia physeal fractures can lead to growth complications such as premature physeal closure (PPC), angular deformity and leg length discrepancy. The aim of our study was to systematically review the literature to assess whether open reduction and internal fixation (ORIF) is associated with lower rates of PPC compared to closed treatment. We searched several databases from 1966 to 2016 for studies that evaluated ORIF versus closed treatment of distal tibia physeal fractures. We performed a meta-analysis using a random effects model to pool odds ratios (OR) for the comparison of PPC rate between children undergoing ORIF versus closed treatment. We also investigated the PPC rate in Salter-Harris (S-H) type I and II fractures. Descriptive, quantitative and qualitative data were extracted. Out of the 253 articles identified, six retrospective cohort studies were eligible, with a total of 970 distal tibia physeal fractures. The pooled OR of PPC between ORIF and closed treatment showed no statistically significant difference [OR = 0.98, 95% confidence interval (CI) 0.48, 1.97; I 2 = 49.8%, p = 0.076]. No significant difference in the rate of PPC was detected in S-H type I and II fractures with ORIF and closed treatment [OR = 1.25, 95% CI 0.72, 2.16; I 2 = 32.1%, p = 0.22]. The cumulative evidence at present does not indicate an association between the method of treatment of distal tibia physeal fractures and the risk of PPC. Both treatment types are feasible, but less surgical-related complications are associated with closed treatment. III.
Hasan, Saqib; Ayalon, Omri B; Yoon, Richard S; Sood, Amit; Militano, Ulises; Cavanaugh, Mark; Liporace, Frank A
Evolution of periarticular implant technology has led to stiffer, more stable fixation constructs. However, as plate options increase, comparisons between different sized constructs have not been performed. The purpose of this study is to biomechanically assess any significant differences between 3.5- and 4.5-mm locked tibial plateau plates in a simple bicondylar fracture model. A total of 24 synthetic composite bone models (12 Schatzker V and 12 Schatzker VI) specimens were tested. In each group, six specimens were fixed with a 3.5-mm locked proximal tibia plate and six specimens were fixed with a 4.5-mm locking plate. Testing measures included axial ramp loading to 500 N, cyclic loading to 10,000 cycles and axial load to failure. In the Schatzker V comparison model, there were no significant differences in inferior displacement or plastic deformation after 10, 100, 1,000 and 10,000 cycles. In regards to axial load, the 4.5-mm plate exhibited a significantly higher load to failure (P = 0.05). In the Schatzker VI comparison model, there were significant differences in inferior displacement or elastic deformation after 10, 100, 1,000, and 10,000 cycles. In regards to axial load, the 4.5-mm plate again exhibited a higher load to failure, but this was not statistically significant (P = 0.21). In the advent of technological advancement, periarticular locking plate technology has offered an invaluable option in treating bicondylar tibial plateau fractures. Comparing the biomechanical properties of 3.5- and 4.5-mm locking plates yielded no significant differences in cyclic loading, even in regards to elastic and plastic deformation. Not surprisingly, the 4.5-mm plate was more robust in axial load to failure, but only in the Schatzker V model. In our testing construct, overall, without significant differences, the smaller, lower-profile 3.5-mm plate seems to be a biomechanically sound option in the reconstruction of bicondylar plateau fractures.
Wetzel, Robert J; Minhas, Shobhit V; Patrick, Brittany C; Janicki, Joseph A
Treatment of pediatric type I open fractures is controversial. Centers have reported good success with emergency room (ER) treatment of low-energy (type I) open pediatric fractures. The purpose of this study was to ascertain the treatment preferences of pediatric orthopaedic surgeons for type I open fractures. We hypothesize that surgeons will have different treatment protocols and preferred location for these injuries. A questionnaire was given to Pediatric Orthopaedic Society of North America (POSNA) members at the 2012 annual meeting. Demographic questions inquired about surgeon's practice environment and experience, whereas clinical questions queried opinions regarding the typical treatments and past experiences with open fractures. Clinical scenarios questioned preferred management of open fractures. A total of 181 surveys were collected from the 503 POSNA members in attendance (36%). Years in practice were well represented with 34%: <10 years, 37%: 10 to 19 years, and 29%: >20 years. Most respondents' practices comprised over 80% pediatric patients (86%), were academic (68%), and worked with residents (77%). After initial treatment of an open fracture, 86% of respondents admitted patients for intravenous antibiotics and 57% gave oral antibiotics. There was no consensus regarding the amount or type of irrigation preferred, use of antibiotics in the irrigation, or whether the bone ends are delivered during irrigation and débridement. Soft-tissue infections and delayed union were noted by 13% and 8%, respectively, of respondents in type I open fractures treated in the ER and in 16% and 30% treated in the operating room (OR). ER treatment was preferred in 19% to 31% of respondents for type I open fractures. When queried if level 1 evidence existed that demonstrated equivalent results between ER and OR management, 92% of respondents would change their practice. Treatment methods of type I open fractures are variable. Many surgeons prefer to treat type I open
Chen, Da-Wei; Li, Bing; Aubeeluck, Ashwin; Yang, Yun-Feng; Zhou, Jia-Qian; Yu, Guang-Rong
Posterior pilon fractures are rare injuries and have not yet gained well recognition. The purpose of this study was to present the treatment outcome for patients with posterior pilon fractures treated with buttress plate. In this retrospective study we identified patients with posterior pilon fractures of the distal tibia who had undergone open reduction and internal fixation at our institute. Between January 2007 and December 2009, 10 patients (mean age, 46.5 years) who had undergone buttress plating via either a posterolateral approach or a dual posterolateral-posteromedial approach, were selected. All 10 patients were available for follow-up. The clinical outcome was evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the visual analogue scale (VAS). The radiological evaluation was performed using the osteoarthritis-score (OA-score). Satisfactory reduction and stable fixation were accomplished in all patients. At a mean follow-up of 36.2 months, all patients had good radiological results and showed satisfactory clinical recovery. The mean AOFAS sore was 87.8, the mean OA-score was 0.6, and the mean VAS scores during rest, active motion, and weight-bearing walking were 0.6, 0.8, and 1.4, respectively. Buttress plating for posterior pilon fractures gave satisfactory clinical outcomes. It also ensured rigid fixation which in turn enabled earlier postoperative mobilization. Level of Evidence IV, Retrospective Study.
Hamilton, Katie; Tarlton, John; Parsons, Kevin; Toscano, Mike; Burton, Neil
To measure the tensile force required for failure of the quadriceps mechanism with different tibial tuberosity widths and different degrees of rotation of the tibial plateau after radial osteotomy of the proximal tibia. Ex vivo study, randomized unblocked design Thirty-five hind limbs from 18 adult Greyhound cadavers. Part 1 (15 limbs)--The center of rotation of the proximal tibial radial osteotomy was advanced craniodistally, progressively reducing absolute tibial tuberosity width (ATTW) for 5 different widths. Part 2 (21 limbs)-Tibial plateau rotation was performed at a set ATTW. Rotation was varied as a function of tibial tuberosity position with rotation proximal, level with, or distal to the tuberosity. All 35 limbs were tested with force applied via the quadriceps mechanism until construct failure occurred. All but 2 limbs failed by fracture of the tibial tuberosity. The tensile force required for failure of the quadriceps mechanism increased linearly with increasing ATTW. Significantly less force (P = .016) was required for failure of the quadriceps mechanism when the rotation of the tibial plateau was distal to the level of the patella tendon (mean 1,877 N) compared to when it was above the level of the patella tendon (mean 2,533 N). Rotation of the tibial plateau distal to the level of the patella tendon insertion point resulted in fracture at the base of the tibial tuberosity, level with the tibial plateau buttress. The overwhelming mode of failure of the quadriceps mechanism was by tibial tuberosity fracture, thus this was the weakest part of the construct. Reducing the tibial tuberosity width and rotation of the tibial plateau segment below the patella tendon insertion decreased the force required for tibial tuberosity fracture. These results support the idea of a safe point with the tibial plateau segment providing buttress to the tibial tuberosity. © Copyright 2015 by The American College of Veterinary Surgeons.
Yu, Xiao; Pang, Qing-Jiang; Chen, Liang; Yang, Chang-Chun; Chen, Xian-Jun
To review postoperative complications reported after closed calcaneus fracture treated by open reduction and internal fixation (ORIF). Postoperative complications reported in the literature between 1995 and 2012 were identified. Papers were retrieved from publicly available databases and included in this study if they met the following criteria: clinical research of cases of closed calcaneus fracture treated by ORIF; ≥10 cases; detailed information about complications, treatment and follow up. Twenty-one clinical reports were analysed (2046 cases). Reported complications (and incidence rates) were: infection and skin flap necrosis (13.6%); neurovascular injury (2.8%); post-traumatic arthritis (1.2%); malreduction/implant problems (0.8%); nonunion (0.1%). Postoperative complications after closed calcaneus fracture are common clinical problems that cannot always be avoided. They can even be life altering, due to the requirement for long-term treatment or amputation and their economic impact on the patient. Complications should be diagnosed and treated promptly, to achieve satisfactory outcomes. Nonsurgical treatment (e.g. local wound care, drugs or physical therapy) can be attempted. If such measures fail, surgical treatment (e.g. debridement, skin flap transplantation, implant removal, re-opening of the reduction and internal fixation or subtalar joint arthrodesis) should be considered.
de La Bernardie, Jérôme; de Dreuzy, Jean-Raynald; Bour, Olivier; Thierion, Charlotte; Ausseur, Jean-Yves; Lesuer, Hervé; Le Borgne, Tanguy
Geothermal energy is a renewable energy source particularly attractive due to associated low greenhouse gas emission rates. Crystalline rocks are in general considered of poor interest for geothermal applications at shallow depths (< 100m), because of the low permeability of the medium. In some cases, fractures may enhance permeability, but thermal energy storage at these shallow depths is still remaining very challenging because of the complexity of fractured media. The purpose of this study is to test the possibility of efficient thermal energy storage in shallow fractured rocks with a single well semi open loop heat exchanger (standing column well). For doing so, a simplified numerical model of fractured media is considered with few fractures. Here we present the different steps for building the model and for achieving the sensitivity analysis. First, an analytical and dimensional study on the equations has been achieved to highlight the main parameters that control the optimization of the system. In a second step, multiphysics software COMSOL was used to achieve numerical simulations in a very simplified model of fractured media. The objective was to test the efficiency of such a system to store and recover thermal energy depending on i) the few parameters controlling fracture network geometry (size and number of fractures) and ii) the frequency of cycles used to store and recover thermal energy. The results have then been compared to reference shallow geothermal systems already set up for porous media. Through this study, relationships between structure, heat exchanges and storage may be highlighted.
Haug, Richard H; Brandt, M Todd
The management of fractures of the mandibular condyle continues to be controversial. This is in part attributable to a misinterpretation of the literature from decades prior, a lack of uniformity of classification of the various anatomical components of the mandibular condyle, and a perceived potential to cause harm through the open approach based in part on the surgeon's lack of a critical examination of the literature. This review explores the key historical articles that deal with the management of mandibular condyle fractures, and those modern-day contributions that represent the state of the art. The authors' intention was to provide the reader with an objective summary of the management of this form of injury, to place its management into a modern-day perspective, and perhaps to minimize the perception of controversy.
Chiang, Chao-Ching; Tzeng, Yun-Hsuan; Lin, Chun-Cheng; Huang, Ching-Kuei; Chang, Ming-Chau
Open reduction and internal fixation (ORIF), the standard treatment for unstable ankle fractures, has well-known wound complications. Minimally invasive surgery (MIS) has been proposed to decrease these complications. The objectives of this study were to describe an algorithm of MIS for fibular plating and compare the radiographic restoration of fibular anatomy, functional outcomes, and complications between ORIF and MIS for ankle fractures. This retrospective study included 71 patients with AO/OTA 44-B ankle fractures treated by a single surgeon. ORIF group consisted of 34 patients (54.5-month follow-up) and MIS group was composed of 37 patients (55.9-month follow-up). Among 37 MIS patients, 13 patients were treated with minimally invasive percutaneous plate osteosynthesis and 24 patients with minimally invasive trans-fracture approach according to our MIS algorithm. Operative outcomes were evaluated and compared between the 2 groups by radiographic measurements, functional assessment, and complications. The MIS group had less blood loss but longer operative time and greater exposure to fluoroscopy. Radiographic measurements revealed similar union time, fibular length, talocrural angle, medial clear space, and tibiofibular clear space in both groups. Lower visual analogue pain score was observed in the MIS group in the early postoperative period. At last follow-up, there were no significant differences regarding pain score, American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and range of motion between the 2 groups. Total complication rate was significantly higher in the ORIF group. Patients with AO/OTA 44-B fractures treated with MIS fibular plating achieved similar radiographic and functional outcomes but had less pain in the early postoperative period and fewer wound complications compared with those treated with ORIF. Level III, retrospective comparative study. © The Author(s) 2016.
Vitale, Sarah A.; Robbins, Gary A.
This study describes a low-cost method for sampling individual fractures in open wellbores in crystalline bedrock utilizing naturally occurring flow conditions in the well. The method entails using the dissolved oxygen alteration method (DOAM) to identify transmissive fractures and vertical flow direction. After obtaining information about relative hydraulic gradients, flow direction in the well is modified using a single control pump to isolate fractures of interest for sampling. Additional dissolved oxygen, injected during the DOAM procedure, serves as a tracer to ensure the water quality in the sampling zone is characteristic of the fracture of interest by requiring a tracer-free zone prior to sampling. Sampling procedures are described conceptually for nine bedrock wells with varying flow conditions containing one, two, or three transmissive inflowing fractures. The method was demonstrated in two crystalline bedrock wells containing one and two transmissive inflowing fractures.
A total of 34 cases of symptomatic valgus deformity of the hindfoot secondary to a malunited extra-articular calcaneal fracture were corrected with laterally based open wedge calcaneal osteotomy. The pre- and postoperative radiographic parameters were compared, and a postoperative clinical evaluation was performed using the American Orthopedic Foot and Ankle Society ankle and hindfoot scoring system. The mean follow-up period was 56.2 (range 24.1 to 97) months. The most significant radiographic changes were improvement in the talonavicular coverage angle (mean 17.3°) on the anteroposterior view. The mean postoperative American Orthopedic Foot and Ankle Society hindfoot and ankle score was 90, with 23 excellent, 8 good, and 3 poor results. Laterally based opening wedge osteotomy of the calcaneus is effective in the management of a valgus heel resulting from malunited extra-articular calcaneal fractures. Lateral decompression of the peroneal tendons and the sural nerve was achieved indirectly through opening wedge lateral calcaneal osteotomy that shifted the weight-bearing axis laterally. Copyright © 2011 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
ORIGINAL ARTICLE Microbiology and injury characteristics in severe open tibia fractures from combat Travis C. Burns, MD, Daniel J. Stinner, MD...Andrew W. Mack, MD, Benjamin K. Potter, MD, Rob Beer, MD, Tobin T. Eckel, MD, Daniel R. Possley, DO, Michael J. Beltran, MD, Roman A. Hayda, MD, Romney C...Joint Surg Br. 1994;76:13–19. 19. Coupland RM. War wounds of bones and external fixation. Injury. 1994;25:211–217. 20. Hayda R, Harris RM, Bass CD
Gonzalez, Tyler A; Macaulay, Alec A; Ehrlichman, Lauren K; Drummond, Rosa; Mittal, Vaishali; DiGiovanni, Christopher W
Ankle fractures represent one of the most common orthopaedic injuries requiring operative treatment. Although open reduction and internal fixation (ORIF) of ankle fractures leads to good results in most patients, poor functional outcomes continue to be reported in some patients for whom anatomic reduction was achieved. It has been theorized that these lesser outcomes may in part be due to a component of missed intra-articular injury that reportedly ranges between 20% and 79%, although to date the true explanation for this subset of lower functional outcomes remains unknown. Such concerns have recently spawned novel techniques of arthroscopically assisted ankle fracture assessment in hopes of enabling better detection and treatment of concomitant intra-articular ankle injuries. The purpose of this systematic review was to summarize the literature comparing standard ORIF to arthroscopically assisted ORIF (AAORIF) for ankle fractures. A systematic review of the English literature was performed using the PubMed database to access all studies over the last 50 years that have documented the functional outcomes of acute ankle fracture management using either a traditional ORIF or an AAORIF technique in the adult population. Relevant publications were analyzed for their respective Levels of Evidence as well as any perceived differences reported in operative time, outcomes, and complications. A total of only 14 ORIF and 4 AAORIF papers fit the criteria for review. There is fair quality (grade B) evidence to support good to excellent outcomes following traditional ORIF of malleolar fractures. There is fair-quality (grade B) evidence that ankle arthroscopy can be successfully employed for identification and treatment of intra-articular injuries associated with acute ankle fractures, but insufficient (grade I) evidence examining the functional outcomes and complication rates after treatment of these injuries and little documentation that this approach portends any improvement
Halvorson, Jason; Jinnah, Riyaz; Kulp, Brenda; Frino, John
The use of the vacuum-assisted closure device (VAC; KCI, San Antonio, Texas) has given the orthopedist a new tool for the successful management of severe traumatic wounds and open fractures. While the VAC's role in the adult population is proving itself as an improved therapy compared to "traditional wound care," it's role within pediatric orthopedics remains less well defined. Questions remain whether VAC therapy provides benefit regarding decreased infection rates as well as decreased need for extensive soft tissue coverage procedures. A review was therefore performed of a pediatric level I trauma center's experience using the VAC therapy for pediatric open fractures with a focus on the rate of superficial, deep, and chronic infection. A retrospective chart review spanning 4.5 years of all pediatric patients younger than 18 years with an open fracture initially treated with VAC therapy was conducted at a level I pediatric trauma center. This yielded 28 patients with 37 open fractures aged 2 to 17 years who were initially treated with wound VAC therapy. Subsequent chart review of these patients was performed examining in-hospital records, operative notes, and clinical follow-up visits for documented cases of superficial, deep, or chronic infection. Of 37 open pediatric fractures treated with a wound VAC, there were no cases of superficial infection and 2 cases of deep infection for an overall infection rate of 5%. Both infections resolved with surgical intervention and antibiotics without chronic infection development. When compared with historical controls, the use of VAC therapy for pediatric open fractures appears to be an equally safe and effective modality to help reduce infection in pediatric open fractures and should be considered a valuable tool in treating these injuries. Copyright 2011, SLACK Incorporated.
Fadakar Alghalandis, Younes
Rapidly growing topic, the discrete fracture network engineering (DFNE), has already attracted many talents from diverse disciplines in academia and industry around the world to challenge difficult problems related to mining, geothermal, civil, oil and gas, water and many other projects. Although, there are few commercial software capable of providing some useful functionalities fundamental for DFNE, their costs, closed code (black box) distributions and hence limited programmability and tractability encouraged us to respond to this rising demand with a new solution. This paper introduces an open source comprehensive software package for stochastic modeling of fracture networks in two- and three-dimension in discrete formulation. Functionalities included are geometric modeling (e.g., complex polygonal fracture faces, and utilizing directional statistics), simulations, characterizations (e.g., intersection, clustering and connectivity analyses) and applications (e.g., fluid flow). The package is completely written in Matlab scripting language. Significant efforts have been made to bring maximum flexibility to the functions in order to solve problems in both two- and three-dimensions in an easy and united way that is suitable for beginners, advanced and experienced users.
Mathieu, L; Mottier, F; Bertani, A; Danis, J; Rongiéras, F; Chauvin, F
The purpose of this study was to report the experience of the French Army Medical Service in the management of neglected open extremity fractures and related-complications in Chad. Delayed treatment of open extremity fractures is possible in a low-resource setting. An observational prospective study was performed in a French Forward Surgical Team deployed in N'Djamena for six months. Twenty-seven patients, 24 men and three women, mean age 30 years old with an open fracture that was managed more than 24 hours after it occurred were included. The mean treatment delay was 83 days. Fractures were located in the tibia in 20 cases. There were 15 non-infected and twelve infected fractures. The number of cases of debridement, flap coverage, and the overall number of procedures were higher in the group with infection, but the difference was not significant. Treatment of infected fractures was complicated by six early recurrent infections, while there were no complications in the group without infection. The mean follow-up was 4.4 months. Infection was controlled in eleven cases, however evaluation of fracture healing was limited because of the short follow-up in the group with infection. Functional outcome of the lower extremities was often complicated by knee stiffness. Delayed management of open fractures depends on the available resources. In low-resource settings, the goals of surgery should be modest. Treatment of non-infected injuries and osteomyelitis is possible. On the other hand, treatment of infected fractures and septic nonunions should be undertaken with caution if all the necessary aspects of treatment, in particular extended antibiotic treatment and sequential procedures are not possible. level IV. Copyright © 2014 Elsevier Masson SAS. All rights reserved.
Pishnamaz, Miguel; Kobbe, Philipp; Herren, Christian; Gradl-Dietsch, Gertraud; Böhle, Franziska; Johannes, Bernd; Kim, Bong-Sung; Horst, Klemens; Knobe, Matthias
Standard open and percutaneous minimally invasive surgical procedures co-exist in the treatment of fractures of the thoracolumbar spine. Shorter skin incisions just above the pedicles are used in minimally invasive procedures. Full-length skin incisions and invasive preparations are applied in the standard open approach. While both methods show equivalent rates of intraoperative surgical complications and comparable clinical and radiological outcomes, blood loss and operation time have shown to be decreased in minimally invasive treatment. However, no study so far has investigated differences in microcirculation. This study hypothesized less impairment of microcirculation in the minimally invasive approach compared to the open approach and an improvement of microcirculation over time. A prospective cohort study was conducted using non-invasive laser-Doppler spectrophotometry (an O2C “oxygen to see” device) for measurement of cutaneous and subcutaneous blood oxygenation (SO2), haemoglobin concentration (Hb), and blood flow at depths of 2, 8, and 15 mm at six locations on the skin. Measurements were performed before surgery, 8 and 24 h after surgery, and 2, 4, 7, 12 and 20 days after surgery, however the number of patients measured decreased towards the later time points. Forty patients were included in the study, 20 with each approach (18 females and 22 males). Pair-wise comparison of the types of surgical procedure for each measurement point revealed a significantly higher flow value in the minimally invasive group at one of the measurement points located between the incisions (P = .041). The point-wise analyses of SO2 and Hb did not show significant differences between the approaches. In conclusion, significantly albeit moderately higher flow values could be found in minimally invasive procedures compared to open operations of thoracolumbar fractures in the area of skin that is spared by the incisions. PMID:29141048
Ali, A M; McMaster, J M; Noyes, D; Brent, A J; Cogswell, L K
In April 2012 the John Radcliffe Hospital in Oxford became a major trauma centre (MTC). The British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4) require system-wide changes in referral practice that may be facilitated by the MTC and its associated major trauma network. From 2008 to 2013 a multistep audit of compliance with BOAST 4 was conducted to assess referral patterns, timing of surgery and outcomes (surgical site infection rates), to determine changes following local intervention and the establishment of the MTC. Over the study period, 50 patients had soft tissue cover for an open lower limb fracture and there was a significant increase in the proportion of patients receiving definitive fixation in our centre (p=0.036). The median time from injury to soft tissue cover fell from 6.0 days to 3.5 days (p=0.051) and the median time from definitive fixation to soft tissue cover fell from 5.0 days to 2.0 days (p=0.003). The deep infection rate fell from 27% to 8% (p=0.247). However, in 2013 many patients still experienced a delay of >72 hours between injury and soft tissue cover, primarily owing to a lack of capacity for providing soft tissue cover. Our experience may be relevant to other MTCs seeking to identify barriers to optimising the management of patients with these injuries.
Tajsic, Nenad B; Sambath, Puon; Nguon, Sophy; Sokh, Vannara; Chheang, Virak; Landsem, Gaute; Zaletel, Ivan; Husum, Hans
A prospective interventional study has been carried out on the teaching effect and sustainability of low-cost trauma training program in open tibia fracture management for health workers. In 2007, an external fixator and a patella-bearing orthosis were developed at a rural workshop in Cambodia. From 2010 to 2016, a core group of nine Cambodian health workers was trained in open fracture management by Norwegian senior surgeons, using the locally made fixator and brace. The training outcome was also assessed by a questionnaire comprising of assertions regarding theoretical understanding, technical skills and self-confidence in understanding the biomechanical properties of locally made external fixator and its application; the use of handmade orthosis and principle in covering of soft-tissue defects. The students managed 23 cases with the new technique with a primary healing rate of 70% (95% CI 48.1-85.5). A significant increase in self-reported technical skills, understanding, and self-confidence was reported. This study demonstrates that the capacity building of reconstructive surgery in low-resource settings by local doctors and paramedics is clearly a reasonable option that may substantially reduce amputation of the limbs.
Van Nielen, Dominic L; Smith, Christopher S; Helfet, David L; Kloen, Peter
Although relatively rare, non-unions and mal-unions of tibial plateau fractures present significant challenges for the orthopedic surgeon. With careful pre-operative planning, tibial plateau mal-union or non-union revision surgery with intra-articular and varus opening osteotomies can provides good functional results when performed early (within 1 year) after primary surgical procedure. We present our treatment algorithm for approaching and treating non-union or mal-union of tibial plateau fractures. Our aim is to give surgeons treating these difficult injuries an overview of the pertinent literature as well as describe the challenges and pitfalls we have experienced when treating non-union or mal-union of tibial plateau fractures. Using two case examples from our institution, one for mal-union and one for mal-reduction, we describe our treatment algorithm and surgical technique for managing these difficult injuries. We also provide a brief literature review outlining relevant studies and summarizing outcomes for similar injuries. A systematic literature review was conducted with the aim of determining the methods and outcomes commonly reported in the literature regarding revision surgery following tibial plateau non-union or mal-union. Due to the nature of revision surgery, there are no long-term randomized trials dealing with outcomes, but rather several smaller case series exist from which larger conclusions have to be drawn. To date, we have successfully treated approximately 35 patients with this technique, and clinical follow-up continues to show good functional outcomes with reduced pain and little radiographic evidence of arthritic changes. Restoring long leg alignment, anatomic reduction of the articular surface, and achieving stable internal fixation are paramount in achieving the best long-term outcome. Due to the shallow soft tissue envelope around the proximal tibia, and the tendency for these fractures to fall into progressive valgus collapse, these
Rueger, J M; Rücker, A H; Hoffmann, M
Closed tibial shaft fractures are the domain of intramedullary nailing. With the introduction of new nail designs and technologies, even small, dislocated distal fragments can be anatomically aligned and safely fixed. Unsolved or to a lesser degree controlled are the problems of distal locking in the freehand technique, which can still be difficult and can lead to a significant radiation exposure, and how to control very short proximal tibial fragments in metaphyseal tibial fractures or tibial segmental fractures, where the proximal fracture line also runs through the metaphysis.By using a suprapatellar approach, i.e. a skin incision proximal to the patella with an entry point into the tibial bone from within the knee at the same site as for a standard infrapatellar approach, and then nailing the tibia in a semi-extended position, i.e. the knee is only flexed 10-20°, the intraoperative dislocation of a short proximal fragment can be avoided. The main indications for semi-extended tibial nailing are a short diaphyseal fragment in an isolated tibial shaft fracture, a segmental fracture where the proximal fracture line is metaphyseal and in patients where infrapatellar soft tissues are compromised.The use of the electromagnetic guidance system SureShot® generates reliable and reproducible results, reduces the operating time and is independent from radiation for distal locking.
Thangarajah, Tanujan; Lakdawala, Ayaz; Battaloglu, Emir; Malik, Atul; Tillu, Abhay
In cases where ankle fracture union has been compromised by persistent syndesmotic diastasis following open reduction internal fixation, both external rotation and shortening of the fibula have been identified as prominent features. This study reports a technique that uses a z-osteotomy to achieve both lengthening and internal rotation of the fibula to correct persistent talar shift following ankle fracture fixation. Four patients with persistent talar shift following open reduction internal fixation for an ankle fracture received z-osteotomy of the fibula to achieve both lengthening and internal rotation. At the latest clinic review, all 4 ankles exhibited satisfactory clinical and radiological union. All patients have returned to full mobility and are satisfied with the outcome. This study demonstrates the effectiveness of lengthening z-osteotomy of the fibula in correcting persistent talar shift following internal fixation of ankle fractures. Therapeutic Level V.
We compared the postoperative complication rates between the less invasive stabilization system (LISS) plating and locking compression plate for open and closed distal femoral fracture fixation for superiority. Retrospective Review. Multicenter. Patients identified through a hospital database who were treated for supracondylar femur fractures using LISS or LCP techniques between January 2005 and July 2010. Medical history, patient demographics, injury characteristics, presence of polytrauma, and surgical characteristics were collected for each patient. χ and logistic regression analysis was performed to compare postoperative infection and nonunion/reoperation regarding both plating techniques. Of 339 distal femoral fractures, 185 (54.6%) were repaired with a LISS plate and 154 (45.4%) were repaired with a LCP. Multivariate analysis revealed only open fractures to be a risk factor for nonunion (Odds ratio 2.42, P = 0.01) and infection (Odds ratio 3.47, P = 0.02), regardless of device used. No difference was seen between either plate type in infection, plate failure, or nonunion. Postoperative infection and nonunion rates are comparable between LISS and LCP for both open and closed distal femoral fracture fixation. As no difference was detected between plates, either may be used to treat distal femur fractures. Nonunion rate was higher than expected based on previous reports. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Mao, Ningfang; Liu, Deding; Ni, Haijian; Tang, Hao; Zhang, Qiulin
The cable pin system is an effective device for fixation of transverse patella fractures. However, whether this device provides superior results using a minimally invasive technique instead of conventional open surgery using the K wire tension band method is unclear. We asked whether a minimally invasive technique would be associated with (1) increased operative time; (2) reduced postoperative pain; (3) faster recovery of ROM; (4) higher knee scores; and (5) reduced complications. Forty patients with displaced transverse fractures of the patella participated in this prospective, randomized, controlled trial. Twenty of these patients underwent a minimally invasive technique and the others had conventional open surgery using K wires. Some data for six of the 20 patients who underwent the minimally invasive technique were published in an earlier prospective, observational trial. At postoperative intervals of 1, 3, 6, 12, and 24 months, pain was measured by VAS scores, active flexion and extension of the knee were measured in degrees by goniometry, and knee function was evaluated using the Böstman clinical grading scale. Operative time was longer in the minimally invasive surgery group (54.3 ± 9.8 minutes versus 48.5 ± 6.1 minutes). Pain scores were better (lower) in the minimally invasive surgery group at 1 and 3 months but not at 6 months. Early flexion, ultimate flexion, and knee scores from 3 to 24 months, likewise, were better in the minimally invasive surgery group. Complications mostly related to symptomatic hardware were less common in the minimally invasive surgery group. The minimally invasive technique is superior to conventional open surgery using K wires in terms of less early postoperative pain, better mobility angles of the injured knee, higher functional score of the injured knee, and decreased incidence of complications. Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Yao, Qi; Ni, Jie; Peng, Li-bin; Yu, Da-xin; Yuan, Xiao-ming
To compare the efficacies of minimally invasive plate osteosynthesis (MIPPO) and interlocking intramedullary nailing (IMN) in the treatment of extra-articular fractures of distal tibia. Retrospective reviews were conducted for 126 patients with extra-articular distal tibia fractures. Treatment was either MIPPO (n = 61) or IMN (n = 65). The outcomes were assessed by comparing operating duration, time to union, the last follow-up American Orthopedic Foot and Ankle Society (AOFAS) score and complication rate. The average follow-up period was 23.7 (12-53) months. In the minimally invasive plate osteosynthesis group, there were deep infections (n = 2), superficial infections (n = 5), delayed union (n = 2), malunion (n = 2) and knee joint pain (n = 10) were observed. In addition, the average operating duration (85.9 ± 18.9 min), average time to union (17.3 ± 3.8 weeks) and average AOFAS (83.2 ± 11.9) were analyzed. In the interlocking intramedullary nailing group, there were delayed union (n = 3), malunion (n = 12) and knee joint pain (n = 22). And the average operating duration (83.3 ± 15.7 min), average time to union (16.5 ± 3.1 weeks) and average AOFAS (84.9 ± 12.0) were analyzed. No statistical significance existed in operating duration, time to union and the last follow-up AOFAS between two groups (P > 0.05). However, the rates of malformation and knee joint pain were higher in the intramedullary nail group than those in the plate group. And the difference was statistically significant (P = 0.015, P = 0.025). Both MIPPO and IMN are effective for extra-articular fractures of distal tibia. However, the former has the advantage of lowers rate of malformation and knee joint pain. Therefore a surgeon should consider the degree of injury while managing extra-articular fracture of distal tibia.
Bhandari, Mohit; Jeray, Kyle J; Petrisor, Brad A; Devereaux, P J; Heels-Ansdell, Diane; Schemitsch, Emil H; Anglen, Jeff; Della Rocca, Gregory J; Jones, Clifford; Kreder, Hans; Liew, Susan; McKay, Paula; Papp, Steven; Sancheti, Parag; Sprague, Sheila; Stone, Trevor B; Sun, Xin; Tanner, Stephanie L; Tornetta, Paul; Tufescu, Ted; Walter, Stephen; Guyatt, Gordon H
The management of open fractures requires wound irrigation and débridement to remove contaminants, but the effectiveness of various pressures and solutions for irrigation remains controversial. We investigated the effects of castile soap versus normal saline irrigation delivered by means of high, low, or very low irrigation pressure. In this study with a 2-by-3 factorial design, conducted at 41 clinical centers, we randomly assigned patients who had an open fracture of an extremity to undergo irrigation with one of three irrigation pressures (high pressure [>20 psi], low pressure [5 to 10 psi], or very low pressure [1 to 2 psi]) and one of two irrigation solutions (castile soap or normal saline). The primary end point was reoperation within 12 months after the index surgery for promotion of wound or bone healing or treatment of a wound infection. A total of 2551 patients underwent randomization, of whom 2447 were deemed eligible and included in the final analyses. Reoperation occurred in 109 of 826 patients (13.2%) in the high-pressure group, 103 of 809 (12.7%) in the low-pressure group, and 111 of 812 (13.7%) in the very-low-pressure group. Hazard ratios for the three pairwise comparisons were as follows: for low versus high pressure, 0.92 (95% confidence interval [CI], 0.70 to 1.20; P=0.53), for high versus very low pressure, 1.02 (95% CI, 0.78 to 1.33; P=0.89), and for low versus very low pressure, 0.93 (95% CI, 0.71 to 1.23; P=0.62). Reoperation occurred in 182 of 1229 patients (14.8%) in the soap group and in 141 of 1218 (11.6%) in the saline group (hazard ratio, 1.32, 95% CI, 1.06 to 1.66; P=0.01). The rates of reoperation were similar regardless of irrigation pressure, a finding that indicates that very low pressure is an acceptable, low-cost alternative for the irrigation of open fractures. The reoperation rate was higher in the soap group than in the saline group. (Funded by the Canadian Institutes of Health Research and others; FLOW Clinical
Harris, C. E.; Morris, D. H.
Using the center-cracked tension specimen geometry, the fracture strength of notched graphite/epoxy laminates is measured experimentally. Four replicate tests are conducted for a variety of laminate-stacking sequences, thicknesses, and notch lengths. Extensive notch-tip damage prior to fracture is characteristic of most laminates. The values of critical crack-tip-opening displacement (CTOD) are calculated from values of crack-opening displacement measured at the notch center line at failure and are found to be independent of notch size for the laminates studied. A Dugdale (1950) model is used along with the estimated CTOD to predict notched laminate strength.
Yang, Chao-hua; Li, Qiang; Li, Guo-ping; You, Chao
We report a special type of skull fracture in children - internal open brain injury (IOBI). We summarize its clinical characteristics and propose a treatment strategy based on our experience. Eight patients between 2 and 5 years old were identified to have IOBI. Preoperative computed tomography (CT) scanning was performed in each case and magnetic resonance imaging was conducted when available. All patients were treated surgically. The clinical data were retrospectively analyzed and each patient underwent follow-up CT scanning. IOBI has no special clinical manifestations other than scalp swelling, linear skull fracture and local brain contusion. Acute cerebral extrusion outside the calvaria and lacerated dura mater were seen during operation in each patient. Each patient's neurological status generally improved after surgery. No patient developed posttraumatic epilepsy during the 4- to 20-month follow-up period. IOBI is a type of head trauma in which dura mater is lacerated and the cerebrum is extruded outside the calvaria but the scalp remains intact. Craniotomy with evacuation of devitalized brain tissue and dural repair should be performed. Copyright 2009 S. Karger AG, Basel.
To explore the effectiveness of open reduction and internal fixation through anterior and posterior approaches in treatment of open Tile type C pelvic fractures at early stage. Between January 2009 and April 2012, 12 patients with open Tile C pelvic fractures were treated. There were 7 males and 5 females, aged 6-53 years (median, 31 years). Of 12 cases, 4 were classified as Tile type C1, 6 as Tile type C2, and 2 as Tile type C3; 5 were rated as Gustilo type II and 7 as Gustilo type III. The injury severity score was 18-57 (mean, 37.2). The interval of injury and admission ranged from 15 minutes to 3 days (median, 50 minutes). The debridement and external fixation were performed at first stage; then open reduction and internal fixation were used through anterior approach (reconstruction plate) and posterior approach (cannulated lag screws). The vacuum sealing drainage was performed during treatment until the wounds healed. Delayed healing of incison was obtained in 12 cases because of wound infection. Anatomical reduction or approximate anatomical reduction was achieved in all 12 cases. The patients were followed up 3-39 months (median, 18 months). No loosening of internal fixation or fracture displacement was observed during follow-up. The fracture healing time was 7-13 weeks (mean, 9.7 weeks). At last follow-up, according to the Matta standard, the outcome was excellent in 10 cases and good in 2 cases; according to Majeed score, the results were excellent in 9 cases, good in 1, and poor in 2. Early internal fixation operation of open Tile type C pelvic fractures can effectively restore the pelvic anatomical structure and stability, reduce the complication, and achieve satisfactory effectiveness.
Koury, S I; Stone, C K; Harrell, G; La Charité, D D
Tillaux fractures are relatively uncommon Salter Harris III fractures of the tibia. The importance of recognizing this fracture is that a residual deformity in the joint surface can lead to premature degenerative arthritis. For this reason, it is important that accurate imaging to assess the congruity of the joint, as well as adequate reduction, is obtained. These fractures can occur in adolescents in the 18-month period during which the distal tibial epiphysis is closing. These injuries occur either by lateral rotation of the foot or by medial rotation of the leg on the fixed foot. Closed reduction is sufficient in most cases; however, if a gap of > or = 2 mm of the articular surface remains, open reduction is usually required to adequately reduce the articular surface. Orthopedic injuries are one of the most common reasons children are brought to the emergency department (ED). Most of these injuries are easily managed by splinting, with outpatient orthopedic follow-up. However, certain fractures need closer evaluation and immediate consultation with an orthopedic surgeon. One relatively uncommon fracture that needs special attention is the Tillaux fracture. Paul Jules Tillaux first described this particular fracture in 1892. He performed experiments on cadavers and found that stress to the anterior inferior tibiofibular ligament could lead to this type of avulsion fracture, which today is termed the Tillaux fracture. The distal tibial epiphysis is involved, and the mechanism usually is forced external rotation of the foot in a 12- to 14-year-old adolescent. This fracture only occurs during a certain time of adolescence, owing to the differential growth rate of the epiphysis, and only under certain circumstances. The fracture is of great importance because it involves a major weight-bearing articular surface. A residual deformity of the joint surface can lead to premature degenerative arthritis. We present a patient with a Tillaux fracture to elaborate on the
The study population is patients with high energy tibial plateau, pilon (distal tibia), and calcaneus fractures . The results of this trial have...reduction, pilon fracture , calcaneus fracture , tibial plateau fracture 5 3. OVERALL PROJECT SUMMARY: The third year of the grant built on the...treatment trial. The study population is patients with high energy tibial plateau, pilon (distal tibia), and calcaneus fractures . The study is guided by
Clinical aspects and the course of treatment of open infected fractures in the knee joint region against a background of moderate and severe radiation sickness are discussed. The experiment involved 35 healthy dogs of both sexes. In all, three experiments were involved: on open infected fractures in the knee joint region in conjunction with radiation sickness; open infected fractures in the knee joint region without radiation sickness; radiation sickness without trauma. Infected open injury to the knee joint against a radiation sickness background is a severe affection. The use of delayed surgical and drug treatment (antibiotics, vitamins, antihistamine preparations) affordedmore » survival of at least one-half of the animals. Oral use of phenoxymethyl-penicillin in large doses established in the blood and synovial fluid of the damaged knee joint a therapeutic concentration of antibiotic of long duration (not less than a day). In radiation damage to knee joint accompanied by fracture of the bone fragment, the best method of surgical treatment is osteosynthesis using metal parts. In open infection of a damaged knee joint against a radiation sickness background, even with proper treatment a tendency toward formation of deforming arthrosis was observed. (OTS)« less
Lindsey, Brock A; Clovis, Nina B; Smith, E Suzanne; Salihu, Sydha; Hubbard, David F
Infection resulting from open fracture is a common problem in orthopedics. The purpose of this project was to study the effect of Interleukin-12 (IL-12) systemic therapy on a previously established open fracture model. One hundred seven male Sprague-Dawley rats were assigned to five groups: (1) normal (baseline), (2) control (controlled for anesthesia), (3) fracture, (4) staph, and (5) staph and IL-12 (SIL). Each group was divided into four time periods: 6, 10, 14, and 21 days after injury and fixation. The operative groups had a standardized femur fracture and fixation using a Kirschner wire as an intramedullary device. The two infection groups (staph and SIL) were inoculated with Staphylococcus aureus following fracture and fixed with an identical technique. The SIL group was treated with systemic IL-12 for a total of 10 doses over 10 days. Significantly decreased serum IL-12 levels were noted at day 10 in the operative groups compared to the normal and control groups. The SIL group showed significantly higher macrophage activation levels and total platelet counts at day 21 compared to all the other groups. The overall infection rate was not changed by IL-12 supplementation; however, bacterial qualitative growth scores were significantly lower in the SIL group at day 10, which corresponded to the lowest level of systemic IL-12 in the fracture group.
Bremmer, Derek; Bookstaver, Brandon; Cairns, Mark; Lindley, Kenneth; Durkin, Martin; Koon, David; Quidley, April Miller
We investigated the clinical effectiveness of antimicrobial prophylaxis in lower-extremity open fractures following the Eastern Association for the Surgery of Trauma Guidelines. This observational, retrospective, single-center study included adults with lower-extremity open fractures of the ankle, tibia, fibula, or femur. The primary endpoint was the incidence of osteomyelitis within 12 months of the fracture. Secondary endpoint comparisons were the time of antibiotic initiation and drug selection. A total of 90 patients were included. Patients suffered from Gustilo and Anderson grades I (14%), II (54.7%), and III (31.3%) fractures. Almost all patients received cefazolin (98%). Among grade III fractures, 59.3% (16/27) of patients received additional gram-negative coverage as recommended by the guidelines. The osteomyelitis rate was 8.9%. There was no difference in osteomyelitis rates among patients with grade III fractures who received or did not receive additional gram-negative coverage: 18.8% (3/16) and 0 (0/11) (p = 0.248), respectively. There was no correlation between median antibiotic start time or antibiotic stop time after closure and the development of osteomyelitis, respectively. Resistant organisms caused 50% (4/8) of the osteomyelitis cases. On univariate analysis, obesity had the most significant association with osteomyelitis (p = 0.026). Bacterial resistance was common among cases of osteomyelitis in our cohort. Obesity was associated with a higher rate of osteomyelitis.
Bhola, Nitin; Jadhav, Anendd; Borle, Rajiv; Khemka, Gaurav; Adwani, Nitin; Bhattad, Mayur
Mandibular fractures are relatively less frequent in children when compared to adults. Pediatric patients present a unique challenge to maxillofacial surgeons in terms of their treatment planning and in their functional needs. We currently describe our experience with lateral compression open cap splint with circummandibular wiring as a treatment modality which involves fewer risks in treating pediatric symphysis/parasymphysis/body mandibular fractures. A retrospective analysis of pediatric patients with mandibular symphysis/parasymphysis/body fractures operated from January 2007 to January 2012 was performed. Clinical photographs and orthopantomogram assessment at the time of presentation, after treatment, and at 6 months postoperatively were evaluated. All the 10 patients were followed up until the period of 6 months, and none of them had any major complications. Postoperatively, there was satisfactory healing and union of fracture fragments in all the patients. Only one patient developed infection at submental region. The 6-month follow-up showed good occlusion, without interference in teeth eruption and no signs of temporomandibular joint problems. Lateral compression open cap splints for treatment of pediatric mandibular symphysis/parasymphysis/body fractures are reliable treatment modalities with regard to occlusion-guided fracture reduction.
O'Toole, Robert V; Hui, Emily; Chandra, Amit; Nascone, Jason W
We hypothesized that open reduction and internal fixation (ORIF) of displaced acetabular fractures in geriatric patients result in a low rate of conversion to hip arthroplasty and satisfactory hip-specific validated outcome scores at medium-term follow-up. Retrospective review. Level I trauma center. One hundred forty-seven consecutive patients who were 60 years or older who had acetabular fractures were treated at our center from 2001 through 2006. During this time period, fractures meeting operative criteria were treated with ORIF unless medical conditions warranted nonoperative treatment. Twenty-nine patients were lost to follow-up, 46 were deceased, and 11 declined to participate, leaving 61 potential patients for inclusion, 46 of whom were treated with ORIF (average follow-up, 4.4 years; range, 1.1-8.0 years). Standardized telephone interviews included hip-specific questions and validated outcome measures. Rates of conversion to hip arthroplasty and hip-specific validated outcome scores. Among 46 patients treated with ORIF (15 others were treated nonoperatively or with percutaneous screw fixation), 28% underwent hip arthroplasty an average 2.5 years after injury (range, 0.4-5.5 years) and had an average Western Ontario and McMaster Universities Index of Osteoarthritis score of 17 (range, 0-56; n = 38). This score is similar to or better than the typical scores after elective arthroplasty for arthritis and much better than the scores for patients with established arthritis (P < 0.05). The average SF-8 Health Survey physical component score was 46.1 (range, 31-62), similar to US population norms for the geriatric age group (P > 0.20). Few data exist regarding the treatment outcomes for geriatric acetabular fractures. It is difficult for clinicians to decide among ORIF, percutaneous fixation, acute arthroplasty, and nonoperative treatment. Our protocol of mostly ORIF showed a high 1-year mortality rate of 25% and a rate of conversion to arthroplasty after ORIF of
... commonly happen because of car accidents, falls, or sports injuries. Other causes are low bone density and osteoporosis, which cause weakening of the bones. Overuse can cause stress fractures, which are very small cracks in the ...
Underground CO2 storage in depleted hydrocarbon reservoirs may become a common practice in the future to lower the concentration of greenhouse gases in the atmosphere. Results from the first experiments conducted in carbonate rocks, for instance the Lacq integrated CCS Pilot site, SW France, are quite exciting. All monitored parameters, such as the CO2 concentration at well sites, well pressures, cap rock integrity and environmental indicators show the long-term integrity of this type of geological reservoirs. Other positive news arise from the OXY-CFB-300 Compostilla Project, NW Spain, where most of the injected CO2 dissolved into the formation brines, suggesting the long-term security of this method. However, in both cases, the CO2- rich fluids partially dissolved the carbonate minerals during their migration through the fractured reservoir, modifying the overall pore volume and pressure regimes. These results support the growing need for a better understanding of the mechanical behavior of carbonate rocks over geological time of scales. In fact, it is well known that carbonates exhibit a variety of deformation mechanisms depending upon many intrinsic factors such as composition, texture, connected pore volume, and nature of the primary heterogeneities. Commonly, tight carbonates are prone to opening-mode and/or pressure solution deformation. The interplay between these two mechanisms likely affects the petrophysical properties of the fault damage zones, which form potential sites for CO2 storage due to their high values of both connected porosity and permeability. On the contrary, cataclastic deformation produces fault rocks that often form localized fluid barriers for cross-fault fluid flow. Nowadays, questions on the conditions of sealing/leakage of carbonate fault rocks are still open. In particular, the relative role played by bulk crushing, chipping, cementation, and pressure solution on connected porosity of carbonate fault rocks during structural
Kanno, Takahiro; Sukegawa, Shintaro; Tatsumi, Hiroto; Karino, Masaaki; Nariai, Yoshiki; Nakatani, Eiji; Furuki, Yoshihiko; Sekine, Joji
The retromandibular transparotid approach (RMA) to condylar fractures of the mandible provides excellent access, but can increase the risk of complications. The aim of this study was to estimate the frequency of facial nerve paralysis (FNP) and associated postoperative complications after open reduction and rigid internal fixation (ORIF) of subcondylar fractures through the RMA. This was a retrospective cohort study of patients with condylar fractures requiring ORIF through the RMA. The inclusion criteria were 1) a medical record of surgical treatment of a subcondylar fracture by RMA; 2) preoperative and postoperative radiographs; 3) mental status permitting an adequate neuromotor examination; 4) absence of a post-injury or pretreatment functional facial nerve deficit; and 5) regular postoperative follow-up longer than 6 months with documentation of complications, functional results, and fixation stability. The predictive variables were age, gender, fracture site, fracture pattern, concomitant fractures, etiology, and plate types. The outcome variable was FNP. Univariate, bivariate, and multiple logistic regression statistics were computed. Fifty patients with 55 displaced mandibular subcondylar fractures (35 men, 15 women; mean age, 44.5 yr; range, 17 to 87 yr) met the inclusion criteria. The condylar fracture involved the neck in 35 patients (63.6%) and the base in 20 patients (36.4%). The fracture pattern was deviation in 11 patients (20.0%), displacement in 23 (41.8%), and dislocation in 21 (38.2%). Precise ORIF with double-buttress fixation resulted in immediate functional recovery in all patients. Seven fractures (12.7%) were associated with FNP that resolved completely within 6 months. Further statistical analysis showed that dislocated and displaced condylar neck fractures were significant risk factors for postoperative FNP (P < .05). Other postoperative complications were minimal. The RMA for subcondylar fractures is feasible and safe. Dislocated
This dissertation investigates the mechanical control on spacing and aperture of equally-spaced fractures in layered materials using the Finite Element Method, based on the theories of elasticity and linear fracture mechanics. It also investigates the effects of fracture spacing and aperture on fluid flow through the equally-spaced fractures. The results show that under a remote extension in the direction perpendicular to the fractures the normal stress acting in this direction between adjacent fractures changes from tensile to compressive as the fracture spacing to layer thickness ratio changes from greater than to less than a critical value. This stress transition precludes further infilling of fractures unless they are driven by mechanisms other than an extension, or there are significant flaws between the fractures. Hence, it defines the condition of saturation for fractures formed under extension in flawless layered materials. When flaws are present, further infilling of fractures is possible depending upon the size and locations of the flaws. The aspect ratio of equally-spaced fractures is linearly related to the average strain, the overburden stress, and the internal fluid pressure. The aspect ratio increases nonlinearly with increasing fracture spacing to layer thickness ratio because of the mechanical interaction between adjacent fractures. The interaction becomes insignificant when the spacing to layer thickness ratio is greater than about 6.0. The aspect ratio also depends on the ratio of Young's modulus of the fractured layer to that of the neighboring layers. This dependence is significant when the fracture spacing to layer thickness ratio is less than 1.3, otherwise it is negligibe. The aspect ratio is insensitive to variations in Poisson's ratios. Fluid flow rate through equally-spaced fractures does not always increases with increasing fracture density, i.e., with decreasing spacing to layer thickness ratio. There is an optimum value for the ratio
Kim, Ji Wan; Oh, Chang-Wug; Byun, Young-Soo; Kim, Jung Jae; Park, Ki Chul
To compare the clinical and radiologic results of conventional open plating (COP) and minimally invasive plate osteosynthesis (MIPO) in the treatment of noncomminuted humeral shaft fractures. Randomized prospective study. Five level 1 trauma centers. Sixty-eight consecutive patients were randomized into 2 study groups: those treated by COP (COP group; n = 32) and those treated by MIPO (MIPO group; n = 36). Simple humeral shaft fractures (AO/OTA classification types A and B) were reduced by open reduction or closed reduction and fixed with a narrow 4.5/5.0 locking compression plate, metaphyseal locking compression plate, or proximal humeral internal locking system plate to the anterior lateral aspect of the humerus. Fracture healing time, operative time, radiation exposure time, and intraoperative nerve injury. To assess shoulder and elbow function, we used the University of California, Los Angeles (UCLA) scoring system and the Mayo elbow performance index, including the range of motion and pain. Radiographic measurements included fracture alignment, delayed union, and nonunion. Thirty-one fractures (97%) healed in the COP group within 16 weeks, whereas 36 fractures (100%) were healed in the MIPO group by 15 weeks. No significant difference was observed in the operative time or complication rates. In both groups, all fractures achieved union without malunion and with excellent functional outcomes by definition of the Mayo elbow performance index and UCLA scoring system. This study confirmed a high overall rate of union and excellent functional outcomes in both MIPO and COP groups. MIPO is equivalent to COP as a safe and effective method for simple types of humeral shaft fractures when surgery is indicated, and the surgeon is experienced in the technique. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Käfer, W; Kinzl, L; Sarkar, M R
Proximal tibial epiphyseal injury is a rare finding in adolescents. We report the case of a 13-year-old boy with simultaneous epiphyseal fractures of both proximal tibiae to illustrate appropriate diagnosis and treatment of this condition. The injury occurred while performing a long jump: a Salter-Harris type II fracture of the right proximal tibia was sustained at take-off and a Salter-Harris type III avulsion fracture of the left tibial tuberosity upon landing. Closed reduction and internal fixation using K-wires were performed on the right side, whereas open reduction and internal fixation were done on the left side, using a lag screw and additional McLaughlin wiring.
Li, L.; Brunet, J. P. L.; Karpyn, Z.; Huerta, N. J.
During geological carbon sequestration (GCS) large quantities of CO2 are injected in underground formations. Cement fractures represent preferential leakage pathways in abandoned wells upon exposure to CO2-rich fluid. Contrasting self- healing and fracture opening behavior have been observed while a unifying framework is still missing. The modelling of this process is challenging as it involves complex chemical, mechanical and transport interactions. We developed a process-based reactive transport model that explicitly simulates flow and multi-component reactive transport in fractured cement by reproducing experimental observations of sharp flow rate reduction during exposure to carbonated water. Mechanical interactions have not been included. The simulation shows a similar reaction network as in diffusion-controlled systems without flow. That is, CO2-rich water induced portlandite dissolution, releasing calcium that further reacted with carbonate to form calcite. This created localized changes in porosity and permeability inducing large differences in the long term response of the system through a complex positive feedback loop (e.g., a decrease in local permeability induces a decrease in flow that in turn amplifies the precipitation of calcite through a reduced acidic brine flow). The calibrated model was used to generate 250 numerical experiments of CO2-flooding in cement fractures with varying initial hydraulic apertures (b) and residence times (τ) defined as the ratio of fracture volume over flow rate. A long τ leads to slow replenishment of carbonated water, calcite precipitation, and self-sealing. The opposite occurs when τ is small with short fractures and fast flow rates. Simulation results indicate that a critical residence time τc - the minimum τ required for self-sealing -divides the conditions that trigger the diverging opening and self-sealing behavior. The τc value depends on the initial aperture size (see figure). Among the 250 simulated
Bang, J; Broeng, L
Two cases of spontaneous fracture and dislocation of the tibial tuberosity in boys (15 and 19 years of age), who had both suffered from Osgood-Schlatter disease are described. The treatment and prognosis are discussed.
Taylor, D. L. P.; Nagy, G. T.; Owen, D. R. J.
Can manufacturers produce hundreds of millions of cans annually, increasingly, food cans are being opened by lifting a tab on the can end that initiates a fracture, which then propagates around a circumferential score. The damage and fracture mechanisms that lead to crack initiation and propagation in the opening process, however, are not fully understood, therefore optimisation of easy open end scores is largely based on trial and error. This paper presents an experimental analysis that concentrates on the combined shear and bending forces as applied to the particular industrial method concerning full aperture easy open ends. The influence of a gradually increasing gap measured between the score and shear force location on traditional groove geometries and depths are examined for two different packaging steels. Earlier studies have shown that the complete opening cycle depends on fracture modes I, II & III as well as their combination. Experimental results for Modes I, II & III will be presented, however attention will focus on the behaviour of the initial fracture point, whereby prior investigations have shown it to be influenced primarily by mode II shearing. After initial specimen manufacture, where the score is formed by pressing a punch into a thin steel sheet the predeformed scored specimens are loaded in shear to simulate the local stress field found during the initial opening phase. Experiments have been completed using a novel Mode II experimental technique that has been designed for use in the majority of commercially available tensile test machines. Experimental results indicate that opening forces can change radically with different gap sizes and that there is considerable potential for the industrialised process of can end manufacture to be optimised through the efficient management and control of the can ends dimensional parameters.
Sefati, Niloofar; Norouzian, Mohsen; Abbaszadeh, Hojjat-Allah; Abdollahifar, Mohammad-Amin; Amini, Abdollah; Bagheri, Mohammad; Aryan, Arefeh; Fathabady, Fatemeh Fadaei
Background: Hypothyroidism is associated with dysfunction of the bone turnover with reduced osteoblastic bone formation and osteoclastic bone resorption. Mesenchymal stem cells (MSCs) secrete various factors and cytokines that may stimulate bone regeneration. The aim of this study was to determine the effects of MSCs-conditioned medium (CM) in hypothyroidism male rats after inducing bone defect. Methods: In this study, 24 male rats were randomly assigned to three groups: (I) hypothyroidism + bone defect (HYPO), (II) hypothyroidism + bone defect + CM (HYPO + CM), and (III) no hypothyroidism + bone defect (control). Four weeks after surgery, the right tibia was removed, and immediately, biomechanical and histological examinations were performed. Results: The results showed a significant reduction in bending stiffness (32.64 ± 3.99), maximum force (14.63 ± 1.89), high stress load (7.59 ± 2.31), and energy absorption (12.68 ± 2.12) at the osteotomy site in hypothyroidism rats in comparison to the control and hypothyroidism + condition medium groups (p < 0.05). There was also a significant decrease in the trabecular bone volume (3.86 ± 3.88) and the number of osteocytes (5800 ± 859.8) at the osteotomy site in hypothyroidism rats compared to the control and hypothyroidism + condition medium groups (p < 0.01 and p < 0.02, respectively). Conclusion: The present study suggests that the use of the CM can improve the fracture regeneration and accelerates bone healing at the osteotomy site in hypothyroidism rats. PMID:28755654
Li, Cheng; Wang, Nan; Bi, Da-Wei
To explore the method and therapeutic effect of minor external fixation combined with Kirschner Treatment for open comminuted fracture of metacarpophalangeal joint. From January 2013 to December 2014, 13 patients with open comminuted fracture of metacarpophalangeal joint were treated by minor external fixation combined with Kirschner wire, including 9 males and 4 females, aged from 18 to 56 years old with an average of 35 years old.According to Gustilo classification, 8 cases were type II, 4 cases were type IIIA, and 1 case was type IIIB. The time from injury to operation ranged from 2 to 7 h with an average of 5 h. All fractures were involved with metacarpal phalangeal joint surface. Fracture healing time and postoperative complications were observed, TAM scoring system by Hand Surgery Association of Chinese Medical Association was used to evaluate functional recovery. All patients were followed up from 3 to 12 months with an average of 7 months. All fractures were obtained bone healing, and the time ranged from 4 to 6 weeks with an average of (4.6±1.0) weeks. No broken and loose needle, pin track infections, malunion, loose bracket, reflection sexual sense of neurological malnutrition occurred. According to TAM scoring system, 7 cases obtained excellent results, 4 cases good, 1 case moderate and 1 case poor. Minor external fixation combined with Kirschner wire for open comminuted fracture of metacarpophalangeal joint has advantages of simple operation, good stability and which could be adjusted at the later stage, less damage for soft tissue periosteum, low inflammatory, earlier functional exercise. It is worth to be popularized and applied.