Infection of Combat-Related Fractures • CID 2007:45 (15 August) • 409 M A J O R A R T I C L E Infectious Complications of Open Type III Tibial...associated with high-energy explosive injuries, often resulting in open tibial fractures complicated by nonunion and infection . We characterize the... infections seen in conjunction with combat-associated type III tibial fractures. Methods. We performed a retrospective medical records review to identify US
Papakostidis, Costas; Kanakaris, Nikolaos K; Pretel, Juan; Faour, Omar; Morell, Daniel Juan; Giannoudis, Peter V
The aim of the present study was to comparatively analyse certain outcome measures of open tibial fractures, stratified per grade of open injury and method of treatment. For this purpose, a systematic review of the English literature from 1990 until 2010 was undertaken, comprising 32 eligible articles reporting on 3060 open tibial fractures. Outcome measures included rates of union progress (early union, delayed union, late union and non-union rates) and certain complication rates (deep infection, compartment syndrome and amputation rates). Statistical heterogeneity across component studies was detected with the use of Cochran chi-square and I(2) tests. In the absence of significant statistical heterogeneity a pooled estimate of effect size for each outcome/complication of interest was produced. All component studies were assigned on average a moderate quality score. Reamed tibial nails (RTNs) were associated with significantly higher odds of early union compared with unreamed tibial nails (UTNs) in IIIB open fractures (odds ratio: 12, 95% CI: 2.4-61). Comparing RTN and UTN modes of treatment, no significant differences were documented per grade of open fractures with respect to both delayed and late union rates. Surprisingly, nonunion rates in IIIB open fractures treated with either RTNs or UTNs were lower than IIIA or II open fractures, although the differences were not statistically significant. Significantly increased deep infection rates of IIIB open fractures compared with all other grades were documented for both modes of treatment (RTN, UTN). However, lower deep infection rates for IIIA open fractures treated with RTNs were recorded compared with grades I and II. Interestingly, grade II open tibial fractures, treated with UTN, presented significantly greater odds for developing compartment syndrome than when treated with RTNs. Our cumulative analysis, providing for each grade of open injury and each particular method of treatment a summarised estimate of
Park, Chul Hyun; Shon, Oog Jin; Kim, Gi Beom
Background: Traditionally, Gustilo Anderson grade IIIb open tibial fractures have been treated by initial wide wound debridement, stabilization of fracture with external fixation, and delayed wound closure. The purpose of this study is to evaluate the clinical and radiological results of staged treatment using negative pressure wound therapy (NPWT) for Gustilo Anderson grade IIIb open tibial fractures. Materials and Methods: 15 patients with Gustilo Anderson grade IIIb open tibial fractures, treated using staged protocol by a single surgeon between January 2007 and December 2011 were reviewed in this retrospective study. The clinical results were assessed using a Puno scoring system for severe open fractures of the tibia at the last followup. The range of motion (ROM) of the knee and ankle joints and postoperative complication were evaluated at the last followup. The radiographic results were assessed using time to bone union, coronal and sagittal angulations and a shortening at the last followup. Results: The mean score of Puno scoring system was 87.4 (range 67–94). The mean ROM of the knee and ankle joints was 121.3° (range 90°–130°) and 37.7° (range 15°–50°), respectively. Bone union developed in all patients and the mean time to union was 25.3 weeks (range 16–42 weeks). The mean coronal angulation was 2.1° (range 0–4°) and sagittal was 2.7° (range 1–4°). The mean shortening was 4.1 mm (range 0–8 mm). Three patients had partial flap necrosis and 1 patient had total flap necrosis. There was no superficial and deep wound infection. Conclusion: Staged treatment using NPWT decreased the risks of infection and requirement of flap surgeries in Gustilo Anderson grade IIIb open tibial fractures. Therefore, staged treatment using NPWT could be a useful treatment option for Gustilo Anderson grade IIIb open tibial fractures. PMID:27746498
Ludwig, Meryl; Hymes, Robert A; Schulman, Jeff; Pitta, Michael; Ramsey, Lolita
Tibia fracture is the most common type of long bone fracture, and intramedullary nailing is the preferred treatment. In open fractures, a provisional plate is often used to maintain reduction. It is unknown whether this practice increases the risk of infection or other complications. This study retrospectively compared patients who were treated at a level 1 trauma center with intramedullary nailing of an open tibia fracture. Patients who were included: (1) were 18 years or older; (2) were treated between January 1, 2005, and June 30, 2013; (3) had an open fracture of the tibia; and (4) were treated operatively with intramedullary nailing, with or without provisional plate fixation. Patient sex, history of diabetes, history of smoking, mechanism of injury, and side of injury were analyzed. Postoperative complications included infection, delayed union or non-union, compartment syndrome, and death. After the authors controlled for age, Gustilo-Anderson type, and AO/Orthopaedic Trauma Association classification, they found that provisional plate use did not significantly increase the risk of infection (adjusted odds ratio, 1.64; 95% confidence interval, 0.51-5.32; P=.41) or any other complications (adjusted odds ratio, 1.24; 95% confidence interval, 0.46-3.35; P=.67). In the subgroup of patients who had a provisional plate (n=35), removal of the plate did not significantly decrease the risk of infection (adjusted odds ratio, 0.43; 95% confidence interval, 0.07-2.69; P=.36) or other complications (adjusted odds ratio, 0.55; 95% confidence interval, 0.12-2.46; P=.44). In open tibia fractures treated with intramedullary nailing, provisional plate stabilization, a valuable reduction aid, did not increase the risk of infection or other complications. Because of the small subgroup size, however, definitive conclusions cannot be drawn about removal of these provisional plates. [Orthopedics. 2016; 39(5):e931-e936.]. Copyright 2016, SLACK Incorporated.
Jaña Neto, Frederico Carlos; de Paula Canal, Marina; Alves, Bernardo Aurélio Fonseca; Ferreira, Pablício Martins; Ayres, Jefferson Castro; Alves, Robson
Objective To analyze the characteristics of patients with Gustilo–Anderson Type III open tibial fractures treated at a tertiary care hospital in São Paulo between January 2013 and August 2014. Methods This was a cross-sectional retrospective study. The following data were gathered from the electronic medical records: age; gender; diagnosis; trauma mechanism; comorbidities; associated fractures; Gustilo and Anderson, Tscherne and AO classifications; treatment (initial and definitive); presence of compartment syndrome; primary and secondary amputations; MESS (Mangled Extremity Severity Score) index; mortality rate; and infection rate. Results 116 patients were included: 81% with fracture type IIIA, 12% IIIB and 7% IIIC; 85% males; mean age 32.3 years; and 57% victims of motorcycle accidents. Tibial shaft fractures were significantly more prevalent (67%). Eight patients were subjected to amputation: one primary case and seven secondary cases. Types IIIC (75%) and IIIB (25%) predominated among the patients subjected to secondary amputation. The MESS index was greater than 7 in 88% of the amputees and in 5% of the limb salvage group. Conclusion The profile of patients with open tibial fracture of Gustilo and Anderson Type III mainly involved young male individuals who were victims of motorcycle accidents. The tibial shaft was the segment most affected. Only 7% of the patients underwent amputation. Given the current controversy in the literature about amputation or salvage of severely injured lower limbs, it becomes necessary to carry out prospective studies to support clinical decisions. PMID:27069881
Stanisław, Bołtuć Witold; Bogusław, Golec Edward
Background: The work presents the assessment of the results of treatment of open tibial shaft fractures in polytrauma patients. Materials and Methods: The study group comprised 28 patients who underwent surgical treatment of open fractures of the tibial shaft with locked intramedullary nailing. The mean age of the patients was 43 years (range from 19 to 64 years). The criterion for including the patients in the study was concomitant multiple trauma. For the assessment of open tibial fractures, Gustilo classification was used. The most common concomitant multiple trauma included craniocerebral injuries, which were diagnosed in 12 patients. In 14 patients, the surgery was performed within 24 h after the injury. In 14 patients, the surgery was delayed and was performed 8–10 days after the trauma. Results: The assessment of the results at 12 months after the surgery included the following features: time span between the trauma and the surgery and complications in the form of osteomyelitis and delayed union. The efficacy of gait, muscular atrophy, edema of the operated limb and possible disturbances of its axis were also taken under consideration. In patients operated emergently within 24 h after the injury, infected nonunion was observed in three (10.8%) males. These patients had grade III open fractures of the tibial shaft according to Gustilo classification. No infectious complications were observed in patients who underwent a delayed operation. Conclusion: Evaluation of patients with open fractures of the tibial shaft in multiple trauma showed that delayed intramedullary nailing performed 8–10 days after the trauma, resulted in good outcome and avoided development of delayed union and infected nonunion. This approach gives time for stabilization of general condition of the patient and identification of pathogens from wound culture. PMID:19753226
Al-Sayyad, Mohammed J
Background: The Taylor spatial frame (TSF) is a modern multiplanar external fixator that combines the ease of application and computer accuracy in the reduction of fractures. A retrospective review of our prospective TSF database for the use of this device for treating open tibial fractures in pediatric, adolescent, and adult patients was carried out to determine the effectiveness and complications of TSF in the treatment of these fractures. Materials and Methods: Nineteen male patients with open tibial fractures were included. Of these fractures, 10 were Gustilo Type II, five were Gustilo Type IIIA (two had delayed primary closure and three had split thickness skin grafting), and four were Gustilo Type IIIB (all had rotational flaps). Twelve of our patients presented immediately to the emergency room, and the remaining seven cases presented at a mean of 3 months (range, 2.2-4.5 months) after the initial injury. The fractures were located in proximal third (n=1), proximal/middle junction (n=2), middle third (n=3), middle/distal junction (n=8), distal third (n=3), and segmental fractures (n=2). Patients were of an average age of 26 years (range, 6-45years). Mean duration of follow-up was 3.5 years. Results: All fractures healed over a mean of 25 weeks (range, 9-46 weeks). All were able to participate in the activities of daily living without any difficulty and most were involved in sports during the last follow-up. Postoperative complications included pin tract infection in 12 patients. Conclusion: The TSF is an effective definitive method of open tibial fracture care with the advantage of early mobilization, ease of soft tissue management through gradual fracture reduction, and the ability to postoperatively manipulate the fracture into excellent alignment. PMID:19753231
Wei, Shijun; Cai, Xianhua; Huang, Jifeng; Xu, Feng; Liu, Ximing; Wang, Qing
Recombinant human bone morphogenetic protein-2 (rhBMP-2) improves healing of open tibial fractures treated with intramedullary nail fixation. However, routine use has not occurred. The purposes of the current study were to provide a systematic review of the literature using rhBMP-2 in the treatment of acute open tibial fractures treated with intramedullary nail fixation and to provide a meta-analysis of the randomized, controlled trials. Multiple databases, reference lists of relative articles, and main orthopedic journals were searched. The basic information and major results were compared. Four studies with a total of 609 patients were included.The secondary intervention rate in the standard-of-care (SOC) group was significantly higher than in the rhBMP-2 combined with absorbable collagen sponge (rhBMP-2/ACS) group (27.1% vs 17.5%, respectively; P<.01). The treatment failure rate in the SOC group was significantly higher (34.3% vs. 21.4%, respectively; P<.01). No significant differences were found in infection rate, hardware failure rate, fracture healing rate at 20 weeks, and postoperative pain level. For patients treated with reamed intramedullary nail fixation, only the treatment failure rate in the SOC group was significantly higher (21.5% vs 14.2%, respectively; P=.02); no other significant difference was observed. Adding rhBMP-2 to the treatment of Gustilo-Anderson grade IIIA and B open tibial fractures led to net savings of approximately $6000 per case.Recombinant human bone morphogenetic protein-2 added to intramedullary nail fixation of open tibial fractures could reduce the frequency of secondary interventions and total health care costs. For reamed patients, adding rhBMP-2 reduced treatment failure. This analysis supports the clinical efficacy of rhBMP-2/ACS for the treatment of these severe fractures. Copyright 2012, SLACK Incorporated.
Tropet, Y; Garbuio, P; Obert, L; Jeunet, L; Elias, B
The purpose of this study was to report the authors' experience with emergency reconstruction of severe tibial shaft fractures. Five male patients were admitted to the emergency room with a grade IIIB open tibial shaft fracture with bone loss (average age, 33 years; age range, 18-65 years). Injuries were the result of motorcycle accidents (N = 2), pedestrian accidents (N = 1), gunshot wound (N = 1), and paragliding fall (N = 1). Primary emergent one-stage management for all patients consisted of administration of antibiotics, debridement, stabilization by locked intramedullary nailing, bone grafting from the iliac crest, and coverage using free muscle flaps (four latissimus dorsi and one gracilis). The average follow-up was 21 months (range, 8 months-3.5 years). Partial weight bearing with no immobilization was started at 3 months, and full weight bearing began 5 months after trauma. No angular complications and no nonunions were observed. There was one case of superficial infection without osteitis. All fractures healed within 6 months in 4 patients and within 10 months in 1 patient. At the last follow-up examination, ankle and knee motion was normal and no pain was noted, except for 1 patient who had associated lesions (ankle motion reduced by 50%). Aggressive emergency management of severe open tibial fractures provides good results. It improves end results markedly, not only by reducing tissue loss from infection, but also reducing healing and rehabilitation times.
Uysal, Emin; Özmeriç, Ahmet
Aim. In these case series which are about type 3 open tibial fractures formed with three different high energy trauma etiologies in different parts of tibia. We aimed to assess our three-stage treatment approach and discuss final results of our elective surgery management with three different fixation methods. Patients and Methods. We assessed 19 patients with type 3 open tibial fractures between 2009 and 2012. Our treatment protocol consisted of three stages. Early intervention in operating room, which including vascular repairs or soft tissue closure, was done if necessary. Definitive surgery was performed using internal or external fixation in the first 15 days. Patients were followed up for at least one year. Last conditions of all our cases were evaluated according to modified Johner and Wruhs criteria. Results. Nine cases were type 3A, seven cases were type 3B, and three cases were type 3C in terms of fracture typing. All patients were followed up for at least one year and mean follow up time was 15 months. In terms of functional and clinical outcome, six cases were evaluated as excellent, eight cases as good, two cases as fair, and three cases as poor. Discussion. Staged treatment option in type 3 open tibial fractures seems to be a good method in reducing complication and achieving the best result. We think that definitive staged treatment protocol including internal fixation with plating or intramedullary nailing (IMN) of the fractures is a reliable method, especially to avoid complications as a result of external fixator and to provide patient rapport. PMID:24967129
Lescure, G; Toledano, E; Terver, S
The authors report a series of 9 cases over the period 1981-1992.Debridement was achieved in a single procedure in 44.5% of the cases, in 2 procedures in 33.3%, in more than 2 procedures in 22.2%. The closure of the wound was achieved by secondary sature in 77.8% of the cases and by a muscule flap in 22.2%. The fixation of the fracture was performed by an external fixator in all cases.Primary consolidation was obtained in 44.4% of the cases. A tibiofibular graft was needed in 4 cases.The mean time to consolidation was 23 months.
Almeida Matos, Marcos; Castro-Filho, Romulo Neves; Pinto da Silva, Bruno Vieira
Introducción: El objetivo del tratamiento de las fracturas abiertas es prevenir las infecciones, estabilizar el hueso e restaurar la función. En relación a los objetivos mencionados, la prevención de infecciones tiene mayor destaque y es el punto mas importante a ser alcanzado. Objetivo: El objetivo de este trabajo es identificar los factores de riesgo asociados con la infección en un grupo de pacientes con fracturas abierta de la tibia. Paciente y métodos. Fue realizado un análisis retrospectivo con pacientes que tuvieron fractura abierta tibial que estaban en tratamiento en el Hospital Roberto Santos-Geral-HGRS, Salvador, Bahía, Brasil, de marzo a octubre de 2009. Fueron excluidos de este estudio todos los niños menores de 8 años con fracturas múltiples o que tenían alguna enfermedad sistémica o en los huesos. De acuerdo con los datos clínicos y demográficos, los pacientes fueron divididos en dos grupos: el grupo 1 estaba constituido por los que no tenían infección en las fracturas y el grupo 2 por los que tenían infección. En los dos grupos se investigo factores que podrían estar asociados a la infección. Resultados. De 50 pacientes estudiados la tasa de infección global fue de 14 (28%, IC95% = 15,5-40,5). El hecho de desenvolver infección fue asociado con el lugar del trauma (OR 3,78; IC 95% = 1,4-5,5, p = 0,02), y la demora en recibir tratamiento adecuado en tiempo superior a 24 horas (OR 3,4; IC95% 1.4-20.8 = p = 0,03). Las fracturas clasificadas como Gustilo I, II, IIIA tuvieron una menor chance de infección cuando comparadas como Gustilo IIIB y IIIC (OR 4.32; CI95%=1.3-19.1; p=0.01). Fracturas clasificadas como Tscherne III y IV tuvieron una mayor frecuencia de infección, lo que resulto ser el factor más importante e significativo (OR 8.07; CI95%=2.4-47.1; p p<0.00). Conclusión. En nuestros resultados observamos; una relación entre infección y la clasificación de Gustilo. También observamos asociación de infección cuando el
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
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
Watts, Chad D; Larson, A Noelle; Milbrandt, Todd A
Stiffness is a common complication following surgically treated tibial eminence fractures. Fractures can be addressed with either open reduction and internal fixation (ORIF) or arthroscopic reduction and internal fixation (ARIF). We sought to evaluate the effects of surgical approach and other modifiable perioperative factors on postoperative arthrofibrosis. We hypothesized that ARIF would result in a lower risk of arthrofibrosis. We retrospectively reviewed the records of all patients aged 18 years and below treated for tibial eminence fractures at our institution from 1998 to 2014. All patients were treated by either pediatric or sports fellowship-trained orthopaedic surgeons and followed until radiographic union and return of range of motion or treatment for arthrofibrosis (minimum 3 mo). Thirty-one patients were included in our analysis, 13 in the ORIF group and 18 in the ARIF group. The groups were similar in regards to sex, age, fracture type, fixation method, and length of postoperative immobilization. However, when compared with the ORIF group, patients in the ARIF group had significantly longer time from injury to surgery (4.2 vs. 6.3 d, P=0.03), operative time (98 vs. 141 min, P=0.02), and tourniquet time (76 vs. 100 min, P=0.006). In the ARIF group, 6 (33.3%) patients acquired arthrofibrosis compared with only 1 (7.7%) patient in the ORIF group. Delaying surgery ≥7 days from injury [hazard ratio (HR)=4.7, P=0.04] and operative time ≥120 minutes (HR=9.1, P=0.03) were risk factors for arthrofibrosis. ARIF was a risk factor in univariate (HR=4.0, P=0.04), but not in multivariate (1.4, P=0.77) analysis. Delayed surgery (≥7 d from injury) and prolonged operative times (≥120 min) were significant risk factors for arthrofibrosis. Although ARIF was not an independent risk factor, these patients were exposed to markedly longer wait times before surgery and operative times when compared with ORIF patients. ORIF is a reasonable option for treatment of
Palmu, Sauli A; Auro, Sampo; Lohman, Martina; Paukku, Reijo T; Peltonen, Jari I; Nietosvaara, Yrjänä
Background Tibial fracture is the third most common long-bone fracture in children. Traditionally, most tibial fractures in children have been treated non-operatively, but there are no long-term results. Methods 94 children (64 boys) were treated for a tibial fracture in Aurora City Hospital during the period 1980–89 but 20 could not be included in the study. 58 of the remaining 74 patients returned a written questionnaire and 45 attended a follow-up examination at mean 27 (23–32) years after the fracture. Results 89 children had been treated by manipulation under anesthesia and cast-immobilization, 4 by skeletal traction, and 1 with pin fixation. 41 fractures had been re-manipulated. The mean length of hospital stay was 5 (1–26) days. Primary complications were recorded in 5 children. The childrens’ memories of treatment were positive in two-thirds of cases. The mean subjective VAS score (range 0–10) for function appearance was 9. Leg-length discrepancy (5–10 mm) was found clinically in 10 of 45 subjects and rotational deformities exceeding 20° in 4. None of the subjects walked with a limp. None had axial malalignment exceeding 10°. Osteoarthritis of the hip and/or knee was seen in radiographs from 2 subjects. Interpretation The long-term outcome of tibial fractures in children treated non-operatively is generally good. PMID:24786903
Golubović, Zoran; Vukajinović, Zoran; Stojiljković, Predrag; Golubović, Ivan; Visnjić, Aleksandar; Radovanović, Zoran; Najman, Stevo
Tibia fracture caused by high velocity missiles is mostly comminuted and followed by bone defect which makes their healing process extremely difficult and prone to numerous complications. A 34-year-old male was wounded at close range by a semi-automatic gun missile. He was wounded in the distal area of the left tibia and suffered a massive defect of the bone and soft tissue. After the primary treatment of the wound, the fracture was stabilized with an external fixator type Mitkovic, with convergent orientation of the pins. The wound in the medial region of the tibia was closed with the secondary stitch, whereas the wound in the lateral area was closed with the skin transplant after Thiersch. Due to massive bone defect in the area of the rifle-missile wound six months after injury, a medical team placed a reconstructive external skeletal fixator type Mitkovic and performed corticotomy in the proximal metaphyseal area of the tibia. By the method of bone transport (distractive osteogenesis), the bone defect of the tibia was replaced. After the fracture healing seven months from the secondary surgery, the fixator was removed and the patient was referred to physical therapy. Surgical treatment of wounds, external fixation, performing necessary debridement, adequate antibiotic treatment and soft and bone tissue reconstruction are essential in achieving good results in patients with the open tibial fracture with bone defect caused by high velocity missiles. Reconstruction of bone defect can be successfully treated by reconstructive external fixator Mitkovic.
Background The rates of soft tissue reconstruction and amputation after open tibial fractures have not been studied on a national perspective. We aimed to determine the frequency of soft tissue coverage after open tibial fracture as well as primary and secondary amputation rates. Methods Data on all patients (> = 15 years) admitted to hospital with open tibial fractures were extracted from the Swedish National Patient Register (1998–2010). All surgical procedures, re-admissions, and mechanisms of injury were analysed accordingly. The risk of amputation was calculated using logistic regression (adjusted for age, sex, mechanism of injury, reconstructive surgery and fixation method). The mean follow-up time was 6 (SD 3.8) years. Results Of 3,777 patients, 342 patients underwent soft tissue reconstructive surgery. In total, there were 125 amputations. Among patients with no reconstructive surgery, 2% (n = 68 patients) underwent amputation. In an adjusted analysis, patients older than 70 years (OR = 2.7, 95%, CI = 1.1-6) and those who underwent reconstructive surgery (OR = 3.1, 95% CI = 1.6-5.8) showed higher risk for amputation. Fixations other than intramedullary nailing (plate, external fixation, closed reduction and combination) as the only method were associated with a significant higher risk for amputation (OR 5.1-14.4). Reconstruction within 72 hours (3 days) showed better results than reconstruction between 4–90 days (p = 0.04). Conclusions The rate of amputations after open tibial fractures is low (3.6%). There is a higher risk for amputations with age above 70 (in contrast: male sex and tissue reconstruction are rather indicators for more severe soft tissue injuries). Only a small proportion of open tibial fractures need soft tissue reconstructive surgery. Reconstruction with free or pedicled flap should be performed within 72 hours whenever possible. PMID:25323662
Howard, N E; Phaff, M; Aird, J; Wicks, L; Rollinson, P
We compared early post-operative rates of wound infection in HIV-positive and -negative patients presenting with open tibial fractures managed with surgical fixation. The wounds of 84 patients (85 fractures), 28 of whom were HIV positive and 56 were HIV negative, were assessed for signs of infection using the ASEPIS wound score. There were 19 women and 65 men with a mean age of 34.8 years. A total of 57 fractures (17 HIV-positive, 40 HIV-negative) treated with external fixation were also assessed using the Checkett score for pin-site infection. The remaining 28 fractures were treated with internal fixation. No significant difference in early post-operative wound infection between the two groups of patients was found (10.7% (n = 3) vs 19.6% (n = 11); relative risk (RR) 0.55 (95% confidence interval (CI) 0.17 to 1.8); p = 0.32). There was also no significant difference in pin-site infection rates (17.6% (n = 3) vs 12.5% (n = 5); RR 1.62 (95% CI 0.44 to 6.07); p = 0.47). The study does not support the hypothesis that HIV significantly increases the rate of early wound or pin-site infection in open tibial fractures. We would therefore suggest that a patient's HIV status should not alter the management of open tibial fractures in patients who have a CD4 count > 350 cells/μl.
Joshi, Anil; Singh, Saurabh; Jain, Sudeep; Rohilla, Narender; Trikha, Vivek; Yadav, Chandra
BACKGROUND: The present study aimed to compare outcome of primary and secondary Illizarov’s fixator application as a treatment method for type III open tibial fractures in terms of non-union and wound infection. METHODS: This prospective study was done in a tertiary care center. Forty-eight type III tibial fractures were treated with Illizarov’s apparatus between 2008 and 2011. The patients were divided into two groups depending on the treatment protocol, timing of wound closure and Illizarov’s application, primary (n=28) and secondary (n=20). RESULTS: In the primary group, healing was achieved in all 28 patients. The median time to recovery was 24 weeks, and the median number of operations was 3. There were 6 patients with a bone defect. In the secondary group, complete recovery was achieved in 18 out of 20 patients. The median time to recovery was 30 weeks, and the median number of operations 5. There were 9 patients with a bone defect. The median time to recovery and the number of operations were significantly smaller in patients undergoing primary operation. Union was 100% in the primary group and more than 95% in the secondary group. Chronic osteomyelitis persisted in one patient and below amputation was done in one patient in the secondary group. CONCLUSION: Primary wound closure and Illizarov’s fixation required a smaller number of operations and shorter time to recovery than secondary wound closure and Illizarov’s fixation, mostly due to a significantly less number of patients with a bone defect in the primary group. PMID:27547283
Ramasamy, P R
Background: Open fractures of tibia have posed great difficulty in managing both the soft tissue and the skeletal components of the injured limb. Gustilo Anderson III B open tibial fractures are more difficult to manage than I, II, and III A fractures. Stable skeletal fixation with immediate soft tissue cover has been the key to the successful outcome in treating open tibial fractures, in particular, Gustilo Anderson III B types. If the length of the open wound is larger and if the exposed surface of tibial fracture and tibial shaft is greater, then the management becomes still more difficult. Materials and Methods: Thirty six Gustilo Anderson III B open tibial fractures managed between June 2002 and December 2013 with “fix and shift” technique were retrospectively reviewed. All the 36 patients managed by this technique had open wounds measuring >5 cm (post debridement). Under fix and shift technique, stable fixation involved primary external fixator application or primary intramedullary nailing of the tibial fracture and immediate soft tissue cover involved septocutaneous shift, i.e., shifting of fasciocutaneous segments based on septocutaneous perforators. Results: Primary fracture union rate was 50% and reoperation rate (bone stimulating procedures) was 50%. Overall fracture union rate was 100%. The rate of malunion was 14% and deep infection was 16%. Failure of septocutaneous shift was 2.7%. There was no incidence of amputation. Conclusion: Management of Gustilo Anderson III B open tibial fractures with “fix and shift” technique has resulted in better outcome in terms of skeletal factors (primary fracture union, overall union, and time for union and malunion) and soft tissue factors (wound healing, flap failure, access to secondary procedures, and esthetic appearance) when compared to standard methods adopted earlier. Hence, “fix and shift” could be recommended as one of the treatment modalities for open III B tibial fractures. PMID:28216752
Background Fat embolism syndrome is a potentially fatal complication of long bone fractures. It is usually seen in the context of polytrauma or a femoral fracture. There are few reports of fat embolism syndrome occurring after isolated long bone fractures other than those of the femur. Case presentation We describe a case of fat embolism syndrome in a 33-year-old Caucasian man. He was being seen for an isolated Gustilo’s grade II open tibial fracture. He was deemed clinically stable, so we proceeded to treat the fracture with intramedullary reamed nailing. He developed fat embolism syndrome intraoperatively and was treated successfully. Conclusion This case caused us to question the use of injury severity scoring for isolated long bone fractures. It suggests that parameters that have been described in the literature other than that the patient is apparently clinically stable should be used to establish the best time for nailing a long bone fracture, thereby improving patient safety. PMID:24731759
Aparicio, Gustavo; Soler, Isabel; López-Durán, Luis
Fat embolism syndrome is a potentially fatal complication of long bone fractures. It is usually seen in the context of polytrauma or a femoral fracture. There are few reports of fat embolism syndrome occurring after isolated long bone fractures other than those of the femur. We describe a case of fat embolism syndrome in a 33-year-old Caucasian man. He was being seen for an isolated Gustilo's grade II open tibial fracture. He was deemed clinically stable, so we proceeded to treat the fracture with intramedullary reamed nailing. He developed fat embolism syndrome intraoperatively and was treated successfully. This case caused us to question the use of injury severity scoring for isolated long bone fractures. It suggests that parameters that have been described in the literature other than that the patient is apparently clinically stable should be used to establish the best time for nailing a long bone fracture, thereby improving patient safety.
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
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
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.
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.
Dexel, Julian; Fritzsche, Hagen; Beyer, Franziska; Harman, Melinda K; Lützner, Jörg
Open-wedge high tibial osteotomy (HTO) is an established treatment for young and middle-aged patients with medial compartment knee osteoarthritis and varus malalignment. Although not intended, a lateral cortex fracture might occur during this procedure. Different fixation devices are available to repair such fractures. This study was performed to evaluate osteotomy healing after fixation with two different locking plates. Sixty-nine medial open-wedge HTO without bone grafting were followed until osteotomy healing. In patients with an intact lateral hinge, no problems were noted with either locking plate. A fracture of the lateral cortex occurred in 21 patients (30.4 %). In ten patients, the fracture was not recognized during surgery but was visible on the radiographs at the 6-week follow-up. Lateral cortex fracture resulted in non-union with the need for surgical treatment in three out of eight (37.5 %) patients using the newly introduced locking plate (Position HTO Maxi Plate), while this did not occur with a well-established locking plate (TomoFix) (0 out of 13, p = 0.023). With regard to other adverse events, no differences between both implants were observed. In cases of lateral cortex fracture, fixation with a smaller locking plate resulted in a relevant number of non-unions. Therefore, it is recommended that bone grafting, another fixation system, or an additional lateral fixation should be used in cases with lateral cortex fracture. III.
Salem, Khaled Hamed
Unreamed nailing has gained acceptance in the treatment of diaphyseal long bone fractures, especially in cases with polytrauma or high-energy injuries. Its application in distal tibial fractures, however, remains controversial. In this study, 101 distal tibial fractures treated using closed unreamed nailing were reviewed after a mean follow-up of 32 months. There were 59 type A und 42 type B fractures. The most common fracture pattern was the A1 spiral fracture (n = 40) followed by the B2 wedge fracture (n = 18). Intra-articular extension was encountered in 14 cases. One-fourth of the patients (n = 24) had open injuries. Forty-seven patients had additional injuries, and nearly one-third of them were polytraumatised. Union occurred after a mean time of 23.9 (range, 11-134) weeks. There were 13 cases of delayed union and seven non-unions; all healed eventually with additional surgery in only six fractures. Malunion was seen in 12 cases (five valgus, two varus and five external torsion), ten of which were associated with unplated fibular fractures. Three fractures (two open) were treated for deep infection. The most common complication seen was fatigue failure of the locking screws (27 cases). Unreamed nailing of distal tibial fractures is associated with a rather high rate of bone healing complications and locking screw failure. The decision for its use in the notoriously challenging fractures of this segment should be critically considered.
Märdian, S; Schwabe, P; Schaser, K-D
The tibia shaft is the most often fractured long bone of human beings. Among others traffic accidents (37.5 %), falls (17.8 %), sport accidents (30.9 %) and assaults (4.5 %) are typical mechanisms. A brief clinical examination including the correct classification of the fracture pattern and even more important the degree of the soft tissue damage are the most crucial factors for the following therapeutic cascade. This follows a defined algorithm based on the degree of soft tissue damage. As biplanar X-ray diagnostics are obligatory, CT scans are subject to complex fracture patterns and accompanying intraarticular pathologies.The treatment of tibial shaft fractures is the preserve of operative stabilization, which should be done primarily depending on the degree of the soft tissue injury. Here intramedullary methods - especially intramedullary nailing - are the golden standard.The most serious complication of these fractures is the development of a compartment syndrome. This requires rapid diagnosis and an adequate surgical management in order to avoid extensive muscle necrosis with ischaemic contractures and irreversible neurovascular deficits. Apart from postoperative infections, which are the predominant complication especially in open injuries, non union provide typical and late complications which are partly difficult to treat. These should, depending on their type, follow a dedicated treatment algorithm.
Keating, J F; O'Brien, P J; Blachut, P A; Meek, R N; Broekhuyse, H M
Ninety-one patients who had ninety-four open fractures of the tibial shaft were randomized into two treatment groups. Fifty fractures (nine type-I, eighteen type-II, sixteen type-IIIA, and seven type-IIIB fractures, according to the classification of Gustilo et al.) were treated with nailing after reaming, and forty-four fractures (five type-I, sixteen type-II, nineteen type-IIIA, and four type-IIIB fractures) were treated with nailing without reaming. The average diameter of the nail was 11.5 millimeters (range, nine to fourteen millimeters) in the group treated with reaming and 9.2 millimeters (range, eight to ten millimeters) in the group treated without reaming. Follow-up information was adequate for forty-five patients (forty-seven fractures) who had been managed with reaming and forty patients (forty-one fractures) who had been managed without reaming. No clinically important differences were found between the two groups with regard to the technical aspects of the procedure or the rate of early postoperative complications. The average time to union was thirty weeks (range, thirteen to seventy-two weeks) in the group treated with reaming and twenty-nine weeks (range, thirteen to fifty weeks) in the group treated without reaming. Four (9 per cent) of the fractures treated with reaming and five (12 per cent) of the fractures treated without reaming did not unite (p = 0.73). There were two infections in the group treated with reaming and one in the group treated without reaming. Significantly more screws broke in the group treated without reaming (twelve; 29 per cent) than in the group treated with reaming (four; 9 per cent) (p = 0.014). There was no difference between the two groups with regard to the frequency of broken nails (two nails that had been inserted after reaming broke, compared with one that had been inserted without reaming). The functional outcome, in terms of pain in the knee, range of motion, return to work, and recreational activity, did not
Kling, T F; Bright, R W; Hensinger, R N
Fractures of the distal end of the tibia in children often involve the physis. They are of particular importance because partial growth arrest can occur and result in angular deformity, limb-length discrepancy, or incongruity of the joint surface (or a combination of these). We evaluated the cases of thirty-two children who had a fracture leading to established partial growth arrest of the distal end of the tibia. Most of this group had had a Salter-Harris Type-III or Type-IV fracture. Twenty-eight of the fractures had been treated by gentle closed reduction and immobilization in a plaster cast. We also evaluated the cases of thirty-three children who were seen by us for treatment of an acute fracture; most of these were Salter-Harris Type-III or Type-IV fractures of the distal end of the tibia. Nineteen of the twenty acute Type-III or Type-IV fractures that were treated with accurate open reduction of the physis and internal fixation healed without growth disturbance, while five of the nine fractures that were treated by closed means formed a bone bridge, presaging a disturbance in growth. This study suggests that Salter-Harris Type-III and Type-IV, and perhaps Type-II, fractures of the distal end of the tibia commonly cause disturbance of growth in the tibia, and that anatomical reduction of the physis by closed or open means may decrease the incidence of these disturbances of growth, including shortening and varus angulation of the ankle.
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.
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.
The aim of the therapy in open tibial fractures grade III was to cover the bone with soft tissue and achieve healed fracture without persistent infection. Open tibial fractures grade IIIC with massive soft tissue damage require combined orthopaedic, vascular and plastic-reconstructive procedures. Negative-pressure wound therapy (NPWT), used in two consecutive cases with open fracture grade IIIC of the tibia diaphysis, healed extensive soft tissue defect with exposure of the bone. NPWT eventually allowed for wound closure by split skin graft within 21-25 days. Ilizarov external fixator combined with application of recombinant human bone morphogenetic protein-7 at the site of delayed union enhanced definitive bone healing within 16-18 months.
Yokoyama, Kazuhiko; Itoman, Moritoshi; Uchino, Masataka; Fukushima, Kensuke; Nitta, Hiroshi; Kojima, Yoshiaki
Background: 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. Materials and Methods: 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 (≤6 h or >6 h), method of soft-tissue management, skin closure time (≤1 week or >1 week), existence of polytrauma (ISS< 18 or ISS≥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. Results: 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
Valls-Mellado, M; Martí-Garín, D; Fillat-Gomà, F; Marcano-Fernández, F A; González-Vargas, J A
We describe a case of a severely comminuted type iiia open tibial fracture, with distal loss of bone stock (7 cm), total involvement of the tibial joint surface, and severe instability of the fibular-talar joint. The treatment performed consisted of thorough cleansing, placing a retrograde reamed calcaneal-talar-tibial nail with proximal and distal blockage, as well as a fibular-talar Kirschner nail. Primary closure of the skin was achieved. After 3 weeks, an autologous iliac crest bone graft was performed to fill the bone defect, and the endomedullary nail, which had protruded distally was reimpacted and dynamized distally. The bone defect was eventually consolidated after 16 weeks. Currently, the patient can walk without pain the tibial-astragal arthrodesis is consolidated. Copyright © 2013 SECOT. Published by Elsevier Espana. All rights reserved.
Seekamp, A; Regel, G; Ruffert, S; Ziegler, M; Tscherne, H
In IIIB and IIIC type open tibial fractures (according to Gustilo) the primary decision that has to be made regarding therapy is wether or not the limb can be salvaged. To standardize the criteria for amputation different salvage scores have been established in recent years. In this study the Hannover Fracture Scale (HFS), the Predictive Salvage Index (PSI), the Mangled Extremity Severity Score (MESS) and the NISSSA score were evaluated regarding their clinical relevance. When ROC Analysis was performed for all these scores in our patients the HFS revealed the highest sensitivity (0.91), but low specificity (0.71). The highest specificity was noted for the MESS (0.97), which in parallel showed the lowest sensitivity (0.59). In general it seems to be essential to make the right decision initially in order to avoid secondary amputation. All the scores mentioned here appear to be helpful in decision making. Salvaged limbs in IIIB and IIIC fractures presented a comparable good outcome, whereas salvaged IIIC injuries with a high score presented an outcome which was as bad as in secondary amputations. Secondary amputated patients required not only significant longer hospitalization but also resulted in poor outcome compared with the patients having received reconstruction or primary amputation.
van Haeff, M J; Sauter, A J
Eight weeks after transposition of the tibial tubercle for recurrent subluxation of the patella, the patient sustained a tibial fracture during rope jumping. In spite of consolidation of the osteotomy in the frontal plane, there remained a small gap in the anterior cortex in the transverse plane through which the tibia failed during bending stress.
Ma, Ching-Hou; Wu, Chin-Hsien; Tu, Yuan-Kun; Lin, Ting-Sheng
We evaluated both the outcome of using a locking plate as a definitive external fixator for treating open tibial fractures and, using finite element analysis, the biomechanical performance of external and internal metaphyseal locked plates in treating proximal tibial fractures. Eight open tibial patients were treated using a metaphyseal locked plate as a low-profile definitive external fixator. Then, finite element models of internal (IPF) as well as two different external plate fixations (EPFs) for proximal tibial fractures were reconstructed. The offset distances from the bone surface to the EPFs were 6 cm and 10 cm. Both axial stiffness and angular stiffness were calculated to evaluate the biomechanical performance of these three models. The mean follow-up period was 31 months (range, 18-43 months). All the fractures united and the mean bone healing time was 37.5 weeks (range, 20-52 weeks). All patients had excellent or good functional results and were walking freely at the final follow-up. The finite element finding revealed that axial stiffness and angular stiffness decreased as the offset distance from the bone surface increased. Compared to the IPF models, in the two EPF models, axial stiffness decreased by 84-94%, whereas the angular stiffness decreased by 12-21%. The locking plate used as a definitive external fixator provided a high rate of union. While the locking plate is not totally rigid, it is clinically stable and may be advisable for stiffness reduction of plating constructs, thus promoting fracture healing by callus formation. Our patients experienced a comfortable clinical course, excellent knee and ankle joint motion, satisfactory functional results and an acceptable complication rate.
Softness, Kenneth A; Murray, Ryan S; Evans, Brian G
Tibial plateau fractures are common injuries that occur in a bimodal age distribution. While there are various treatment options for displaced tibial plateau fractures, the standard of care is open reduction and internal fixation (ORIF). In physiologically young patients with higher demand and better bone quality, ORIF is the preferred method of treating these fractures. However, future total knee arthroplasty (TKA) is a consideration in these patients as post-traumatic osteoarthritis is a common long-term complication of tibial plateau fractures. In older, lower demand patients, ORIF is potentially less favorable for a variety of reasons, namely fixation failure and the need for delayed weight bearing. In some of these patients, TKA can be considered as primary mode of treatment. This paper will review the literature surrounding TKA as both primary treatment and as a salvage measure in patients with fractures of the tibial plateau. The outcomes, complications, techniques and surgical challenges are also discussed. PMID:28251061
Pitta, Guilherme Benjamin Brandão; Dos Santos, Thays Fernanda Avelino; Dos Santos, Fernanda Thaysa Avelino; da Costa Filho, Edelson Moreira
Fractures of the tibial plateau are relatively rare, representing around 1.2% of all fractures. The tibia, due to its subcutaneous location and poor muscle coverage, is exposed and suffers large numbers of traumas, not only fractures, but also crush injuries and severe bruising, among others, which at any given moment, could lead compartment syndrome in the patient. The case is reported of a 58-year-old patient who, following a tibial plateau fracture, presented compartment syndrome of the leg and was submitted to decompressive fasciotomy of the four right compartments. After osteosynthesis with internal fixation of the tibial plateau using an L-plate, the patient again developed compartment syndrome.
van Dreumel, R L M; van Wunnik, B P W; Janssen, L; Simons, P C G; Janzing, H M J
Tibial plateau fractures account for approximately 1% of all fractures. They usually occur after a direct high-energy trauma. Despite adequate treatment, these fractures can result in malalignment and secondary osteoarthritis (OA). Research concerning long-term functional outcome is limited. The primary aim of this study was to evaluate mid- to long-term functional outcome of surgically treated tibial plateau fractures. The secondary aim was to investigate whether radiological characteristics of OA one year after surgery are predictive of functional outcome at follow-up. All consecutive patients with fractures of the proximal tibia, which were surgically treated in our level-2 trauma centre between 2004 and 2010, were included in this study. Initial trauma radiographs were analysed for fracture classification, using both the Schatzker and AO/OTA classification systems, by three different raters. Immediate postoperative and 1-year postoperative radiographs were analysed for osteoarthritis by an experienced radiologist, using the Kellgren and Lawrence scale. Functional outcome of the included patients was measured using the Dutch version of the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire. Seventy one patients out of a group of 96 included patients completed the survey. Median KOOS scores are 89.8% for pain, 91.1% for 'other symptoms', 89.7% for daily function, 72.5% for sports and recreation and 75.0% for quality of life. Median KOOS overall score is 82.99%. We did not find a correlation between the KOOS scores and the absolute age for any of the subscales. There was no significant relationship between radiological characteristics of osteoarthritis and functional outcome. This is the first study to describe mid- to long-term functional outcome after ORIF for all types of tibial plateau fractures, with the use of the KOOS. Patients should be informed about the likelihood of lower functional outcome in the long-term. This study shows that
Soulier, Robert; Fallat, Lawrence
Pediatric distal tibial fractures generally occur without significant long-term sequelae, and patients are commonly able to return to their preinjury activities after proper management. The literature reports excellent outcomes after anatomical reduction of distal tibial and ankle physeal fractures with closed or open treatment. Treatment options include simple immobilization of nondisplaced fractures, and closed or open reduction for restoration of anatomic alignment of displaced fractures. Soft tissue interposition within the fracture can threaten successful closed reduction, and may warrant open management if closed reduction fails to produce a satisfactory result. Despite the documented possibility of soft tissue interposition preventing closed reduction of pediatric ankle fractures, there is a paucity of literature reporting this complication. We report a unique case of an irreducible Salter-Harris type II distal tibial physeal fracture secondary to interposition of the posterior tibial tendon. Copyright 2010 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
The Effect of a Single Treatment of the Protonics System on Lower Extremity Kinematics during Gait and the Lateral Step Up Exercise . (in review) Gait...section in a comparison with a matched control group of subjects who have not sustained a fracture. Due to the low number of tibial stress fractures...fractures must be confirmed by x-rays, bone scans or MRIs. Tibial stress reactions have been operationally defined as bony pain specifically along the
Aydın, Adem; Atmaca, Halil; Müezzinoğlu, Ümit Sefa
Traumatic dislocation of the knee joint is an uncommon complex, multiple ligamentous injury resulting from a high-energy trauma. Significant lack of functions can be seen because of both early and late complications of these injuries such as popliteal artery disruption, peroneal nerve injury, persistent instability and posttraumatic arthritis. Therefore, the emergency surgery is necessary due to possibility of neurovascular compromise and limb loss. Controversies over operative versus closed immobilization of traumatic complex, multiple ligamentous knee injury are still debated. We report a case of traumatic anterior dislocation of the right knee with an ipsilateral tibial shaft fracture in association with right popliteal artery occlusion of a professional athlete who was returned to his sports activity by surgical treated tibia fracture and conservative treatment of the knee dislocation.
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.
Jalgaonkar, Azal A; Dachepalli, Sunil; Al-Wattar, Zaid; Rao, Sudhir; Kochhar, Tony
Avulsion fractures of the tibial tuberosity are typically sustained by adolescent males during sporting activities. Tibial tuberosity avulsions with simultaneous proximal tibial epiphyseal fractures are rare injuries. We present an unusual case of Ogden type IIIA avulsion fracture of tibial tuberosity with a Salter Harris type IV posterior fracture of proximal tibial epiphysis in a 13-year-old boy. We believe that the patient sustained the tibial tuberosity avulsion during the take-off phase of a jump while playing basketball due to sudden violent contraction of the quadriceps as the knee was extending. This was then followed by the posterior Salter Harris type IV fracture of proximal tibial physis as he landed on his leg with enormous forces passing through the knee. Although standard radiographs were helpful in diagnosing the complex fracture pattern, precise configuration was only established by computed tomography (CT) scan. The scan also excluded well-recognized concomitant injuries including ligament and meniscal injuries. Unlike other reported cases, our patient did not have compartment syndrome. Anatomic reduction and stabilization with a partially threaded transepiphyseal cannulated screw and a metaphyseal screw followed by early mobilization ensured an excellent recovery by the patient.Our case highlights the importance of vigilance and a high index of suspicion for coexisting fractures or soft tissue injuries when treating avulsion fractures of tibial tuberosity. A CT scan is justified in such patients to recognize complex fracture configurations, and surgical treatment should be directed appropriately to both the fractures followed by early rehabilitation. Patients with such injuries warrant close monitoring for compartment syndrome during the perioperative period.
Gluteal strain/ tendinitis Greater trochanteritis TOTAL Groin sfrain/ tendinitis Hip/ groin injury other Pelvic sfress fracture 32 19 Thigh...Medial collateral sfrain 79 28 27 Medial plica syndrome 1 Patellar tendinitis 7 Patellofemoral pain syndrome 16 Pes Anserinus tendinitis 1...Knee other 24 Lower leg TOTAL 127 Achilles tendinitis 19 Acute fibular fracture 3 Acute tibial fracture 1 Anterior compartment syndrome 7
Feibel, Robert J; Uhthoff, Hans K
Ankle arthrodesis in a plantigrade position. In high-energy open injuries with segmental bone loss: proximal tibial metaphyseal corticotomy with distal Ilizarov bone transport for compensation of leg length discrepancy. Posttraumatic loss of the tibial plafond, usually resulting from open fracture type IIIC. Ipsilateral foot injuries impairing ambulation after fusion. Severe injury to the posterior tibial nerve with absent plantar sensation. Soft-tissue injury not manageable surgically. Inadequate patient compliance. Advanced age. Severe osteoporosis. Acute infection. Standard technique: anteromedial longitudinal incision. Removal of remaining articular cartilage. Passing of Ilizarov wires through the distal fibula, talar neck and body. Placement of 5-mm half-pins through stab incisions, perpendicular to the medial face of the tibial shaft. A lateral to medial 1.8-mm Ilizarov wire in the proximal tibial metaphysis is optional. Callus distraction/Ilizarov bone transport: exposure through an anteromedial incision or transverse traumatic wound. Removal of small residual segment of tibial plafond blocking transport. Retain small vascularized bone fragments not blocking transport. For Ilizarov external fixation, two rings in the proximal tibial region. Drill osteoclasis of the tibial metaphysis 1 cm distal to the tibial tuberosity and complete with Ilizarov osteotome. Secure the Ilizarov threaded rods or clickers. Weight bearing as tolerated. Begin distraction 14 days after corticotomy at a rate of 0.5-1 mm per day depending on patient's age. After docking: Ilizarov ankle arthrodesis. Between January 1993 and September 1996, four patients (two men, two women) with severe, nonreconstructable fractures of the tibial plafond were treated. Callus distraction and Ilizarov bone transport in three patients. Age range 19-68 years (average age 45.7 years). Mean follow-up 6.6 years (4 years 9 months to 7 years 4 months). Average duration of the entire treatment in external
Alt, Volker; Donell, Simon T; Chhabra, Amit; Bentley, Anthony; Eicher, Alexander; Schnettler, Reinhard
The purpose of this study was to determine the cost savings from a societal perspective for recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) in grade III A and B open tibial fractures treated with a locked intramedullary nail and soft-tissue management in the UK, Germany, and France. Health care system costs (direct health care costs) and costs for productivity losses (indirect health care costs) were calculated using the raw data from the Bone Morphogenetic Protein Evaluation Group in Surgery for Tibial Trauma "BESTT study". Return-to-work time for estimation of productivity losses was assumed to correspond with the time of fracture healing. For calculation of secondary interventions costs and productivity losses the respective 2007/2008 national tariffs for surgical procedures and average national wages for the UK, Germany, and France were used. For a 1 year perspective, overall treatment costs per patient after the initial surgery of the control vs. the rhBMP-2 group were 44,757 euros vs. 36,847 euros for the UK, 50,197 euros vs. 40,927 euros for Germany and 48,766 euros vs. 39,474 euros for France in favour of rhBMP-2 with overall savings overall savings per case of rhBMP-2 treatment of 7911 euros for the UK, 9270 euros for Germany, and 9291 euros for France which was mainly due to reduced productivity losses by significant faster fracture healing in the rhBMP-2 group (p=0.01). These savings largely offset the upfront price of rhBMP-2 of 2266 euros (1790 pounds) in the UK, euros 2970 in Germany, and 2950 euros in France. Total net savings can be estimated to be 9.6 million euros for the UK, 14.5 million euros for Germany, and 11.4 million euros for France. The results depend on the methodology used particularly for calculation of productivity losses and return-to-work time which was assumed to correspond with fracture healing time. In summary, despite the apparent high direct cost of rhBMP-2 in grade III A and B open tibial fractures, at a national
Lowenberg, David W; Githens, Michael; Boone, Christopher
There is a growing mass of literature to suggest that circular external fixation for high-energy tibial fractures has advantages over traditional internal fixation, with potential improved rates of union, decreased incidence of posttraumatic osteomyelitis, and decreased soft tissue problems. To further advance our understanding of the role of circular external fixation in the management of these tibial fractures, randomized controlled trials should be implemented. In addition to complication rates and radiographic outcomes, validated functional outcome tools and cost analysis of this method should be compared with open reduction with internal fixation. Copyright © 2014 Elsevier Inc. All rights reserved.
Lee, Jae Hoon; Chung, Duke Whan; Han, Chung Soo
The purpose of this study was to analyze the utility and the clinical outcomes of anterolateral thigh (ALT)-free flaps and conversion from external to internal fixation with plating and bone grafting in Gustilo type IIIB open tibial fractures. A total of 21 patients were analyzed retrospectively. The mean follow-up period was 18 months and the mean age was 46.7 years. There were 18 men and three women. The mean time from injury to flap coverage was 11.6 days. The mean size of flaps used was 15.3 × 8.2 cm. The mean size of bone defects was 2.26 cm. Segmental bone defects were observed in 5 five cases, for which bone transport or vascularized fibular graft were performed. When flaps were successful and the fracture sites did not have any evidence of infection, internal fixation with plates and bone grafting were performed. Flaps survived in 20 cases. In the 20 cases with successful flaps, two cases developed osteomyelitis, but the 20 cases achieved solid bone union at a mean of 8.6 months after the injury, salvaging the lower extremity in 100% of the cases. At the last follow-up, 9 nine cases were measured excellent or good; 6, fair; and 6, poor in the functional assessment based on the method developed by Puno et al. ALT- free flaps to cover soft tissue defects in Gustilo type IIIB open tibial fractures are considered as useful option for the treatment of composite defects. In addition, conversion to internal fixation and bone grafting can be an alternative method in order to reduce the risk of complications and inconvenience of external fixators.
Salem, Khaled Hamed
Unreamed nails have revolutionised the treatment of tibial shaft fractures. Many authors, however, have reported increasing bone healing complications with these implants. Unfortunately, few studies have addressed the factors affecting bone healing after unreamed tibial nailing. One-hundred and sixty tibial fractures in 158 patients (mean age 39.5 years) fixed using unreamed nails were reviewed. There were 78 AO type-A, 65 type-B and 17 type-C fractures (115 closed and 45 open fractures). Twelve patient, injury and surgery variables were analysed for their influence on fracture healing. Union occurred in all fractures after a mean time of 24.3 weeks. Additional surgery to achieve union, apart from dynamisation, was done in nine (6%) cases. The most important variables affecting healing were the mechanism of trauma (p=0.005), fracture site gap (p=0.01), degree of comminution (p=0.0003), associated soft tissue injuries (p=0.02) and the time to dynamisation (p=0.0001). High-energy trauma and fracture comminution have a negative impact on bone union and require close follow-up. It is essential to avoid distraction over three millimetres with unreamed nailing. Dynamisation is advised within ten weeks in axially stable fractures to encourage bone healing and avoid failure of the locking screws.
Manco, L.G.; Schneider, R.; Pavlov, H.
An insufficiency fracture of the tibial plateau may be the cause of knee pain in patients with osteoporosis. The diagnosis is usually not suspected until a bone scan is done, as initial radiographs are often negative or inconclusive and clinical findings are nonspecific and may simulate osteoarthritis or spontaneous osteonecrosis. In five of 165 patients referred for bone scans due to nontraumatic knee pain, a characteristic pattern of intense augmented uptake of radionuclide confined to the tibial plateau led to a presumptive diagnosis of insufficiency fracture, later confirmed on radiographs.
Scolaro, John A; Broghammer, Francis H; Donegan, Derek J
The optimal treatment strategy for distal tibia fractures, especially those with intraarticular extension, remains controversial. Although open reduction and internal fixation with a plate and screw device is commonly performed for these injuries, the risk of soft tissue complications using this approach is significant. Staged treatment protocols and alternative means of fixation have been proposed to address these undesired events. Although potentially more technically demanding than fixation of diaphyseal or extraarticular tibial fractures, intramedullary nail (IMN) fixation of simple intraarticular distal tibia fractures is a viable treatment alternative with unique advantages. This article presents a review of the literature and rationale for intramedullary tibial nail fixation of simple intraarticular distal tibia fractures and a surgical approach commonly utilized for successful implementation.
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
Haller, Justin M; Marchand, Lucas; Rothberg, David L; Kubiak, Erik N; Higgins, Thomas F
The purpose of the study was to compare the inflammatory cytokine and matrix metalloproteinase (MMP) concentrations in synovial fluid after acute plafond fracture with acute tibial plateau fracture. Between December 2011 and August 2014, we prospectively enrolled patients with acute tibial plateau and plafond fractures. Synovial fluid aspirations were obtained from injured and uninjured joints. The concentrations of IL-1β, IL-1RA, IL-6, IL-8, IL-10, MCP-1, TNF-α, MMP-1, -3, -9, -10, -12, and -13 were quantified using multiplex assays. A Bonferroni correction was used so that the adjusted alpha level for significance was p < 0.004. We enrolled 45 tibial plateau fractures and 19 plafond fractures. Mean patient age was 42 years (range, 20-60) and 64% were male patients. There were 24 low-energy (OTA 41B) plateau fractures and eight low-energy (OTA 43B) plafond fractures. There were 21 high-energy (6 OTA 41B3 and 15 OTA 41C) plateau fractures and 11 high-energy (OTA43C) plafond fractures. All cytokines and MMPs except MMP-13 were significantly elevated in plafond fractures compared to uninjured ankles. When comparing acutely injured joints, IL-8 (p < 0.001), IL-1β (p = 0.002), and MMP-12 (p = 0.001) were significantly higher in plafond fractures compared to plateau fractures. Concentrations of IL-1RA (p = 0.008) and MCP-1 (p = 0.005) were higher in plafond fractures, and MMP-10 (p = 0.01) was higher in plateau fractures, but these differences did not reach significance. In conclusion, several cytokines and MMPs were significantly elevated in acute plafond fractures as compared to acute tibial plateau fractures. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Prat-Fabregat, Salvi; Camacho-Carrasco, Pilar
Tibial plateau fractures are complex injuries produced by high- or low-energy trauma. They principally affect young adults or the ‘third age’ population. These fractures usually have associated soft-tissue lesions that will affect their treatment. Sequential (staged) treatment (external fixation followed by definitive osteosynthesis) is recommended in more complex fracture patterns. But one should remember that any type of tibial plateau fracture can present with soft-tissue complications. Typically the Schatzker or AO/OTA classification is used, but the concept of the proximal tibia as a three-column structure and the detailed study of the posteromedial and posterolateral fragment morphology has changed its treatment strategy. Limb alignment and articular surface restoration, allowing early knee motion, are the main goals of surgical treatment. Partially articular factures can be treated by minimally-invasive methods and arthroscopy is useful to assist and control the fracture reduction and to treat intra-articular soft-tissue injuries. Open reduction and internal fixation (ORIF) is the gold standard treatment for these fractures. Complex articular fractures can be treated by ring external fixators and minimally-invasive osteosynthesis (EFMO) or by ORIF. EFMO can be related to suboptimal articular reduction; however, outcome analysis shows results that are equal to, or even superior to, ORIF. The ORIF strategy should also include the optimal reduction of the articular surface. Anterolateral and anteromedial surgical approaches do not permit adequate reduction and fixation of posterolateral and posteromedial fragments. To achieve this, it is necessary to reduce and fix them through specific posterolateral or posteromedial approaches that allow optimal reduction and plate/screw placement. Some authors have also suggested that primary total knee arthroplasty could be an option in specific patients and with specific fracture patterns. Cite this article: Prat
Franke, J; Hohendorff, B; Alt, V; Thormann, U; Schnettler, R
Intramedullary nailing is the standard procedure for surgical treatment of closed and Gustilo-Anderson Grade I-II° open fractures of the tibial shaft. The use of intramedullary nailing for the treatment of proximal metaphyseal tibia fractures is frequently followed by postoperative malalignment, whereas plate osteosynthesis is associated with higher rates of postoperative infection. Intramedullary nailing of tibial fractures is generally performed through an infrapatellar approach. The injured extremity must be positioned at a minimum of 90° of flexion in the knee joint to achieve optimal exposure of the correct entry point. The tension of the quadriceps tendon causes a typical apex anterior angulation of the proximal fragment. The suprapatellar approach improves reduction of the fracture and reduces the occurrence of malalignment during intramedullary nailing of extra-articular proximal tibial fractures. The knee is positioned in 20° of flexion to neutralise traction forces secondary to the quadriceps muscle, thus preventing an apex anterior angulation of the proximal fragment. An additional advantage of the technique is that it allows the surgeon to avoid or minimise further soft tissue damage because of the distance between the optimal incision point and the usual area of soft tissue damage.
Jo, Ho-Seung; Park, Jin-Sung; Byun, June-Ho; Lee, Young-Bok; Choi, Young-Lac; Cho, Seong-Hee; Moon, Dong-Kyu; Lee, Sang-Hyuk; Hwang, Sun-Chul
The purpose of this study was to determine the standard hinge position to minimize effects from medial open-wedge high tibial osteotomy (HTO) on the posterior tibial slope. Sixteen cadaveric knees underwent medial open-wedge osteotomy using either the standard or the low hinge position. To define the standard hinge position, a line 3 cm inferior to the medial tibial plateau towards the fibular head and located its intersection with a longitudinal line 1 cm medial to the fibular shaft was drawn. Low hinge position was defined as the point 1 cm inferior to the standard position. After tibial osteotomy, computed tomography scans of each knee were taken and three-dimensional models were constructed to characterize hinge position orientation and measure the osteotomy site effects on posterior tibial slope, medial proximal tibial angle, and gap ratio (the ratio of the anterior to posterior gap in the opened wedge). In two low hinge position specimens, the tibial lateral cortex hinge fracture occurred. Osteotomy through the low hinge position resulted in significantly greater posterior tibial slope compared to the standard hinge position (mean ± standard deviation) (11.2 ± 3.0° and 5.6 ± 2.5°, respectively; p < 0.001). Medial proximal tibial angle was also significantly greater for low compared to standard hinge position (95.4 ± 3.5° and 88.0 ± 3.5°, respectively; p < 0.001). Gap ratio was not significantly different between the two groups. Hinge position significantly affects the posterior tibial slope and medial proximal tibial angle following medial open-wedge HTO. Accurate hinge position is crucial to prevent complications from changes in posterior tibial slope and medial proximal tibial angle after surgery.
van Zanten, Malou C; Mistry, Raakhi M; Suami, Hiroo; Campbell-Lloyd, Andrew; Finkemeyer, James P; Piller, Neil B; Caplash, Yugesh
Severe compound tibial fractures are associated with extensive soft-tissue damage, resulting in disruption of lymphatic pathways that leave the patient at risk of developing chronic lymphedema. There are limited data on lymphatic response following lower limb trauma. Indocyanine green fluorescence lymphography is a novel, real-time imaging technique for superficial lymphatic mapping. The authors used this technique to image the superficial lymphatic vessels of the lower limbs in patients with severe compound tibial fracture. Baseline demographics and clinical and operative details were recorded in a prospective cohort of 17 patients who had undergone bone and soft-tissue reconstruction after severe compound tibial fracture between 2009 and 2014. Normal lymphatic images were obtained from the patients' noninjured limbs as a control. In this way, the authors investigated any changes to the normal anatomy of the lymphatic system in the affected limbs. Of the 17 patients, eight had free muscle flaps with split-thickness skin grafting, one had a free fasciocutaneous flap, one had a full-thickness skin graft, six had local fasciocutaneous flaps, and one had a pedicled gastrocnemius flap. None of the free flaps demonstrated any functional lymphatic vessels; the fasciocutaneous flaps and the skin graft demonstrated impaired lymphatic vessel function and dermal backflow pattern similar to that in lymphedema. Local flaps demonstrated lymphatic blockage at the scar edge. Severe compound fractures and the associated soft-tissue injury can result in significant lymphatic disruption and an increased risk for the development of chronic lymphedema.
Berson, L; Davidson, R S; Dormans, J P; Drummond, D S; Gregg, J R
Twenty-four patients with distal tibial growth disturbance were reviewed. Disturbances were classified as physeal bar (prior to deformity), angular, linear or combined deformities. Treatment consisted of osteotomy in fourteen, epiphyseodesis in seven, excision of bony bar in two, and observation in one patient. Follow up was an average 36.6 months (range 4-129 months) after treatment of growth disturbance. The age at time of injury was 10.4 years of age average (range 3-15 years). There were 12 SH2, 2 SH3, 7 SH4, and 3 SH5 distal tibial physeal fractures. Thirteen of 15 fractures considered high energy and only 1 of 9 fractures considered low energy resulted in angular deformity. Angular and linear deformities presented an average 46 months (range 12-120 months) and physeal bars at an average 14 months (range 6-25 months) after injury. Patients with a delay in presentation of growth disturbance greater than 24 months had angular deformities in 92% compared with 33% in children presenting less than or at 24 months. Treatment based on type of deformity, age at time of injury, and growth remaining was considered successful in 83%. Patients with angular or linear deformities were more likely to present late, have high energy injuries, be male patients and have Salter-Harris types IV and V. Early diagnosis and treatment of growth disturbance can prevent severe deformity.
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
Jacobi, Matthias; Villa, Vincent; Reischl, Nikolaus; Demey, Guillaume; Goy, Damien; Neyret, Philippe; Gautier, Emanuel; Magnussen, Robert A
Opening wedge high tibial osteotomy (HTO) is an accepted treatment option for medial compartment knee osteoarthritis with associated varus lower limb axis in younger, more active patients. A concern with the use of this technique is that posterior tibial slope (PTS) and tibial rotation can be altered. We hypothesized that there is a tendency to increase the PTS and internal rotation of the distal tibia during the procedure and that certain intra-operative parameters may influence the amount of change that can be expected. A cadaveric model and surgical navigation system were used to evaluate the influence of certain intra-operative factors of the degree of PTS and tibial rotation change observed during medial opening HTO. Parameters evaluated included: degree of osteotomy opening, knee flexion angle, location of limb support (thigh versus foot), performance of a posteromedial release, the status of the lateral cortical hinge, and the degree of osteoarthritis present in the knee. Combining measurements of all specimens and parameters, a mean PTS increase of 2.7° ± 3.9° and a mean tibial internal rotation of 1.5° ± 2.9° were observed. Clinically, significant changes in tibial slope (>2°) occurred in 50.4 % of corrections, while significant changes in tibial rotation (>5°) occurred in only 11.9 % of corrections. Patients with significant osteoarthritis and concomitant flexion contracture, cases where large corrections were required, and procedures in which the lateral cortical hinge was disrupted were associated with increased PTS change. The other factors evaluated did not exert a significant influence of the degree of PTS change observed. Surgeons should be vigilant for possible PTS change, particularly in high-risk situations as outlined above. Routine use of an intra-operative measure of PTS is recommended to avoid inadvertent slope change.
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
Ziran, Bruce H; Becher, Stephen John
The purpose of this article was to evaluate the relationship of radiographic features of tibial plateau fractures to the development of compartment syndrome. We hypothesized that the direction and degree of initial displacement of the femur on the tibia, and the amount of tibial widening (TW), were correlated with the development of compartment syndrome. Retrospective case-control study. Single level 1 trauma center. Retrospective evaluation of 158 patients with 162 plateau fractures. Grouping with and without compartment syndrome. The following data were obtained: age, sex, Schatzker and OTA/AO classification, open/closed status, TW, and femoral displacement (FD). A univariate statistical and a logistical regression analysis were performed to determine significance. The overall rate of compartment syndrome was 11%. Univariate analysis found both the TW and FD to be significant with respect to development of compartment syndrome (P < 0.05). Higher Schatzker (IV-VI) and OTA/AO grades were also correlated (P < 0.05) with increased incidence of compartment syndrome. Logistic regression found FD and Schatzker grade to be significant. Our study is the first to identify easily obtained radiographic parameters that correlate to the occurrence compartment syndrome. There may also be a relationship between TW and FD, as noted by regression result. This study helps to assess which patients with a fracture are at higher risk for developing a compartment syndrome. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Antabak, Anko; Luetić, Tomislav; Cavar, Stanko; Davila, Slavko; Bogović, Marko; Batinica, Stipe
Diaphyseal fractures of both lower leg bones are the most common fractures of lower extremities, and account for about 15% of all fractures of long bones in children. These fractures are usully unstabilae, difficult to reposition, and retention of the fragments, and the process of their treatment is not fully compliant. The paper analyzes the late results of treating 234 children with tibial fractures, depending on the method of treatment (surgical and conservative method). Twenty-three children had open fractures (9.8%). Nonsurgical method was used in the treatment of 194 children, and surgical in 40 children. The most frequent surgical method was closed reposition of the fragments, and percutaneous elastic stable intramedullary nailing with titanium wires. The success of the treatment was measured: residual angular deformities and difference in length between treated and healthy leg. Secondary displacement of fragments after primary conservative treatment was found in 32 children. Angular deformities of the treated tibia was seen in 80 children, 68 (35.0%) treated conservatively and 12 (30.0%) surgically. In 131 (67.5%) conservatively treated and 29 (72.5%) surgically treated children there were no differences in the length of sick and healthy leg. Results of treatment in our children confirmed that there were no statistically significant differences in late effects depending on treatment methods.
Ward, A S; Carty, N J
We report the case of a traumatic arteriovenous fistula of the peroneal vessels following a bone graft operation for an un-united tibial fracture. The fistula was recognised as a result of a bruit at the site of the fracture. The fistula was repaired and the fracture subsequently united.
In brief Stress fractures of the proximal middle third of the tibia are common; those of the distal tibia are less common; and longitudinal stress fractures are rare. The basketball player in this case report had a rare longitudinal tibial pilon stress fracture, for which few diagnostic or treatment guidelines existed.
Sundaram, R O; Cohen, D; Barton-Hanson, N
Tibial plateau fractures following anterior cruciate ligament (ACL) reconstruction are extremely rare. This is the first reported case of a tibial plateau fracture following four-strand gracilis-semitendinosus autograft ACL reconstruction. The tibial tunnel alone may behave as a stress riser which can significantly reduce bone strength.
Matoković, Damir; Šimić-Klarić, Andrea; Rajić, Marijana Tomić; Crnković, Helena Tesari; Jurinić, Mislav; Jovanović, Savo
Tibial tuberosity fractures are rare in childhood, most frequently due to excessive quadriceps muscle contraction. On performing long jump, a 15-year-old boy sustained tibial tuberosity avulsion fracture type II according to Watson-Jones. The patient was treated operatively with fragment repositioning and screw fixation. Ten months after the injury and rehabilitation, he resumed his sports activities with full range knee motion.
Masrouha, Karim Z.; El-Bitar, Youssef; Najjar, Marc; Saghieh, Said
The management of soft tissue defects in tibial fractures is essential for limb preservation. Current techniques are not without complications and may lead to poor functional outcomes. A salvage method is described using three illustrative cases whereby a combination of flaps and antibiotic-impregnated polymethylmethacrylate beads are employed to fill the bony defect, fight the infection, and provide a surface for epithelial regeneration and secondary wound closure. This was performed after the partial failure of all other options. All patients were fully ambulatory with no clinical, radiographic or laboratory sign of infection at their most recent follow-up. Although our findings are encouraging, this is the first report of epithelialization of the skin on a polymethylmethacrylate scaffold. Further studies investigating the use of this technique are warranted. PMID:27517073
Woyski, Dustin; Emerson, Jason
Fractures of the tibial shaft in patients with ipsilateral total knee arthroplasty are rare but difficult to treat. Nonoperative treatment of these fractures with casting or bracing limits weight bearing for an extended period and can result in unacceptable malalignment. Operative fixation with plate and screws also limits early weight bearing and requires healing of soft tissue that is of poor quality. The authors present a method of internal fixation that uses a standard intramedullary tibial nail and suprapatellar instrumentation. This method can easily be performed, avoids the tibial baseplate, and does not require alteration of the instrumentation or intramedullary nail.
Shauver, Melissa S.; Aravind, Maya S.; Chung, Kevin C.
The literature has shown that long-term outcomes for both below-knee amputation and reconstruction following type III-B and III-C tibial fracture are poor. Yet, patients often report satisfaction with their treatment and/or outcomes. The aim of this study is to explore the relationship between patient outcomes and satisfaction after open tibial fractures via qualitative methodology. Twenty patients who were treated for open tibial fractures at one institution were selected using purposeful sampling and interviewed in-person in a semi-structured manner. Data were analyzed using grounded theory methodology. Despite reporting marked physical and psychosocial deficits, participants relayed high satisfaction. We hypothesize that the use adaptive coping techniques successfully reduces stress, which leads to an increase in coping self-efficacy that results in the further use of adaptive coping strategies, culminating in personal growth. This stress reduction and personal growth leads to satisfaction despite poor functional and emotional outcomes. PMID:20948418
Duwelius, P J; Rangitsch, M R; Colville, M R; Woll, T S
Seventy-five adults who sustained 76 tibial plateau fractures were treated according to a prospective protocol using instability in extension as the principal indication for operative fixation. Patients showing instability underwent closed manipulative reduction under fluoroscopic guidance. If significant joint depression persisted after reduction, elevation of the fracture was performed either from below using bone punches through a cortical window or via limited arthrotomy. Iliac crest bone graft was used to buttress depressed fractures. Fixation was then secured using 7-mm cannulated screws with washers or buttress plates and screws. Postoperatively, 58 of 76 knees were managed in a hinged knee brace, allowing the patient early range of motion and protected weightbearing for 8 weeks. Patients who were found to have a stable knee were treated with Bledsoe braces according to the postoperative protocol. In the 75 patients, 18 of the 76 knees were unsuitable for percutaneous screw fixation because of fracture complexity requiring plates, severe open injuries, or inadequate reductions with limited fixation had been done. A minimum followup of 12 months was obtained in 55 patients (range, 12-59 months). All fractures had healed at the time of followup. Eighty-seven percent of the patients at followup had a successful outcome using Rasmussen's criteria. Fourteen of these patients had arthroscopic assisted reduction or evaluation. All seven patients who had poor outcomes had AO Type C3 fracture patterns. Severely depressed or comminuted fractures or fractures with significant metaphyseal diaphyseal extension may not be suitable for this technique and require the addition of an external fixation device or buttress plate to maintain the reduction and allow for early range of motion.
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.
Vander Have, Kelly L; Ganley, Theodore J; Kocher, Mininder S; Price, Charles T; Herrera-Soto, Jose A
Tibial eminence fractures are rare injuries in children and adolescents. Displaced fractures require reduction and fixation. Operative stabilization can be accomplished with either open or arthroscopic reduction and fixation. Whereas loss of extension has been reported, there are no reports in the literature that quantify loss of motion or provide guidance for treatment. To report a series of patients who developed knee stiffness after operative treatment for displaced tibial eminence fractures. Case series; Level of evidence, 4. Review of medical records and imaging studies of pediatric patients with displaced tibial eminence fractures who developed arthrofibrosis after surgical intervention. Thirty-two patients were identified. Twenty-four required reoperation for loss of flexion (n = 9), loss of extension (n = 4), or both (n = 11). Manipulation under anesthesia resulted in distal femoral fractures and subsequent growth arrest in 3 patients. Twenty-nine patients were able to achieve near full knee motion at final follow-up. Children with tibial spine fractures are at risk for arthrofibrosis. Stabilization of the fracture is important to allow early postoperative rehabilitation. Should stiffness occur, manipulation of the knee should be performed only in conjunction with lysis of adhesions.
Dibbern, Kevin; Kempton, Laurence B; Higgins, Thomas F; Morshed, Saam; McKinley, Todd O; Marsh, J Lawrence; Anderson, Donald D
Patients with tibial pilon fractures have a higher incidence of post-traumatic osteoarthritis than those with fractures of the tibial plateau. This may indicate that pilon fractures present a greater mechanical insult to the joint than do plateau fractures. We tested the hypothesis that fracture energy and articular fracture edge length, two independent indicators of severity, are higher in pilon than plateau fractures. We also evaluated whether clinical fracture classification systems accurately reflect severity. Seventy-five tibial plateau fractures and 52 tibial pilon fractures from a multi-institutional study were selected to span the spectrum of severity. Fracture severity measures were calculated using objective CT-based image analysis methods. The ranges of fracture energies measured for tibial plateau and pilon fractures were 3.2-33.2 Joules (J) and 3.6-32.2 J, respectively, and articular fracture edge lengths were 68.0-493.0 mm and 56.1-288.6 mm, respectively. There were no differences in the fracture energies between the two fracture types, but plateau fractures had greater articular fracture edge lengths (p < 0.001). The clinical fracture classifications generally reflected severity, but there was substantial overlap of fracture severity measures between different classes. Similar fracture energies with different degrees of articular surface involvement suggest a possible explanation for dissimilar rates of post-traumatic osteoarthritis for fractures of the tibial plateau compared to the tibial pilon. The substantial overlap of severity measures between different fracture classes may well have confounded prior clinical studies relying on fracture classification as a surrogate for severity. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:618-624, 2017.
Chmielnicki, M; Prokop, A
Tibial shaft fractures are among the most common long bone fractures in humans. The incidence is 1-2 per 100,000. The gold standard of treatment for AO type 42 A-C fractures is a locking intramedullary nail. The development of new implants has extended the indications for this minimally invasive technique, so that now AO types 41 and 43 can also be treated with special nails. Fixed-angle screw anchors increase primary stability and supplemental locking devices located proximally and distally extend the spectrum of use to metaphyseal fractures. The cannulated Targon TX titanium nail can be introduced, either with or without reaming. Using an operative video, the treatment of a tibial fracture with an intramedullary nail is demonstrated in stages and the operative steps further illustrated on artificial bone. Georg Thieme Verlag KG Stuttgart · New York.
Fürmetz, Julian; Soo, Chris; Behrendt, Wolf; Thaller, Peter H.; Siekmann, Holger; Böhme, Jörg; Josten, Christoph
A common treatment of tibial defects especially after infections is bone transport via external fixation. We compare complications and outcomes of 25 patients treated with a typical Ilizarov frame or a hybrid system for bone reconstruction of the tibia. Average follow up was 5.1 years. Particular interest was paid to the following criteria: injury type, comorbidities, development of osteitis and outcome of the different therapies. The reason for segmental resection was a second or third grade open tibia fractures in 24 cases and in one case an infection after plate osteosynthesis. Average age of the patients was 41 years (range 19 to 65 years) and average defect size 6.6 cm (range 3.0 to 13.4 cm). After a mean time of 113 days 23 tibial defects were reconstructed, so we calculated an average healing index of 44.2 days/cm. Two patients with major comorbidities needed a below knee amputation. The presence of osteitis led to a more complicated course of therapy. In the follow up patients with an Ilizarov frame had better results than patients with hybrid systems. Bone transport using external fixation is suitable for larger defect reconstruction. With significant comorbidities, however, a primary amputation or other methods must be considered. PMID:27114814
Shadgan, Babak; Pereira, Gavin; Menon, Matthew; Jafari, Siavash; Darlene Reid, W; O'Brien, Peter J
We sought to examine the occurrence of acute compartment syndrome (ACS) in the cohort of patients with tibial diaphyseal fractures and to detect associated risk factors that could predict this occurrence. A total of 1,125 patients with tibial diaphyseal fractures that were treated in our centre were included into this retrospective cohort study. All patients were treated with surgical fixation. Among them some were complicated by ACS of the leg. Age, gender, year and mechanism of injury, injury severity score (ISS), fracture characteristics and classifications and the type of fixation, as well as ACS characteristics in affected patients were studied. Of the cohort of patients 772 (69 %) were male (mean age 39.60 ± 15.97 years) and the rest were women (mean age 45.08 ± 19.04 years). ACS of the leg occurred in 87 (7.73 %) of all tibial diaphyseal fractures. The mean age of those patients that developed ACS (33.08 ± 12.8) was significantly lower than those who did not develop it (42.01 ± 17.3, P < 0.001). No significant difference in incidence of ACS was found in open versus closed fractures, between anatomic sites and following IM nailing (P = 0.67). Increasing pain was the most common symptom in 71 % of cases with ACS. We found that younger patients are definitely at a significantly higher risk of ACS following acute tibial diaphyseal fractures. Male gender, open fracture and IM nailing were not risk factors for ACS of the leg associated with tibial diaphyseal fractures in adults. Level IV.
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.
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
Bagherifard, Abolfazl; Jabalameli, Mahmoud; Hadi, Hosseinali; Rahbar, Mohammad; Minator Sajjadi, Mohammadreza; Jahansouz, Ali; Karimi Heris, Hossein
Background Tibial plateau fractures can be successfully fixed utilizing 3.5 mm locking plates. However, there are some disadvantages to using these plates. Objectives In the current prospective study, we investigated the outcome of treating different types of tibial plateau fractures with 3.5 mm simple plates which, to our knowledge, has not been evaluated in previous studies. Materials and Methods Between 2011 and 2013, 32 patients aged 40 ± 0.2 years underwent open reduction and internal fixation for tibial plateau fractures with 3.5 mm simple plates. The patients were followed for 16.14 ± 2.1 months. At each patient’s final visit, the articular surface depression, medial proximal tibial angle, and slope angle were measured and compared with measurements taken early after the operation. The functional outcomes were measured with the WOMAC and Lysholm knee scores. Results The mean union time was 13 ± 1.2 weeks. The mean knee range of motion was 116.8° ± 3.3°. The mean WOMAC and Lysholm scores were 83.5 ± 1.8 and 76.8 ± 1.6, respectively. On the early postoperative and final X-rays, 87.5% and 84% of patients, respectively, had acceptable reduction. Medial proximal tibial and slope angles did not change significantly by the last visit. No patient was found to have complications related to the type of plate. Conclusions In this case series study, the fixation of different types of tibial plateau fractures with 3.5 mm simple non-locking and non-precontoured plates was associated with acceptable clinical, functional, and radiographic outcomes. Based on the advantages and costs of these plates, the authors recommend using 3.5 mm simple plates for different types of tibial plateau fractures. PMID:27626010
Shin, Young-Soo; Sim, Hyun-Bo; Yoon, Jung-Ro
A 63-year-old woman developed tibial nerve injury caused by an overlong K wire and 4.5-mm cortical lag screw through the first distal hole below the osteotomy during medial opening-wedge high tibial osteotomy (HTO), leading to a lack of sensation on the sole of the foot with no disturbances in motor functions. The temporary lag screw in the first distal hole below the osteotomy is often inserted by an excessive length in order to compress the potentially fractured opposite cortex. By doing so, posterior neurovascular structures including the tibial nerve and the popliteal vessels can be injured. To avoid this type of injury during medial opening-wedge HTO, proper knee position and appropriate Hohmann retractor position in combination with meticulous insertion of the K wire or screw under fluoroscopic control are essential. In addition, our study reinforces the fact that different presentations of injury to the tibial nerve should be carefully considered in the absence of common diagnostic features, including weakness of the toe flexors and posterior tibial muscle of the leg with intractable pain.
Aoki, Stephen K; Curtis, Stuart H
This study evaluates the initial fixation strength of tibial eminence fracture repair using 1, 2, 3, and 4 sutures to determine the optimal number of sutures required to adequately secure the avulsed fragment to the tibia. Sixteen skeletally immature porcine knees were stripped of all soft tissues, isolating the femur-anterior cruciate ligament (ACL)-tibia complex. Type III tibial eminence fractures were simulated in the specimens, and each specimen was randomly assigned to a repair group using 1, 2, 3, or 4 #2 FiberWire sutures (Arthrex, Inc, Naples, Florida). Initial fixation strength of the repair was measured by single cycle pull to failure testing using a materials testing machine (Instron, Norwood, Massachusetts). The mean ultimate failure force during anterior tibial translation was 389±128, 627±66, 703±77, and 802±29 N for 1, 2, 3, and 4 sutures, respectively. The lower limit of the 95% confidence interval was >500 N (estimated force of native ACL during activities of daily living) for each group with ≥2 sutures. In this study, at least 2 high-strength sutures were needed for tibial eminence fracture repairs to withstand potential forces seen across the ACL in the postoperative period. Suture fixation of tibial eminence fractures is a reproducible method requiring a minimum of 2 high-strength polyester sutures to resist forces seen during early rehabilitation.
Clement, N. D.; Tawonsawatruk, T.; Simpson, C. J.; Simpson, A. H. R. W.
Objectives The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison. Methods A total of 15 radiographs of tibial shaft fractures treated by intramedullary nailing (IM) were scored by three observers using the RUST system. Following discussion on how the criteria of the RUST system should be implemented, 45 sets (i.e. AP and lateral) of radiographs of IM nailed tibial fractures were scored by five observers. Finally, these 45 sets of radiographs were rescored with the baseline post-operative radiograph available for comparison. Results The initial intraclass correlation (ICC) on the first 15 sets of radiographs was 0.67 (95% CI 0.63 to 0.71). However, the original description was being interpreted in different ways. After agreeing on the interpretation, the ICC on the second cohort improved to 0.75. The ICC improved even further to 0.79, when the baseline post-operative radiographs were available for comparison. Conclusion This study demonstrates that the RUST scoring system is a reliable and repeatable outcome measure for assessing tibial fracture healing. Further improvement in the reliability of the scoring system can be obtained if the radiographs are compared with the baseline post-operative radiographs. Cite this article: Mr J.M. Leow. The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre. Bone Joint Res 2016;5:116–121. DOI: 10.1302/2046-3758.54.2000628. PMID:27073210
Maheshwari, Jitendra; Pandey, Vinay Kumar; Mhaskar, Vikram Arun
In most classifications of tibial plateau fractures, including one used most widely-Schatzker classification, fractures are described as a combination of medial and lateral condyle, primarily in the sagittal plane. Coronal component of these fractures, affecting the posterior tibial condyle is now well recognized. What is not described is anterior coronal component of the fracture, what we are calling "anterior tibial condyle fracture". These fractures are often missed on routine antero-posterior and lateral knee X-rays due to an overlap between the fracture and the normal bone. Eight cases of anterior tibial condyle fractures with posterior subluxation of the tibia, six of which were missed by the initial surgeon and two referred to us early, are described. Two of the six late cases and both the early ones were operated. Reconstruction of the anterior condyle and posterior cruciate ligament reconstruction was done. Primary outcome measures such as union of the fracture, residual flexion deformity, range of motion and stability were studied at the end of 6 months. All operated fractures united. There was no posterior sag in any. In those presenting late and were operated, the flexion deformity got corrected in all (average from 15° to 0°) and mean flexion achieved was 100° (range: 80-120°). In those presenting early and were operated, there was no flexion deformity at 6 months and a mean flexion achieved was 115° (range: 100-130°). None of the operated patients had instability. This article attempts to highlight that this injury is often missed. They should be suspected, diagnosed early and treated by reconstruction of anterior condyle, posterior cruciate ligament reconstruction.
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.
Raman, Subha; Wallace, E Christine
Irreducible fracture of the distal tibial physis due to interposed soft tissue including periosteum is well documented in the orthopedic literature but is uncommon. This condition has been associated with subsequent growth disturbance and requires open reduction. There are very few prior reports of MRI depiction of soft tissue interposition and none of periosteal interposition in the distal tibial physis. This is a relatively common location of physeal injury and related growth disturbance. We present a case of periosteum trapped in the distal tibial physis, diagnosed on MRI, in a Salter-Harris II fracture and its management implications.
Hinterwimmer, Stefan; Beitzel, Knut; Paul, Jochen; Kirchhoff, Chlodwig; Sauerschnig, Martin; von Eisenhart-Rothe, Rüdiger; Imhoff, Andreas B
Valgus-producing open-wedge high tibial osteotomy is an established treatment for varus malalignment and medial osteoarthritis, with reproducible results in the frontal plane. However, an undesirable but often accepted increase in posterior tibial slope and decrease in patellar height are still routinely seen. To evaluate the influence of valgus open-wedge high tibial osteotomy on posterior tibial slope and patellar height when special techniques are used to minimize unwanted changes. Case series; Level of evidence, 4. Twenty-five patients, 3 women and 22 men (mean age, 40.2 years), underwent valgus open-wedge high tibial osteotomy. Several technical steps were taken to prevent an increase in posterior tibial slope during the osteotomy. To minimize patellar height changes, the tibial tuberosity was left on either the proximal or distal fragment, depending on the desired patellofemoral effect. The medial and lateral posterior slope was measured using the proximal posterior cortex as a reference; the patellar height was assessed with the Caton-Deschamps Index and compared on preoperative and postoperative radiographs. No significant posterior tibial slope changes were observed. Patellar height increased with both types of tibial tuberosity osteotomy. With the proximal osteotomy, the Caton-Deschamps Index increased from 0.95 to 0.97; with the distal osteotomy, it increased from 0.89 to 0.95. The change was not significant with either osteotomy. The posterior tibial slope did not change on the medial side, measuring 4.2 preoperatively and postoperatively. The lateral slope decreased from 5.4 to 5.1. There was no correlation between the correction in the coronal plane and the changes in the sagittal plane. Open-wedge high tibial osteotomy can be performed without significant changes in patellar height or posterior tibial slope if specific intraoperative methods are used to prevent their occurrence. Analysis and control of sagittal changes in valgus open-wedge high
Maheshwari, Jitendra; Pandey, Vinay Kumar; Mhaskar, Vikram Arun
Background: In most classifications of tibial plateau fractures, including one used most widely-Schatzker classification, fractures are described as a combination of medial and lateral condyle, primarily in the sagittal plane. Coronal component of these fractures, affecting the posterior tibial condyle is now well recognized. What is not described is anterior coronal component of the fracture, what we are calling “anterior tibial condyle fracture”. These fractures are often missed on routine antero-posterior and lateral knee X-rays due to an overlap between the fracture and the normal bone. Materials and Methods: Eight cases of anterior tibial condyle fractures with posterior subluxation of the tibia, six of which were missed by the initial surgeon and two referred to us early, are described. Two of the six late cases and both the early ones were operated. Reconstruction of the anterior condyle and posterior cruciate ligament reconstruction was done. Primary outcome measures such as union of the fracture, residual flexion deformity, range of motion and stability were studied at the end of 6 months. Results: All operated fractures united. There was no posterior sag in any. In those presenting late and were operated, the flexion deformity got corrected in all (average from 15° to 0°) and mean flexion achieved was 100° (range: 80-120°). In those presenting early and were operated, there was no flexion deformity at 6 months and a mean flexion achieved was 115° (range: 100-130°). None of the operated patients had instability. Conclusion: This article attempts to highlight that this injury is often missed. They should be suspected, diagnosed early and treated by reconstruction of anterior condyle, posterior cruciate ligament reconstruction. PMID:25298560
Ali, A M; Yang, L; Hashmi, M; Saleh, M
The two main challenges in the management of bicondylar tibial plateau fractures are: Firstly, the compromised skin and soft tissue envelope which invite a high rate of complications following attempted open reduction and dual plating. Secondly, poor bone quality and comminuted fracture patterns, which create difficulty in achieving stable fixation. Although dual plating is considered to be the best mechanical method of stabilizing these complex fractures, there remains concern regarding the high rate of complications associated with extensive soft tissue dissection, required for the insertion of these plates in an already compromised knee. The Sheffield Hybrid fixator (SHF) technique offers a solution to the two main problems of these difficult fractures by minimizing soft tissue dissection, since bone fragments are reduced and fixed percutaneously, and providing superior cancellous bone purchase with beam loading stabilization for comminuted fractures. Our biomechanical testing showed the SHF with four tensioned wires to be as strong as dual plating and able to provide adequate mechanical stability in the fixation of bicondylar tibial plateau fractures. This was confirmed clinically by a prospective review of the use of the SHF at our centre, for managing complex and high-energy tibial plateau fractures with a good final outcome and no cases of deep infection or septic arthritis.
Sales, Jafar Ganjpour; Soleymaopour, Jafar; Ansari, Maroof; Afaghi, Farhad; Goldust, Mohamad
Tibial condyle fractures affect knee stability and motion. Treatment of bicondylar type of tibial plateau fracture is a challenging problem. This study aimed at evaluating the application of hybrid external fixators with minimum deformation in these patients and the resulted outcomes. In this descriptive analytical study, 28 patients with bicondylar tibial plateau fractures treated by HEF device were evaluated. The surgeon used a semicircular and one circular wire instead of the one or two loop of conventional HEF device for a better range of motion of the knee joint. Treatment outcomes including quality of walking, union condition, knee range of motion, complications and the final outcome according to the knee score (rusmussen) were checked. Twenty-eight male patients, with the mean age of 40.54 +/- 13.83 years were enrolled in the study. Complications occurred in 8 (28.6%) patients; 7 cases with superficial infection and 1 patient with deep vein thrombosis. All complications were managed medically with no significant consequences left. All the patients were able to walk with no aid except in one case. In 96.4% and 89.3% of the cases, the clinical and radiological outcomes were good to excellent, respectively according to the knee score. In 85.7% of the patients, the knee range of motion was in normal limits. Application of hybrid external fixator using one and half ring instead of one or two fixator rings in treating bicondylar tibial fractures was associated with desired clinical and radiological results.
Mellick, L B; Reesor, K
Pediatric training in child abuse has consistently emphasized a strong association between nonaccidental injuries and spiral fractures of long bones. Isolated spiral tibial fractures of childhood have previously been recognized by the orthopedic specialty to most frequently be accidental in etiology. The authors present evidence that supports a predominantly accidental etiology for isolated spiral tibial fractures of young children. This article presents a series in which 9 of 10 such spiral fractures were most likely the result of an accident and not child abuse or gross neglect. Additionally, almost all of these fractures presented as a gait disturbance and should be included in the differential of this complaint.
Wang, Joon Ho; Bae, Ji Hoon; Lim, Hong Chul; Shon, Won Yong; Kim, Cheol Woong; Cho, Jae Woo
High tibial osteotomy can affect the posterior tibial slope in the sagittal plane because of the triangular configuration of the proximal tibia. However, the effect of the location of cortical hinge on posterior tibial slope has not been previously described. Posterolateral location of the cortical hinge will increase posterior tibial slope after medial open wedge osteotomy, and lateral location of the cortical hinge will not affect the change of the posterior tibial slope. Controlled laboratory study. We performed incomplete valgus open wedge osteotomy on 12 paired knees of 6 fresh-frozen human cadavers (age, 63.4 + or - 7.5 years) using an OrthoPilot navigation system. The left and right legs of each specimen were randomly assigned to a posterolateral (group A) or a lateral (group B) cortical hinge group. Changes in mean medial proximal tibial angle, posterior tibial slope, and opening wedge angle were measured and compared after surgery. In group A, mean medial proximal tibial angle changed from 84.37 degrees + or - 2.8 degrees to 93.48 degrees + or - 3.06 degrees (P = .028); mean posterior tibial slope increased significantly from 8.71 degrees + or - 0.81 degrees to 12.16 degrees + or - 0.84 degrees (P = .031); and mean wedge angle was 1.92 degrees + or - 0.46 degrees . In group B, mean medial proximal tibial angle changed from 82.98 degrees + or - 2.53 degrees to 90.89 degrees + or - 3.25 degrees (P = .027); mean posterior tibial slope changed from 9.19 degrees + or - 1.11 degrees to 9.78 degrees + or - 1.27 degrees (P = .029); and mean wedge angle was 7.25 degrees + or - 0.72 degrees . The location of the intact cortical hinge affects the posterior tibia slope. During medial open wedge osteotomy, the change of posterior tibial slope was larger in the posterolateral than in the lateral cortical hinge group. To prevent the unintentional increase of the posterior tibial slope, special attention should be paid to locate the intact cortical hinge on the lateral
patellofemoral joint pain during running. Medicine and Science in Sports and Exercise , 36, S56. Dierks, T.A., Davis, I.S. & Hamill, J. (2004). Lower extremity...knee flexion / extension , and knee internal/external rotation were assessed. Timing difference values of 0% stance indicated synchronous coupling. CRP...and continuous excursion ratios. Differences were primarily observed between the tibial internal/external rotation with knee flexion / extension
Asik, Mehmet; Cetik, Ozgur; Talu, Ufuk; Sozen, Yunus V
This retrospective review evaluated the results of arthroscopy-assisted surgery for tibial plateau fractures in 45 patients with closed tibial plateau fractures. The fracture involved articular depression in 27 patients in whom lifting and bone grafting with autogenous corticocancellous iliac bone graft was required. In 23 patients there were also meniscal lesions, which were treated by partial resection in 16 and repaired in 7. Internal fixation was performed using screws in 36 knees and plate in 10 knees. Radiological results were evaluated according to the Resnic-Niwoyama criteria; mean follow-up was 36 months (range 14-72). There was no intraoperative complication in the series, but postoperatively there were one infection and one loss of correction. Results were satisfactory in 89% of cases, according the Rasmussen criteria. Arthroscopy is thus an excellent and minimally invasive method for assessment and treatment of tibial plateau fractures. The advantages are complete and anatomical reduction in the fractured articular surface and evaluation of other concomitant intra-articular pathology and entails only little additional morbidity, especially compared to arthrotomy.
Chen, Lixin; Ma, Shaoyun; Li, Xianpeng
Twenty six patients with fracture of tibial plateau was under arthroscopy assisted reduction, the joint surface of bone graft, and USES the steel plate fixation treatment. Average surgery time was 65 min (70-120 min), average fracture healing time was 15 weeks (12-17 weeks), joint surface anatomical reattachment rate was 92.9%. Using break knee function criteria evaluation of curative effect: 18 cases great 6 cases wed, 2 cases ok, fine rate was 92.3%. No infection, deep venous thrombosis and small leg fascia chamber syndrome and other complications. Conclusion is that treatment of tibial plateau fractures under arthroscope has advantages of small trauma, check intuitively and reset accurately, functional recovery of patients are satisfied, the treatment has certain clinical application value.
Ghafil, Dior; Ackerman, Pieter; Baillon, Renaud; Verdonk, Rene; Delince, Philippe
Interlocking intramedullary nailing is currently the preferred treatment for most tibial fractures requiring operative treatment, with good results and a relatively low complication rate as reported in large clinical series. However, vascular and neurological complications caused by interlocking screws have been reported. In addition, insertion of distal interlocking screws can be technically demanding and may entail substantial exposure. We present the results with an expandable self-locking nail in the management of 52 AO type A and B tibial shaft fractures. The mean time to union was 15.8 weeks and the rate of union was 98%. The average surgical time was 60 minutes. Complications were those usually seen in diaphysis nailing and no complication was noted during nail expansion. Interlocking screws are not necessary, which reduces the risk of iatrogenic lesions. The expandable nail allows effective management of AO type A and B diaphyseal fractures of the tibia, a lower radiation exposure and shorter operative time.
Luo, Cong-Feng; Sun, Hui; Zhang, Bo; Zeng, Bing-Fang
1) To introduce a computed tomography-based "three-column fixation" concept; and 2) to evaluate clinical outcomes (by using a column-specific fixation technique) for complex tibial plateau fractures (Schatzker classification Types V and VI). Prospective cohort study. Level 1 trauma center. Twenty-nine cases of complex tibial plateau fractures were included. Based on routine x-ray and computed tomography images, all the fractures were classified as a "three-column fracture," which means at least one separate fragment was found in lateral, medial, and posterior columns in the proximal tibia (Schatzker classification Types V and VI). The patients were operated on in a "floating position" with a combined approach, an inverted L-shaped posterior approach combined with an anterior-lateral approach. All three columns of fractures were fixed. Operative time, blood loss, quality of reduction and alignment, fracture healing, complications, and functional outcomes based on Hospital for Special Surgery score and lower-extremity measure were recorded. All the cases were followed for average 27.3 months (range, 24-36 months). All the cases had satisfactory reduction except one case, which had a 4-mm stepoff at the anterior ridge of the tibial plateau postoperatively. No case of secondary articular depression was found. One case had secondary varus deformity, one case had secondary valgus deformity, and two cases of screw loosening occurred postoperatively. No revision surgery was performed. Two cases had culture-negative wound drainage. No infection was noted. The average radiographic bony union time and full weightbearing time were 13.1 weeks (range, 11-16 weeks) and 16.7 weeks (range, 12-24 weeks), respectively. The mean Short Form 36, Hospital for Special Surgery score, and lower-extremity measure at 24 months postoperatively were 89 (range, 80-98), 90 (range, 84-98), and 87 (range, 80-95), respectively. The average range of motion of the affected knee was 2.7° to 123.4° at
Hill, Brian W; Rizkala, Amir R; Li, Mengnai
Pediatric proximal tibial epiphysis fractures are uncommon and have subsequently received little attention in terms of treatment and outcomes. We studied the clinical and functional outcomes of 13 patients with Salter-Harris III and IV fractures of the proximal tibial epiphysis after operative fixation. Associated meniscus, ligamentous, or neurovascular injury was present in 100% of this cohort. Provisional external fixation and locked plating spanning the open physis were used in the majority of cases. The mean clinical follow-up was 15.69 months, where all fractures progressed to union. Good functional outcomes with a low complication rate are possible after operative fixation of these infrequent injuries.
Ducat, A; Sariali, E; Lebel, B; Mertl, P; Hernigou, P; Flecher, X; Zayni, R; Bonnin, M; Jalil, R; Amzallag, J; Rosset, P; Servien, E; Gaudot, F; Judet, T; Catonné, Y
Valgus high tibial osteotomy is considered to be an effective treatment for unicompartmental medial osteoarthritis. It is generally admitted that tibial slope increases after open-wedge high tibial osteotomy and decreases after closing-wedge high tibial osteotomy. However, the effects on posterior tibial slope of closing- or opening-wedge osteotomies remain controversial. We analyzed the modifications of tibial slope after opening- and closing-wedge high tibial osteotomies and compared the results of these two procedures. We hypothesized that there was no difference in postoperative tibial slope between opening and closing-wedge osteotomies. This prospective consecutive nonrandomized multicenter study was conducted between January 2008 and March 2009 and included 321 patients: 205 men and 116 women. A total of 224 patients underwent an opening-wedge high tibial osteotomy and 97 a closing-wedge osteotomy. The mean age was 52 years ± 9 and the mean body mass index was 28kg/m(2) ± 5. The main etiology was primary arthritis. Posterior tibial slope was measured preoperatively and at the last follow-up on a lateral radiograph in relation to the posterior tibial cortex. In the opening-wedge group, a definite 0.6° increase in tibial slope (P=0.016) was observed. In the closing-wedge group, a definite 0.7° decrease in tibial slope (P=0.02) was found. Fourteen percent of the opening-wedge osteotomies increased tibial slope by 5° or more versus only 2% of the closed-wedge osteotomies (P<0.001). Twelve percent of the closing-wedge high tibial osteotomies led to a decrease of 5° or more of the tibial slope versus 7% of the opening-wedge osteotomies (P<0.02). These results confirm what is generally reported in the literature, i.e., an increase in tibial slope in opening-wedge high tibial osteotomy and a decrease in the slope in closing-wedge osteotomies. These tibial slope changes appear to be very limited in this series, less than 1° on average. However, there was a bias
Streubel, Philipp N; Glasgow, Donald; Wong, Ambrose; Barei, David P; Ricci, William M; Gardner, Michael J
To evaluate the prevalence and magnitude of sagittal plane deformity in bicondylar tibial plateau fractures. Retrospective radiographic review. Two Level I trauma centers. Sagittal inclination of the medial and lateral plateau measured in relation to the longitudinal axis of the tibia using computed tomographic reconstruction images. Seventy-four patients (mean age, 49 years; range, 16-82 years; 64% male) with acute bicondylar tibial plateau fractures (Orthopaedic Trauma Association 41C, Schatzker VI) treated from October 2006 to July 2009. The average sagittal plane angulation of the lateral plateau was 9.8° posteriorly (range, 17° anteriorly to 37° posteriorly). The medial plateau was angulated 4.1° posteriorly on average (range, 16° anteriorly to 31° posteriorly). Forty-two lateral plateaus were angulated more than 5° from the "normal" anatomic slope (defined as 5° of posterior tibial slope). Of these, 76% were angulated posteriorly. Forty-three (58%) of the medial plateaus were angulated greater than 5° from normal, of which only 47% were inclined posteriorly (P = 0.019 compared with lateral plateaus). In 68% of patients, the difference between medial and lateral plateaus was greater than 5°; the average intercondylar slope difference was 9° (range, 0°-31°; P < 0.001). Spanning external fixation did not affect the slope of either the medial or lateral tibial plateau. Intraobserver and interobserver correlations were high for both the medial and lateral plateaus (r > 0.81, P < 0.01). Considerable sagittal plane deformity exists in the majority of bicondylar tibial plateau fractures. The lateral plateau has a higher propensity for sagittal angulation and tends to have increased posterior slope. Most patients have a substantial difference between the lateral and medial plateau slopes. The identification of this deformity allows for accurate preoperative planning and specific reduction maneuvers to restore anatomic alignment.
Momaya, Amit M; Hlavacek, Jimmy; Etier, Brian; Johannesmeyer, David; Oladeji, Lasun O; Niemeier, Thomas E; Herrera, Nicholas; Lowe, Jason A
Tibial plateau fractures are challenging to treat due to the high incidence of postoperative infections. Treating physicians should be aware of risk factors for postoperative infection in patients who undergo operative fixation. A retrospective review was undertaken to identify all patients with tibial plateau fractures over a 10 year period (2003-2012) who underwent open reduction internal fixation. A total of 532 patients were identified who met the inclusion criteria. Several patient and clinical characteristics were recorded, and those variables with a significant association (p<0.05) with postoperative infection after a univariate analysis were further analyzed using a multivariate analysis. Fifty-nine (11.1%) of the 532 patients developed a deep infection. The average length of follow-up for patients was 19.5 months. Methicillin-resistant Staphylococcus aureus was the most common species, and it was isolated in 26 (44.1%) patients. Open fractures, the presence of compartment syndrome, and a Schatzker type IV-VI were found to be independent risk factors for deep infection. The rate of deep infection remains high after operative fixation of tibial plateau fractures. Patients with risk factors for infection should be counseled on the possibility of reoperation, and surgeons should consider MRSA prophylaxis in those patients who are at higher risk. Copyright © 2016 Elsevier Ltd. All rights reserved.
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
Kempegowda, Harish; Maniar, Hemil H; Richard, Raveesh; Tawari, Akhil; Jove, Graham; Suk, Michael; Beebe, Michael J; Han, Chris; Tornetta, Paul; Kubiak, Erik N; Horwitz, Daniel S
The purpose of this study was to evaluate posterior malleolar injuries associated with nailed tibial fractures and to determine the quality of reduction based on the sequence of fixation in associated fracture patterns. Retrospective cohort study. 1113 tibia fractures treated with an intramedullary nail at 3 level I trauma centers. Tibial shaft fractures with posterior malleolar injury were analyzed regarding type of fracture, mechanism of injury, energy of injury, fracture characteristic, surgical characteristics including sequence of fixation, obvious intraoperative displacement of the posterior malleolar fragment, and the quality of reduction. One group ("malleolus-first") consisted of patients in whom the posterior malleolus was fixed before tibial nailing and the other group ("tibia-first") included patients in whom tibial nailing was done before posterior malleolus fixation. Intraoperative displacement, quality of reduction. Ninety-six of 1113 (9%) nailed tibial shaft fracture patients had a concomitant posterior malleolus fracture (9%). Of the 96 posterior malleolar fracture patients, 70 patients were operatively treated (73%). In the malleolus-first group (54 patients), intraoperative displacement of the posterior malleolar fragment was observed in 1 patient, and 1 case of poor reduction of the posterior malleolar fragment was observed (2%). In the tibia-first group (16 patients), obvious intraoperative displacement of the posterior malleolar fragment was observed in 5 patients (31%), and poor reduction of the posterior malleolar fragment was observed in 7 patients (44%). These percentages of patients with poor quality of reduction were statistically significantly different (p ≤ 0.01). Many low-energy tibia fractures with a spiral configuration do have an associated posterior malleolus fracture. In order to avoid intraoperative displacement and poor reduction, we recommend fixation of the posterior malleolar fragment before nailing of the tibia in
section in a comparison with a matched control group of subjects who have not sustained a fracture. Due to the low number of tibial stress...operationally defined as bony pain specifically along the distribution of the tibia that is worsened with impact loading and relieved with rest. There is...been operationally defined as bony pain specifically along the distribution of the tibia that is worsened with impact loading and relieved with rest
Robertson, Greg A J; Wood, Alexander M
Acute tibial shaft fractures represent one of the most severe injuries in sports. Return rates and return-to-sport times after these injuries are limited, particularly with regard to the outcomes of different treatment methods. To determine the current evidence for the treatment of and return to sport after tibial shaft fractures. OVID/MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Collaboration Database, Web of Science, PEDro, SPORTDiscus, Scopus, and Google Scholar were all searched for articles published from 1988 to 2014. Inclusion criteria comprised studies of level 1 to 4 evidence, written in the English language, that reported on the management and outcome of tibial shaft fractures and included data on either return-to-sport rate or time. Studies that failed to report on sporting outcomes, those of level 5 evidence, and those in non-English language were excluded. Systematic review. Level 4. The search used combinations of the terms tibial, tibia, acute, fracture, athletes, sports, nonoperative, conservative, operative, and return to sport. Two authors independently reviewed the selected articles and created separate data sets, which were subsequently combined for final analysis. A total of 16 studies (10 retrospective, 3 prospective, 3 randomized controlled trials) were included (n = 889 patients). Seventy-six percent (672/889) of the patients were men, with a mean age of 27.7 years. Surgical management was assessed in 14 studies, and nonsurgical management was assessed in 8 studies. Return to sport ranged from 12 to 54 weeks after surgical intervention and from 28 to 182 weeks after nonsurgical management (mean difference, 69.5 weeks; 95% CI, -83.36 to -55.64; P < 0.01). Fractures treated surgically had a return-to-sport rate of 92%, whereas those treated nonsurgically had a return rate of 67% (risk ratio, 1.37; 95% CI, 1.20 to 1.57; P < 0.01). The general principles are to undertake surgical management for displaced fractures and to attempt nonsurgical
Chen, Hongwei; Chang, Shimin; Pan, Jun
The posterior tibial plateau fracture is drawing increasing attention from orthopedists in recent years with the popularity of CT. However, due to the particular and severity of posterior tibial plateau fracture, there is still controversy in its classification and treatment. It is very difficult to achieve the ideal reduction and fixation by conventional techniques and approaches. The modified posterior approach is favorable for posterior tibial plateau fracture, but disadvantages remain. Recently, the lateral approach is applied by doctors. It is ideal for treatment of posterior tibial plateau fracture. Because of the complexity of local anatomical structure, the operative management of posterior tibial plateau fractures is a contentious issue as revealed in the recent surge of published literature addressing the surgical approach. This review mainly summaries the diagnosis, classification and surgery of the posterior tibial plateau fractures. PMID:26131147
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.
Cutler, L; Molloy, A; Dhukuram, V; Bass, A
Distal tibial physeal fractures are the second most common growth plate injury and the most common cause of growth arrest and deformity. This study assesses the accuracy of pre-operative planning for placement of the screws in these fractures using either standard radiographs or CT scans. We studied 62 consecutive physeal fractures over a period of four years. An outline of a single cut of the CT scan was used for each patient. An ideal position for the screw was determined as being perpendicular to and at the midpoint of the fracture. The difference in entry point and direction of the screw between the ideal and the observers' assessments were compared using the paired Student's t-test. There was a statistically significant improvement (p < 0.0001) in the accuracy of the point of insertion and the direction of the screw on the pre-operative plan when CT scans were used rather than plain radiographs. We would, therefore, recommend that CT scans are routinely used in the pre-operative assessment and treatment of distal tibial physeal fractures.
Silva, Carlos Francisco Bittencourt; Camara, Eduardo Kastrup Bittencourt; Vieira, Luiz Antonio; Adolphsson, Fernando; Rodarte, Rodrigo Ribeiro Pinho
Objective: To radiographically evaluate individuals who underwent opening wedge proximal tibial osteotomy, with the aim of analyzing the proximal tibial slope in the frontal and sagittal planes, and the patellar height. Method: The study included 22 individuals who were operated at the National Traumatology and Orthopedics Institute (INTO) for correction of varus angular tibial deviation using the opening wedge osteotomy (OWO) technique with the Orthofix monolateral external fixator. Patients with OWO whose treatment was completed between January 2000 and December 2006 were analyzed. The measurement technique consisted of using anteroposterior radiographs with loading and lateral views with the operated knees flexed at 30°. Results: There were no statistically significant differences between the pre and postoperative tibial slope and patellar height values in the patients evaluated. Conclusion: Opening wedge proximal tibial osteotomy is a technique that avoids the problems presented by high proximal tibial osteotomy, since it is done without causing changes to the extensor mechanism, ligament imbalance or distortions in the proximal tibia. PMID:27022577
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
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.
Intramedullary nailing of the tibia with suprapatellar entry and semi-extended positioning makes it technically easier to nail the proximal and distal fractures. The purpose of this article was to describe a simple method for suprapatellar nailing (SPN). A step-by-step run through of the surgical technique is described, including positioning of the patient. There are as yet only a few clinical studies that illustrate the complications with this method, and there has been no increased frequency of intraarticular damage. Within the body of the manuscript, information is included about intraarticular damage and comments with references about anterior knee pain.
Intramedullary nailing of the tibia with suprapatellar entry and semi-extended positioning makes it technically easier to nail the proximal and distal fractures. The purpose of this article was to describe a simple method for suprapatellar nailing (SPN). A step-by-step run through of the surgical technique is described, including positioning of the patient. There are as yet only a few clinical studies that illustrate the complications with this method, and there has been no increased frequency of intraarticular damage. Within the body of the manuscript, information is included about intraarticular damage and comments with references about anterior knee pain. PMID:27340503
Cassard, X; Beaufils, P; Blin, J L; Hardy, P
Arthroscopic treatment of tibial plateau fractures may reduce morbidity compared to open articular surgery. But bony fixation is necessarily percutaneous and minimal. The purpose of our study was not only to assess immediate results but also long term functional and anatomic results after arthroscopic treatment of tibial plateau fractures, with special reference to radiographical results. Twenty-six patients (mean age 42 years, range 18 to 70 years, 17 men, 9 women) were arthroscopically treated for a fresh tibial plateau fracture. According to Schatzker classification, there was 2 type I, 17 type II, 6 type III and 1 type IV. No type V or VI were treated in this series. The fixation device was: percutaneous cannulated screw in 23 cases, Kirchner wire in 2 cases, and bone cement filing of the fracture site in 1 case. We did not use cancellous bone graft but we used a hydroxyapatite plug in one case. There were 8 meniscal injuries: 2 underwent arthroscopic suture, 1 had partial meniscectomy and 5 were left in place. Twenty-six cases were suitable for immediate post op follow up. 19 were reviewed at long term. A clinical (Knee Society scoring system) and radiographical examination were done with an average follow-up of 32.7 months. There were no complications except one immediate postoperative septic osteoarthritis (case with hydroxyapatite plug) and one bony depression of the lateral tibial plateau at the fourth month. Passive motion of the knee started at 1.8 days postop with no pain. Mean flexion at 3 months was 130 degrees. At revision, the average score was: 94.1 for the knee, 94.7 for the function. In two cases we found early signs of osteoarthrosis. There were no secondary bony depression or significant valgus deformity on X-rays. Arthroscopic management of tibial plateau fractures allows a complete articular screening. Rapid rehabilitation, short hospital stay, and low rate of complications reduce morbidity. The long term results are as good as those with
Ares, Oscar; Seijas, Roberto; Cugat, Ramón; Alvarez, Pedro; Aguirre, Mario; Catala, Jordi
Fractures of the tibial tuberosity are uncommon injuries that mainly occur in 14 to 16 year-old adolescents involved in sports activities. The mechanism of injury is related to jumping while practicing sports. This retrospective study presents the outcome of fractures of the tibial tuberosity in a series of 18 adolescent soccer players treated with the same surgical technique in one center. The hypothesis was that our surgical technique with two parallel screws, one proximal and one distal to the physis, avoids physis injury and has no repercussions on growth. The average age was 14.7 years. All patients were male. The fractures included 4 type IIA, 3 type IIB, 6 type IIIA, and 5 type IIIB (Ogden classification). All patients underwent open reduction and internal fixation consisting of screw placement parallel to the joint surface, sparing the tibial physis. There were no complications in any case, and all patients were able to resume their previous sports activities. The technique used appeared to be safe. Screws were removed in 8 patients owing to local discomfort. All patients achieved the same competition level as before the injury.
Kilcoyne, Kelly G; Dickens, Jonathan F; Rue, John-Paul
Tibial stress fractures are a common overuse injury among military recruits. The purpose of this study was to determine what, if any, long-term effects that tibial stress fractures have on military personnel with respect to physical activity level, completion of military training, recurrence of symptoms, and active duty service. Twenty-six military recruits included in a previous tibial stress fracture study were contacted 10 years after initial injury and asked a series of questions related to any long-term consequences of their tibial stress fracture. Of the 13 patients available for contact, no patients reported any necessary limited duty while on active duty, and no patient reported being separated or discharged from the military as a result of stress fracture. Tibial stress fractures in military recruits are most often an isolated injury and do not affect ability to complete military training or reflect a long-term need for decreased physical activity.
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
Westermann, Robert W; DeBerardino, Thomas; Amendola, Annunziato
The High Tibial Osteotomy (HTO) is a reliable procedure in addressing uni- compartmental arthritis with associated coronal deformities. With osteotomy of the proximal tibia, there is a risk of altering the tibial slope in the sagittal plane. Surgical techniques continue to evolve with trends towards procedure reproducibility and simplification. We evaluated a modification of the Arthrex iBalance technique in 18 paired cadaveric knees with the goals of maintaining sagittal slope, increasing procedure efficiency, and decreasing use of intraoperative fluoroscopy. Nine paired cadaveric knees (18 legs) underwent iBalance medial opening wedge high tibial osteotomies. In each pair, the right knee underwent an HTO using the modified technique, while all left knees underwent the traditional technique. Independent observers evaluated postoperative factors including tibial slope, placement of hinge pin, and implant placement. Specimens were then dissected to evaluate for any gross muscle, nerve or vessel injury. Changes to posterior tibial slope were similar using each technique. The change in slope in traditional iBalance technique was -0.3° ±2.3° and change in tibial slope using the modified iBalance technique was -0.4° ±2.3° (p=0.29). Furthermore, we detected no differences in posterior tibial slope between preoperative and postoperative specimens (p=0.74 traditional, p=0.75 modified). No differences in implant placement were detected between traditional and modified techniques. (p=0.85). No intraoperative iatrogenic complications (i.e. lateral cortex fracture, blood vessel or nerve injury) were observed in either group after gross dissection. Alterations in posterior tibial slope are associated with HTOs. Both traditional and modified iBalance techniques appear reliable in coronal plane corrections without changing posterior tibial slope. The present modification of the Arthrex iBalance technique may increase the efficiency of the operation and decrease radiation
Westermann, Robert W; DeBerardino, Thomas; Amendola, Annunziato
Introduction The High Tibial Osteotomy (HTO) is a reliable procedure in addressing uni- compartmental arthritis with associated coronal deformities. With osteotomy of the proximal tibia, there is a risk of altering the tibial slope in the sagittal plane. Surgical techniques continue to evolve with trends towards procedure reproducibility and simplification. We evaluated a modification of the Arthrex iBalance technique in 18 paired cadaveric knees with the goals of maintaining sagittal slope, increasing procedure efficiency, and decreasing use of intraoperative fluoroscopy. Methods Nine paired cadaveric knees (18 legs) underwent iBalance medial opening wedge high tibial osteotomies. In each pair, the right knee underwent an HTO using the modified technique, while all left knees underwent the traditional technique. Independent observers evaluated postoperative factors including tibial slope, placement of hinge pin, and implant placement. Specimens were then dissected to evaluate for any gross muscle, nerve or vessel injury. Results Changes to posterior tibial slope were similar using each technique. The change in slope in traditional iBalance technique was -0.3° ±2.3° and change in tibial slope using the modified iBalance technique was -0.4° ±2.3° (p=0.29). Furthermore, we detected no differences in posterior tibial slope between preoperative and postoperative specimens (p=0.74 traditional, p=0.75 modified). No differences in implant placement were detected between traditional and modified techniques. (p=0.85). No intraoperative iatrogenic complications (i.e. lateral cortex fracture, blood vessel or nerve injury) were observed in either group after gross dissection. Discussion & Conclusions Alterations in posterior tibial slope are associated with HTOs. Both traditional and modified iBalance techniques appear reliable in coronal plane corrections without changing posterior tibial slope. The present modification of the Arthrex iBalance technique may increase the
Chen, Y J; Shih, H N; Huang, T J; Hsu, R W
A 58-year-old woman with a diagnosis of a tear of the posterior tibial tendon associated with the os accessory navicular fracture was treated surgically. We believe that the dysfunction of the posterior tibial tendon was associated with an os accessory navicular fracture. This case is proposed as a new subclassification that was separate from the traditional classification of the tear of the posterior tibial tendon.
Ferreira, N; Marais, L C
Bicondylar tibial plateau fractures are serious injuries to a major weight-bearing joint. These injuries are often associated with severe soft tissue injuries that complicate surgical management. We reviewed 54 consecutive patients who sustained bicondylar tibial plateau fractures that were treated with limited open reduction and cannulated screw fixation combined with fine-wire circular external fixation. Forty-six patients met the inclusion criteria of this retrospective review. Eight patients were excluded because they did not complete a minimum of 1-year follow-up. Thirty-six patients had Schatzker type-VI, and ten patients had Schatzker type-V fractures. All fractures were united without loss of reduction; there were no incidences of wound complications, osteomyelitis or septic arthritis. The average Knee Society Clinical Rating Score was 81.6, translating to good clinical results. Minor pin track infection was the most common complication encountered. This review concludes that fine-wire circular external fixation, combined with limited open reduction and cannulated screw fixation, consistently produces good functional results without serious complications.
To explore the treatment of low-energy tibial plateau fractures with arthroscopic percutaneous osteosynthesis. From May 2004 to April 2008, 27 cases of tibial plateau fractures were treated with arthroscopic management. There were 19 males and 8 females, aged 18-61 years old (mean 41.5 years old). Fracture was caused by traffic accident in 18 cases, by falling from height in 6 cases, by bruise in 2 cases, and by other in 1 case. There were 8 cases of type I, 12 cases of type II, 2 cases of type III and 5 cases of type IV according to Schatzker classification. The time from injury to operation was 3-15 days (mean 5.2 days). After symptomatic managements were performed arthroscopically in 11 cases of meniscus tear, 4 cases of medial collateral ligament rupture of knee joint, 3 cases of anterior cruciate ligament rupture of knee joint and 2 cases of cartilage fracture resulting in joint bodies, fracture was reduced and fixed with 2 or 4 cannulated screws (7 mm in diameter). Autograft of ilium was given 6 cases of bone defect. Early functional exercise was done. The operation time was 55-150 minutes (mean 93 minutes); the hospitalization days were 7-22 days (mean 16 days). All incision healed primarily. Edema of the affected leg occurred in all patients and subsided after 3 days of symptomatic management. In one patient who did not cooperate in functional exercise, adhesion occurred and normal function was recovered after by manual dissolution under conditions of anesthesia after 3 months of operation. All patients were followed up 6-36 months (mean 16.6 months). The range of motion of knee joint was 105-140 degrees (mean 121 degrees). According to Lysholm scale of knee joint, the score was 72-100 points (mean 93.6 points) 6 months after operation. The X-ray film showed no signs of osteoarthritis. Arthroscopic percutaneous osteosynthesis yields satisfactory results and can be accepted as an alternative and effective method for the treatment of low-energy tibial plateau
Dwyer, Amitabh Jitendra; John, Bobby; Krishen, Maharaj; Hora, Rajeev
Forty-eight children with an average age of 7.2 years (range: 3-12 years) were examined clinically and radiographically at an average 4-year follow-up (range: 2-10 years), between 1989 and 2000 to analyze correction of deformities following tibial shaft fractures. An inconsistent alteration in the length of the fractured tibia was observed. Anterior angular deformity realigned maximally (52.7%) followed by varus (40.9%) and valgus (23.9%) deformities. Posterior deformity corrected the least (18.5%). In the sagittal plane, acceptable critical anterior and posterior angular deformities that corrected completely were 12 degrees and 6 degrees respectively. In the coronal plane, acceptable critical angular deformities were 10 degrees varus and 8 degrees valgus.
therapy with biodegradable polv-(IDL,- lactide - co-glycolide) cefazolin-loaded microspheres for the prevention of infection in experimental open...risk of infection. The objective of this study was to evaluate the efficacy of local antibiotic therapy with biodegradable poly-(DL- lactide -co-glycolide...antibiotic Bacterial Inoculum was microencapsulated in a copolymer of poly-(DL- lactide -co-glycolide) that gradually biodegrades to Staphylococcus aureus
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.
Abd-Almageed, Emad; Marwan, Yousef; Esmaeel, Ali; Mallur, Amarnath; El-Alfy, Barakat
Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 43-C tibial plafond/pilon fractures represent a challenge for the treating orthopedic surgeon. We assessed the outcomes of using hybrid external fixation for this fracture type. The present prospective cohort study was started in August 2009 and ended by July 2012. Thirty consecutive patients (mean age 37.4 ± 10.7 years) with a type C tibial plafond fracture who had presented to our tertiary care orthopedic hospital were included. Motor vehicle accidents and fall from height were the cause of the fracture in 14 (46.7%) and 13 (43.3%) patients, respectively. A type C3 fracture was present in 25 patients (83.3%), and type C1 and C2 fractures were present in 2 (6.7%) and 3 (10.0%) patients, respectively. Nine fractures (30.0%) were open. Hybrid external fixation was used for all fractures. All fractures were united; clinical healing was achieved by a mean of 18.1 ± 2.2 weeks postoperatively and radiologic healing at a mean of 18.9 ± 1.9 weeks. The fixator was removed at a mean of 20.4 ± 2.0 weeks postoperatively. At a mean follow-up point of 13.4 ± 2.6 months, the mean modified Mazur ankle score was 84.6 ± 10.4. It was not associated with wound classification (p = .256). The most commonly seen complication was ankle osteoarthritis (17 patients; 56.7%); however, it was mild in >50.0% of the affected patients. In conclusion, using hybrid external fixation for type C tibial plafond fractures resulted in good outcomes. However, this should be investigated further in studies with a higher level of evidence. Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
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
Bhandari, Mohit; Guyatt, Gordon; Tornetta, Paul; Schemitsch, Emil H; Swiontkowski, Marc; Sanders, David; Walter, Stephen D
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. 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. 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 = 0.16). The present study demonstrates a
Eidelman, Mark; Katzman, Alexander
Most tibial shaft fractures in children can be treated with closed reduction and cast fixation, but some fractures need external or internal fixation. The Taylor spatial frame (Smith & Nephew, Memphis, Tennessee) is a relatively new external fixator that can correct 6-axis deformities with computer accuracy. This article reports our experience using the Taylor spatial frame as a rewarding treatment modality for complex tibial fractures in children and adolescents.
Liu, Guan-Yi; Xiao, Bai-Ping; Luo, Cong-Feng; Zhuang, Yun-Qiang; Xu, Rong-Ming; Ma, Wei-Hu
Background: There are few posterolateral approaches that do not require the common peroneal nerve (CPN) dissection. With the nerve exposure, it would pose a great challenge and sometimes iatrogenic damage over the surgical course. The purpose was to present a case series of patients with posterolateral tibial plateau fractures treated by direct exposure and plate fixation through a modified posterolateral approach without exposing the common peroneal nerve (CPN). Materials and Methods: 9 consecutive cases of isolated posterior fractures of the posterolateral tibial plateau were operated by open reduction and plate fixation through the modified posterolateral approach without exposing the CPN between June 2009 and January 2012. Articular reduction quality was assessment according to the immediate postoperative radiographs. At 24 month followup, all patients had radiographs and were asked to complete a validated outcome measure and the modified Hospital for Special Surgery (HSS) Knee Scale. Results: All patients were followedup, with a mean period of 29 months (range 25–40 months). Bony union was achieved in all patients. In six cases, the reduction was graded as best and in three cases the reduction was graded as middle according to the immediate postoperative radiographs by the rank order system. The average range of motion arc was 127° (range 110°–134°) and the mean postoperative HSS was 93 (range 85–97) at 24 months followup. None of the patients sustained neurovascular complication. Conclusions: The modified posterolateral approach through a long skin incision without exposing the CPN could help to expand the surgical options for an optimal treatment of this kind of fracture, and plating of posterolateral tibial plateau fractures would result in restoration and maintenance of alignment. This approach demands precise knowledge of the anatomic structures of this region. PMID:27053799
A 40 year old welder who underwent opening-wedge high tibial osteotomy for correction of alignment in a varus knee developed persistent pain with loss of knee extension. The posterior tibial slope increased from 9 degrees to 20 degrees after the osteotomy and caused the anteromedial knee pain and limited extension. The patient then underwent a revision osteotomy using a closing wedge technique to correct tibial slope. The osteotomy was performed, first from the medial cortex in the lateral direction, and second in the anteroposterior direction to remove the tibial bone in wedge shape and obtain full extension of the knee. The posterior tibial slope decreased to 8 degrees after the revision osteotomy and the patients returned to pain-free daily life. We reviewed this unique technique for correction of sagittal malalignment using a closing-wedge osteotomy for revision after opening-wedge osteotomy. PMID:19941664
Ryb, Gabriel; Dischinger, Patricia; Kleinberger, Michael; Burch, Cynthia; Ho, Shiu
Objective To determine the effect of aging on the occurence of femoral and tibial fractures during vehicular crashes. Methods The Crash Injury Research and Engineering Network (CIREN), which includes occupants of a vehicle < 8 years old with at least one AIS ≥3 or two AIS ≥2 injuries in different body regions, comprised the study population. The occurrence of femoral and tibial fractures during vehicular crashes was analyzed in relation to age and other confounders [gender, BMI, stature, change in velocity (Δv), restraint use, occupant position (driver vs. passenger) and principal direction of force (PDOF)] using χ2, Mantel-Haenszel χ2 and student t test. Multiple logistic regression (MLR) models were built for the prediction of femoral and tibial fractures with age as the independent variable and possible confounders as co-variates. An α = 0.05 was used for all statistics. Results The incidence of femoral and tibial fractures in the study population (N=1,418) was 23% and 27%, respectively. Univariate analyses revealed a negative association between increasing age and femoral fractures and no association between age and tibial fractures. MLR models revealed no clear effect of increasing age on the occurrence of either femoral or tibial fractures. Obesity, frontal PDOF, and high Delta;v affected the occurrence of femoral fractures. Tibial fractures were influenced by occupant position (driver), frontal PDOF, high Δv and shorter stature. Conclusion Despite the known changes in bone composition and strength with aging, elderly vehicular occupants do not experience higher odds of incurring femoral and tibial fractures during crashes. PMID:19026239
Nha, Kyung-Wook; Kim, Hyun-Jung; Ahn, Hyeong-Sik; Lee, Dae-Hee
It is unclear whether open- or closed-wedge high tibial osteotomy (HTO) results in significant changes in posterior tibial slope, with no consensus on the magnitude of such changes. Furthermore, methods of measuring posterior tibial slope differ among studies. This meta-analysis was therefore designed to evaluate whether posterior tibial slope increases after open-wedge HTO and decreases after closed-wedge HTO and to quantify the magnitudes of the slope changes after open- and closed-wedge HTO using various methods of measuring posterior tibial slope. Posterior tibial slope increases after open-wedge and decreases after closed-wedge HTO. The magnitude of change is similar for the 2 methods, and the value obtained for posterior tibial slope change is affected by the method of measurement. Meta-analysis. Multiple comprehensive databases, including MEDLINE, EMBASE, the Cochrane Library, and KoreaMed, were searched for studies that evaluated the posterior slope of the proximal tibia in patients who had undergone open- and/or closed-wedge HTO. Studies were included that compared pre- and postoperative posterior tibial slopes, regardless of measurement method, including anterior and posterior tibial cortex or tibial shaft axis as a reference line, in patients who underwent open- or closed-wedge HTO. The quality of each included study was appraised with the Newcastle-Ottawa Scale. Twenty-seven studies were included in the meta-analysis. Pooled data, which included subgroups of 3 methods, showed that posterior tibial slope increased 2.02° (95% CI, 2.66° to 1.38°; P = .005) after open-wedge HTO and decreased 2.35° (95% CI, 1.38° to 3.32°; P < .001) after closed-wedge HTO. This meta-analysis confirmed that posterior tibial slope increased after open-wedge HTO and decreased after closed-wedge HTO when the results of a variety of measurement methods were pooled. The magnitude of change after open- and closed-wedge HTO was similar and small (approximately 2°), suggesting
Plasschaert, V F; Johansson, C G; Micheli, L J
This article describes the use of intramedullary rodding as a treatment for an anterior tibial stress fracture in a patient with high functional demands: a professional ballet dancer. In our patient, a year of conservative treatment and later tibial drilling was unsuccessful. After sustaining a complete fracture at the site of the stress fracture, he was treated with intramedullary rodding and was able to dance 21 weeks after surgery. The fracture went on to complete healing. The role of prophylactic intramedullary nailing in this difficult fracture is discussed.
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
Bhandari, Mohit; Einhorn, Thomas A; Schemitsch, Emil; Heckman, James D; Tornetta, Paul; Leung, Kwok-Sui; Heels-Ansdell, Diane; Makosso-Kallyth, Sun; Della Rocca, Gregory J; Jones, Clifford B; Guyatt, Gordon H
Objective To determine whether low intensity pulsed ultrasound (LIPUS), compared with sham treatment, accelerates functional recovery and radiographic healing in patients with operatively managed tibial fractures. Design A concealed, randomized, blinded, sham controlled clinical trial with a parallel group design of 501 patients, enrolled between October 2008 and September 2012, and followed for one year. Setting 43 North American academic trauma centers. Participants Skeletally mature men or women with an open or closed tibial fracture amenable to intramedullary nail fixation. Exclusions comprised pilon fractures, tibial shaft fractures that extended into the joint and required reduction, pathological fractures, bilateral tibial fractures, segmental fractures, spiral fractures >7.5 cm in length, concomitant injuries that were likely to impair function for at least as long as the patient’s tibial fracture, and tibial fractures that showed <25% cortical contact and >1 cm gap after surgical fixation. 3105 consecutive patients who underwent intramedullary nailing for tibial fracture were assessed, 599 were eligible and 501 provided informed consent and were enrolled. Interventions Patients were allocated centrally to self administer daily LIPUS (n=250) or use a sham device (n=251) until their tibial fracture showed radiographic healing or until one year after intramedullary fixation. Main outcome measures Primary registry specified outcome was time to radiographic healing within one year of fixation; secondary outcome was rate of non-union. Additional protocol specified outcomes included short form-36 (SF-36) physical component summary (PCS) scores, return to work, return to household activities, return to ≥80% of function before injury, return to leisure activities, time to full weight bearing, scores on the health utilities index (mark 3), and adverse events related to the device. Results SF-36 PCS data were acquired from 481/501 (96%) patients, for whom
Feng, Wei; Fu, Li; Liu, Jianguo; Li, Dongsong; Qi, Xin
To investigate the clinical behavior of deep frozen and irradiated bone allografts in the treatment of depressed tibial plateau fractures. Twenty-two patients with a tibial plateau fracture were treated with cancellous bone allografts. The bone allograft preparation process included fresh-freezing at -70 °C for 4 weeks and gamma-irradiation at 25 kGy. All of the patients were followed for 1-2 years. The clinical effects were assessed using the Rasmussen score for tibial head fractures and X-rays. Postoperatively, the average excellent and fair Rasmussen scores were 88.9%. Only one patient developed an infection, with no integration between allograft and recipient bone observed. All of the other bone allografts were incorporated successfully, and no osteoporosis or sclerosis was observed. The frozen and gamma-irradiated bone allograft is a good alternative in the treatment of tibial plateau fractures, which we have shown can integrate with the surrounding host bone.
Moon, Sang Won; Park, Sin Hyung; Lee, Byung Hoon; Oh, Minkyung; Chang, Minho; Ahn, Jin Hwan; Wang, Joon Ho
To evaluate whether hinge position affects the change in posterior tibial slope in medial open-wedge high tibial osteotomy (HTO). We retrospectively evaluated 19 knees from 17 patients who underwent medial open-wedge HTO by 3-dimensional computed tomography scan before and after surgery. A 3-dimensional image model was constructed by applying reverse-engineering software to the computed tomography DICOM (Digital Imaging and Communications in Medicine) files. The hinge axis (i.e., the position of the hinge compared with the anteroposterior axis on an axial view), posterior tibial slope, medial-proximal tibial angle, and gap ratio (i.e., the ratio of anterior gap to posterior gap in the opened wedge) were measured. The mean hinge axis was 4.92° ± 3.86°. Posterior tibial slope increased from 7.29° ± 2.56° preoperatively to 10.48° ± 3.01° postoperatively (P = .001). The mean medial-proximal tibial angle was 85.96° ± 1.97° preoperatively and 93.13° ± 3.17° postoperatively (P = .001). The mean gap ratio was 62.48% ± 7.26%. Linear regression analysis determined that the hinge axis (P = .0001) was a significant factor changing posterior tibial slope. Hinge position affected the change in posterior tibial slope in medial open-wedge HTO; in particular, a posterolateral hinge position led to an increase in posterior tibial slope. Level IV, therapeutic study. Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
Ogawa, Hiroyasu; Matsumoto, Kazu; Ogawa, Takahiro; Takeuchi, Kentaro; Akiyama, Haruhiko
Background: Medial opening wedge high tibial osteotomy (HTO) is a well-established surgery for medial compartment knee osteoarthritis (OA) wherein the lower extremity is realigned to shift the load distribution from the medial compartment of the knee to the lateral compartment. However, this surgery is known to affect the posterior tibial slope angle (PTSA), which could lead to abnormal knee kinematics and instability, and eventually to knee OA. Although PTSA control is as important as coronal realignment, few appropriate measurements for this parameter have been reported. The placement of a wedge spacer might have an effect on PTSA. Purpose: To elucidate the relationship between the PTSA and the direction of insertion of a wedge spacer. Study Design: Case series; Level of evidence, 4. Methods: This study assessed 43 knees from 34 patients who underwent medial opening wedge HTO for knee OA. Pre- and postoperative lateral radiographs of the knee as well as postoperative computed tomography scans were performed to evaluate the relationship among PTSA, wedge insertion angle (WIA), and opening gap ratio (distance of the anterior opening gap/distance of the posterior opening gap at the osteotomy site). Results: The PTSA significantly increased from 9.0° ± 2.8° preoperatively to 13.2° ± 4.1° postoperatively (P < .001), resulting in a mean ΔPTSA of 4.7° ± 4.5°. The mean opening gap ratio was 0.86 ± 0.11, and the mean WIA was 25.9° ± 8.4°. The WIA and opening gap ratio were both highly correlated with ΔPTSA (r = 0.71 and 0.72, respectively), implying that a smaller WIA or smaller gap ratio leads to less increase in posterior slope. Conclusion: The direction of wedge insertion is highly correlated with PTSA increase, which suggests that the PTSA can be controlled for by adjusting the direction of wedge insertion during surgery. Clinical Relevance: Study results suggest that it is possible to adjust the PTSA by controlling the WIA during surgery. Proper
Konda, Sanjit R; Driesman, Adam; Manoli, Arthur; Davidovitch, Roy I; Egol, Kenneth A
To examine 1-year functional and clinical outcomes in patients with tibial plateau fractures with tibial eminence involvement. Retrospective analysis of prospectively collected data. Academic Medical Center. All patients who presented with a tibial plateau fracture (Orthopaedic Trauma Association (OTA) 41-B and 41-C). Patients were divided into fractures with a tibial eminence component (+TE) and those without (-TE) cohorts. All patients underwent similar surgical approaches and fixation techniques for fractures. No tibial eminence fractures received fixation specifically. Short musculoskeletal functional assessment (SMFA), pain (Visual Analogue Scale), and knee range-of-motion (ROM) were evaluated at 3, 6, and 12 months postoperatively and compared between cohorts. Two hundred ninety-three patients were included for review. Patients with OTA 41-C fractures were more likely to have an associated TE compared with 41-B fractures (63% vs. 28%, P < 0.01). At 3 months postoperatively, the +TE cohort was noted to have worse knee ROM (75.16 ± 51 vs. 86.82 ± 53 degree, P = 0.06). At 6 months, total SMFA and knee ROM was significantly worse in the +TE cohort (29 ± 17 vs. 21 ± 18, P ≤ 0.01; 115.6 ± 20 vs. 124.1 ± 15, P = 0.01). By 12 months postoperatively, only knee ROM remained significantly worse in the +TE cohort (118.7 ± 15 vs. 126.9 ± 13, P < 0.01). Multivariate analysis revealed that tibial eminence involvement was a significant predictor of ROM at 6 and 12 months and SFMA at 6 months. Body mass index was found to be a significant predictor of ROM and age was a significant predictor of total SMFA at all time points. Knee ROM remains worse throughout the postoperative period in the +TE cohort. Functional outcome improves less rapidly in the +TE cohort but achieves similar results by 1 year. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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.
Gómez-Salazar, J; Tovar-López, J; Hernández-Rodríguez, G; De la Concha-Ureta, H
Arterial pseudoaneurysm of the lower limb is an infrequent entity, particularly in the infrapopliteal segment. It is commonly associated to vascular repairs or follows a localized arterial lesion, a fracture or a surgical procedure. There is little information in Mexico about this entity in cases involving the anterior tibial artery, and secondary to trauma and osteosynthesis. Given that sudden bleeding due to rupture of the pseudoaneurysm is a possible catastrophic outcome for the viability of the segment, it is important to timely detect and diagnose the pseudoaneurysm. Treatment indications contained in the international literature are controversial. Solution-oriented approaches may be either surgical or endovascular. Current reports show that the best treatment option is an autologous saphenous vein graft, which maintains blood flow and minimizes the risk of peripheral ischemia. The purpose of this paper is to report the case of a patient who sustained the above mentioned complication and provide a literature review. This topic should be further investigated, as this condition may go unnoticed in a large number of cases, given that its symptoms are silent.
Wang, Yukai; Luo, Congfeng; Hu, Chengfang; Sun, Hui; Zhan, Yu
Posterolateral tibial plateau fractures are not uncommon and the diagnosis can be easily missed. The treatment is technically demanding, which can easily lead to malunion of the posterolateral tibial plateau fracture. Here, we describe an innovative intra-articular osteotomy for the treatment of posterolateral tibial plateau fracture malunion. From 2010 through 2012, 13 patients with a posterolateral tibial plateau fracture malunion were treated in our trauma center. The patients were referred because of instability or knee pain. The instability was confirmed by physical examinations preoperatively. The depression malunion and lower limb alignment were evaluated on X-rays and computed tomography scans. All posterolateral tibial plateau fracture malunions were treated with an innovative intra-articular osteotomy via an extended anterolateral approach. The mean follow-up was 19.6 months (range, 14-28 months). The posterolateral osteotomy healed at an average of 15.1 weeks. The depression malunion was corrected in all patients, which was from 15.4 mm preoperatively to 3.3 mm at 12 months postoperatively. The average Lysholm, Knee Society Score, and visual analog scale scores were 91.7, 92.5, and 0.5, respectively. No loss of reduction, nonunion, or wound infection was observed. An innovative intra-articular osteotomy via an extended anterolateral approach is an effective treatment for posterolateral tibial plateau fracture malunion. The treatment achieved satisfactory functional results and knee stability restoration.
Milenković, Sasa; Mitković, Milorad; Micić, Ivan; Mladenović, Desimir; Najman, Stevo; Trajanović, Miroslav; Manić, Miodrag; Mitković, Milan
Distal tibial pilon fractures include extra-articular fractures of the tibial metaphysis and the more severe intra-articular tibial pilon fractures. There is no universal method for treating distal tibial pilon fractures. These fractures are treated by means of open reduction, internal fixation (ORIF) and external skeletal fixation. The high rate of soft-tissue complications associated with primary ORIF of pilon fractures led to the use of external skeletal fixation, with limited internal fixation as an alternative technique for definitive management. The aim of this study was to estimate efficacy of distal tibial pilon fratures treatment using the external skeletal and minimal internal fixation method. We presented a series of 31 operated patients with tibial pilon fractures. The patients were operated on using the method of external skeletal fixation with a minimal internal fixation. According to the AO/OTA classification, 17 patients had type B fracture and 14 patients type C fractures. The rigid external skeletal fixation was transformed into a dynamic external skeletal fixation 6 weeks post-surgery. This retrospective study involved 31 patients with tibial pilon fractures, average age 41.81 (from 21 to 60) years. The average follow-up was 21.86 (from 12 to 48) months. The percentage of union was 90.32%, nonunion 3.22% and malunion 6.45%. The mean to fracture union was 14 (range 12-20) weeks. There were 4 (12.19%) infections around the pins of the external skeletal fixator and one (3.22%) deep infections. The ankle joint arthrosis as a late complication appeared in 4 (12.90%) patients. All arthroses appeared in patients who had type C fractures. The final functional results based on the AOFAS score were excellent in 51.61%, good in 32.25%, average in 12.90% and bad in 3.22% of the patients. External skeletal fixation and minimal internal fixation of distal tibial pilon fractures is a good method for treating all types of inta-articular pilon fractures. In
Ozel, Omer; Yucel, Bulent; Mutlu, Serhat; Orman, Osman; Mutlu, Harun
In this study, postoperative changes in the posterior tibial slope angle and clinical outcomes following open-wedge high tibial osteotomy were evaluated. This study included 39 knees (18 left, 21 right) of 35 patients (three male, 32 female; median age, 53 years; age range 37-64 years) with symptomatic isolated medial joint osteoarthritis who underwent open-wedge high tibial osteotomy and fixation with a Puddu plate. The patients were clinically assessed according to the Lysholm knee score, a visual analogue pain scale, and a patient satisfaction questionnaire. Radiological assessment was made according to the changes in the posterior tibial slope angle and the correlation between these changes and clinical signs. The median follow-up period was 11 years (range 7-14 years). Significant improvements were observed in the preoperative and postoperative clinical scores of the Lysholm knee scale, visual analogue pain scale, and patient satisfaction questionnaire (p < 0.05). Radiological assessment showed that the posterior tibial slope angle was significantly higher during the postoperative and follow-up periods (p 0.05). There was no correlation between the postoperative Lysholm scores and the increase in the posterior tibial slope angle (p = n.s.). We conclude that both the conventional Puddu plate design and its anteromedial plate placement are what increase the tibial slope after an opening-wedge proximal tibial osteotomy. Therefore, current new plate design may help preserve the posterior tibial slope angle. IV.
Mulhall, K J; Dowdall, J; Grannell, M; McCabe, J P
We analysed the outcome of open reduction and internal fixation of type III tibial spine fractures, assessing treatment and determining a treatment protocol. A total of 10 patients presented over 3 years to our institution with a mean age of 15 years (range 10-21), a male-to-female ratio of 8:2. left to right 6:4 and anterior to posterior spine fracture 9:1. Only one patient had associated meniscal injury noted at arthroscopy (no treatment required). The mode of injury was road traffic accidents four, sports injuries three and falls three. The mean follow-up was 9 months. There were seven excellent results and three good results. Those patients with good results exhibited either minimal quadriceps weakness, extensor lag (< 10 degrees) or antero-posterior laxity. This reflects the experience of other authors in dealing with these injuries in younger patients. There is widespread agreement that types I and II should be treated by plaster cast alone and that is also the policy at our institution. We recommend a routine treatment protocol in type III injuries of (1) examination under anaesthesia, (2) arthroscopy (evaluating the fracture, cruciate integrity and other associated injuries), (3) open reduction and screw fixation and (4) vigorous physiotherapy/rehabilitation of all type III fractures, as we feel this provides the best possible outcome in these injuries.
Milner, Clare E; Hamill, Joseph; Davis, Irene
Tibial stress fractures are a serious overuse injury in runners. Greater vertical loading rates and tibial shock have been found in runners with previous tibial stress fracture compared to controls. The timing of these variables occurs very early in the stance phase and suggests that conditions shortly after footstrike may be important in determining injury risk. The purpose of this study was to further investigate lower extremity mechanics in early stance in runners with a history of tibial stress fracture. In addition, the relationships between these variables were explored. Twenty-three runners with a history of tibial stress fracture were investigated. They were compared with 23 age and mileage matched control subjects with no previous lower extremity bony injuries. Data were collected as subjects ran at 3.7 m/s. All variables of interest were computed over the period from footstrike to the impact peak of the vertical ground reaction force. Independent t-tests and effect sizes were used to assess the differences between the groups. Pearson Product Moment correlations were used to determine whether initial stance variables were related to tibial shock in the two groups. Sagittal plane knee stiffness was significantly greater in the tibial stress fracture group. Stiffness was also positively correlated with shock. Knee excursion, knee angle at footstrike and shank angle at footstrike were not different between groups. These findings provide further support for the relationship between mechanics during initial loading and tibial stress fractures in runners. This relationship may be important in terms of retraining gait to reduce the risk of stress fracture in runners.
Martinez de Albornoz, Pilar; Leyes, Manuel; Forriol, Francisco; Del Buono, Angelo; Maffulli, Nicola
To ascertain whether changing position and size of the spacer may modify the load and displacement of the tibial plateau when performing an opening wedge high tibial osteotomy. Fifteen sawbones tibia models were used. In the axial plane, the anterior, medial, and posterior thirds of the tibial plateau were marked, and the medial and posterior thirds were called "point 1" and "point 2", respectively. A 7.5-mm-stainless steel indenter was used to apply the load over these two points: the load applied to point 1 simulated the load to that site when the knee was extended, and the load to point 2 simulated the load to the same area when the knee was flexed. Maximum load (N) and displacement (mm) were calculated. The system was shown to withstand higher loads with less displacement when the plate was posterior than it could do with the plate in the middle position. Significant differences were also found when comparing the anterior and middle position of the plate with the greatest displacement when the plate was anterior. The differences were increased when comparing the anterior and posterior positions of the plate. No statistical differences (n.s.) were found when using different spacers. The maximum stiffness was achieved if the plate was posterior and in point 1 indenter position, in which the force vector stands on the points of the lateral and medial supports (Fμ = 198.8 ± 61.5 N). The lowest stiffness was observed when the plate was anterior, and the force was applied to point 2 (Fμ = 29.7 ± 5.1 N). Application of the plate in a more posterior position provides greater stability.
Archer, Matthew; Parkin, Tom; Latimer, Mark David
We report the case of an 11-year-old boy presenting with a type III tibial eminence fracture. The fracture fragment was reduced arthroscopically. Two 1.6 mm retrograde K-wires were inserted from the tibial metaphysis across the physis and into the fracture fragment using a standard anterior cruciate ligament tibial tunnel guide. Once the wires were clearly visible within the joint the tips were bent over by ∼120°. The wires were then tensioned around a single small fragment screw inserted into the tibial metaphysis. An exceptionally strong fixation was achieved. The boy was mobilised without a brace. The wires were removed at 12 weeks and he returned to full activity at 14 weeks.
Jaiswal, Atin; Kachchhap, Naiman-Deepak; Tanwar, Yashwant S; Kumar, Birendra; Yadav, Sachin K
High-energy tibial plateau fracture poses a significant challenge and difficulty for orthopaedic surgeons. Fracture of tibial plateau involves major weight bearing joint and may alter knee kinematics. Anatomic reconstruction of the proximal tibial articular surfaces, restoration of the limb axis (limb alignment) and stable fixation permitting early joint motion are the goals of the treatment. In cases of complex bicondylar tibial plateau fractures, isolated lateral plating is frequently associated with varus malalignment and better results have been obtained with bilateral plating through dual incisions. However sometimes a complex type of bicondylar tibial plateau fractures is encountered in which medial plateau has a biplaner fracture in posterior coronal plane as well as sagittal plane. In such fractures it is imperative to fix the medial plateau with buttressing in both planes. One such fracture pattern of the proximal tibia managed by triple plating through dual posteromedial and anterolateral incisions is discussed in this case report with emphasis on mechanisms of this type of injury, surgical approach and management.
Hake, Mark E; Goulet, James A
Fractures of the tibial plateau are challenging injuries to treat. The lateral tibial plateau is fractured more commonly than the medial plateau and the workhorse approach for these fractures is the anterolateral approach. This approach allows visualization of the lateral joint, metaphysis, and can be extensile if there is shaft extension. We present our technique for performing the anterolateral approach while treating a Schatzker III tibial plateau fracture. Special attention is given to performing a submeniscal arthrotomy to view the joint surface and judge the reduction. A femoral distractor is placed to assist with elevation the joint surface and visualization of the lateral plateau. A cortical window is created using a triple reamer from the sliding hip screw set. The reduction is performed and supported with cancellous bone chips. Finally, a lateral locking plate with rafting screws is placed. Knowledge of this approach and the strategies needed to address lateral and some bicondlar tibial plateau fractures are crucial to good patient outcomes.
Parkkinen, Markus; Madanat, Rami; Lindahl, Jan; Mäkinen, Tatu J
The risk factors are unclear for deep surgical site infection after plate fixation of proximal tibial fractures. The objective of this study was to identify the patient and surgical procedure-related risk factors for infection using established criteria for deep surgical site infection. A total of 655 proximal tibial fractures were treated with open reduction and plate fixation at our center between 2004 and 2013. We identified 34 patients with deep surgical site infection. A control group of 136 patients was randomly selected from the non-infected cohort. Potential risk factors for deep surgical site infection were identified by reviewing surgical, medical, and radiographic records. Independent risk factors for infection were identified from multivariable logistic regression analysis using a stepwise procedure. The prevalence of deep surgical site infection was 5.2%, the mean age of affected patients was 55 years (range, 16 to 84 years), and 35% of patients were female. Twenty-eight of 34 deep infections were diagnosed within 2 months (acute onset), and only 6 infections were diagnosed >6 months after the index surgical procedure. Nine of the 28 acute-onset infections were treated with antibiotic therapy and debridement. Seventeen patients (50%) required muscle flap coverage, and 5 patients (15%) eventually required above-the-knee amputation. In the multivariable logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (95% CIs), independent predictors of infection were patient age of ≥50 years (OR, 3.6 [95% CI, 1.3 to 10.1]); obesity, defined as a body mass index of ≥30 kg/m(2) (OR, 6.5 [95% CI, 2.2 to 18.9]); alcohol abuse (OR, 6.7 [95% CI, 2.4 to 19.2]); OTA/AO-type-C fracture (OR, 2.8 [95% CI, 1.1 to 7.5]); use of a temporary spanning external fixator (OR, 3.9 [95% CI, 1.4 to 11.1]); and a 4-compartment fasciotomy (OR, 4.5 [95% CI, 1.3 to 15.7]). There is high morbidity associated with deep surgical site infection in plated proximal
Daghino, Walter; Messina, Marco; Filipponi, Marco; Alessandro, Massè
Background: The tibial pilon fractures represent a complex therapeutic problem for the orthopedic surgeon, given the frequent complications and outcomes disabling. The recent medical literature indicates that the best strategy to reduce amount of complications in tibial pilon fractures is two-stages procedure. We describe our experience in the primary stabilization of these fractures. Methods: We treated 36 cases with temporary external fixation in a simple configuration, called "tripolar": this is an essential structure (only three screws and three rods), that is possible to perform even without the availability of X-rays and with simple anesthesia or sedation. Results: We found a sufficient mechanical stability for the nursing post-operative, in absence of intraoperative and postoperative problems. The time between trauma and temporary stabilization ranged between 3 and 144 hours; surgical average time was 8.4 minutes. Definitive treatment was carried out with a delay of a minimum of 4 and a maximum of 15 days from the temporary stabilization, always without problems, both in case of ORIF (open reduction, internal fixation) or circular external fixation Conclusion: Temporary stabilization with external fixator in ‘tripolar’ configuration seems to be the most effective strategy in two steps treatment of tibial pilon fractures. These preliminary encouraging results must be confirmed by further studies with more cases. PMID:27123151
Pizanis, Antonius; Garcia, Patric; Pohlemann, Tim; Burkhardt, Markus
Reduction of the articular surface in displaced tibial plateau fractures is still challenging and may result in joint incongruence, leading to posttraumatic arthrosis. Conventional techniques use bone tamps and similar instruments, which can increase the surgical trauma due to their size. "Balloon tibioplasty" is a novel minimally invasive technique for the reduction of depressed tibial plateau fractures. We successfully applied an inflatable balloon, commercially available from kyphoplasty, to elevate the depressed articular fragments. This technique allowed for reduction of the depressed tibial plateau fragment without classic fenestration of the tibia, thereby minimizing surgical trauma. Furthermore, under fluoroscopic control, optimal centering of the expanding tibioplasty balloon allows a widespread and continuously increasing reduction force to the fracture area. After fluoroscopy or arthroscopic confirmation of reduction of the articular surface, the cavity resulting from tibioplasty was filled with ceramic bone cement through small incisions and fractures were fixed with a small fragment locking T-plate (3.5 mm). Balloon tibioplasty was applied in 5 patients with displaced tibial plateau fractures (OTA type B2/3). No intra- or postoperative complications were observed. This new technique may be a useful tool to facilitate the reduction of select depressed tibial fractures in the future.
Zelle, Boris A; Boni, Guilherme; Hak, David J; Stahel, Philip F
Reamed locked intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Supra-patellar tibial nailing in the semiextended position has been suggested as a safe and effective surgical technique that allows mitigating certain challenges of the standard subpatellar approach. Suprapatellar nailing seems to facilitate achieving and maintaining fracture reduction, particularly in proximal third tibia fractures. Preliminary investigations have suggested that this technique is associated with a low rate of complications, including a reduced incidence of postoperative anterior knee pain. Further clinical investigations are necessary to establish overall complication rates and long-term subjective outcomes.
O'Neill, Barry James; Ryan, Katie; Burke, Neil G; Moroney, Paul John
Stress fractures occurring within the lower limbs are relatively common in athletes and military personnel. The specific bones affected are often predictable when the patient's activities are considered. We present an unusual case of bilateral distal tibial stress fractures sustained while playing as a goalkeeper in field hockey, in an otherwise healthy 46-year-old woman. PMID:25188931
Yim, Ji Hyeon; Seon, Jong Keun; Song, Eun Kyoo
Although opening-wedge high tibial osteotomy (HTO) is used to correct deformities, it can simultaneously alter tibial slope in the sagittal plane because of the triangular configuration of the proximal tibia, and this undesired change in tibial slope can influence knee kinematics, stability, and joint contact pressure. Therefore, medial opening-wedge HTO is a technically demanding procedure despite the use of 2-dimensional (2-D) navigation. The authors evaluated the posterior tibial slope pre- and postoperatively in patients who underwent navigation-assisted opening-wedge HTO and compared posterior slope changes for 2-D and 3-dimensional (3-D) navigation versions. Patients were randomly divided into 2 groups based on the navigation system used: group A (2-D guidance for coronal alignment; 17 patients) and group B (3-D guidance for coronal and sagittal alignments; 17 patients). Postoperatively, the mechanical axis was corrected to a mean valgus of 2.81° (range, 1°-5.4°) in group A and 3.15° (range, 1.5°-5.6°) in group B. A significant intergroup difference existed for the amount of posterior tibial slope change (Δ slope) pre- and postoperatively (P=.04).Opening-wedge HTO using navigation offers accurate alignment of the lower limb. In particular, the use of 3-D navigation results in significantly less change in the posterior tibial slope postoperatively than does the use of 2-D navigation. Accordingly, the authors recommend the use of 3-D navigation systems because they provide real-time intraoperative information about coronal, sagittal, and transverse axes and guide the maintenance of the native posterior tibial slope. Copyright 2012, SLACK Incorporated.
Haller, J M; Holt, D C; McFadden, M L; Higgins, T F; Kubiak, E N
The aim of this study was to report the incidence of arthrofibrosis of the knee and identify risk factors for its development following a fracture of the tibial plateau. We carried out a retrospective review of 186 patients (114 male, 72 female) with a fracture of the tibial plateau who underwent open reduction and internal fixation. Their mean age was 46.4 years (19 to 83) and the mean follow-up was16.0 months (6 to 80). A total of 27 patients (14.5%) developed arthrofibrosis requiring a further intervention. Using multivariate regression analysis, the use of a provisional external fixator (odds ratio (OR) 4.63, 95% confidence interval (CI) 1.26 to 17.7, p = 0.021) was significantly associated with the development of arthrofibrosis. Similarly, the use of a continuous passive movement (CPM) machine was associated with significantly less development of arthrofibrosis (OR = 0.32, 95% CI 0.11 to 0.83, p = 0.024). The effect of time in an external fixator was found to be significant, with each extra day of external fixation increasing the odds of requiring manipulation under anaesthesia (MUA) or quadricepsplasty by 10% (OR = 1.10, p = 0.030). High-energy fracture, surgical approach, infection and use of tobacco were not associated with the development of arthrofibrosis. Patients with a successful MUA had significantly less time to MUA (mean 2.9 months; sd 1.25) than those with an unsuccessful MUA (mean 4.86 months; sd 2.61, p = 0.014). For those with limited movement, therefore, performing an MUA within three months of the injury may result in a better range of movement. Based our results, CPM following operative fixation for a fracture of the tibial plateau may reduce the risk of the development of arthrofibrosis, particularly in patients who also undergo prolonged provisional external fixation. ©2015 The British Editorial Society of Bone & Joint Surgery.
Uzun, Metin; Bilen, Fikri Erkal; Eralp, Levent
Objectives: The aim of the treatment of tibial plateau fractures is to obtain a pain-free and fully functional knee with closed reduction, percutaneous cannulated screw fixation and hexapodal external fixator reconstruction for high energy compound upper tibial fractures. Methods: Patients with comminuted tibial plateau fractures underwent closed reduction, percutaneous fixation with cannulated screws, and reconstruction with hexapodal external fixator. The follow-up period was 24 months. Results: The clinical and radiological results were good or excellent. The average knee flexion was 125°. Conclusion: Our results are successful in the initial stage, however, it should be pointed out that during the long term follow-up osteoarthritis may develop leading to worsening of the condition. Level of Evidence IV, Case Series. PMID:24644420
Dubina, Andrew G; Paryavi, Ebrahim; Manson, Theodore T; Allmon, Christopher; O'Toole, Robert V
The aim of this study was to investigate the effects of compartment syndrome and timing of fasciotomy wound closure on surgical site infection (SSI) after surgical fixation of tibial plateau fractures. Our primary hypothesis was that SSI rate is increased for fractures with compartment syndrome versus those without, even accounting for confounders associated with infection. Our secondary hypothesis was that infection rates are unrelated to timing of fasciotomy closure or fixation. We conducted a retrospective cohort study of operative tibial plateau fractures with ipsilateral compartment syndrome (n=71) treated with fasciotomy at our level I trauma center from 2003 through 2011. A control group consisted of 602 patients with 625 operatively treated tibial plateau fractures without diagnosis of compartment syndrome. The primary outcome measure was deep SSI after ORIF. Fractures with compartment syndrome had a higher rate of SSI (25% versus 8%, p<0.001). The difference remained significant in our multivariate model (odds ratio, 7.27; 95% confidence interval, 3.8-13.9). Delay in timing of fasciotomy closure was associated with a 7% increase per day in odds of infection (95% confidence interval, 0.2-13; p<0.05). Tibial plateau fractures with ipsilateral compartment syndrome have a significant increase in rates of SSI compared with those without compartment syndrome (p<0.001). Delays in fasciotomy wound closure were also associated with increased odds of SSI (p<0.05). Copyright © 2016 Elsevier Ltd. All rights reserved.
Lin, K-C; Tarng, Y-W; Lin, G-Y; Yang, S-W; Hsu, C-J; Renn, J-H
The three-column fixation concept is becoming popular in orthopedic practice. Posterior column fracture is an uncommon type of tibial plateau fracture. The supine position for the surgical approach is familiar to most surgeons; however, it is difficult to achieve good reduction and fixation in posterior column fracture. The prone position and direct posterior approach can achieve proper reduction and fixation for posterior column tibial plateau fracture, yielding good functional outcome. Between January 2010 and January 2012, 184 tibial plateau fractures were diagnosed and operated on in our institution. Sixteen posterior column tibial plateau fractures (10 male and 6 female patients, with a mean age of 41.5 ± 14.3 years) were diagnosed by preoperative plain films and CT scans. Ten patients presented with fracture-dislocation of the knee joint. A direct posterior approach in prone position was used to reduce the tibial condyle and fix it with an anti-glide buttress plate. Radiographic evaluation included reduction quality and bone union. Functional evaluation included Lysholm score and Tegner activity score. All fractures healed within 6 months, without secondary displacement. Ten knees had postoperative anatomic reduction (0mm step-off) and 6 had acceptable reduction (< 2mm step-off). At 34.4 ± 9.6 months, median extension was 3 (5-10) and flexion 135 (100-145). The mean Lysholm score was 95 (75-100) and the mean Tegner activity score was 6 (5-8). All patients were satisfied with the operation. No cases of post-traumatic osteoarthritis of the knee occurred during follow-up. The prone position and direct posterior approach has great advantages in terms of reduction and stable fixation, yielding good results. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
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.
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
Wiegand, N; Naumov, I; Vámhidy, L; Nöt, L G
Avulsion fractures of the anterior tibial intercondylar eminence in childhood are rare and are severe injuries of the knee. Since the injury is equivalent in aetiology with ruptures of the anterior cruciate ligament, the treatment requires anatomic reduction and preservation of the stability of the joint. The aim of the study was to demonstrate our experiences with the arthroscopy-guided Herbert-screw fixation in the treatment of displaced tibial eminence fractures in children. Between January 2004 and December 2011, a total of eight children were treated surgically with Type II or Type III anterior tibial eminence fractures; another four children with undisplaced, Type I fractures were treated conservatively, applying with cast fixation for 6 weeks. Radiological consolidation, stability and functional outcome were assessed during the follow-up examinations. On the 12th postoperative week, we did not find instability in any of the patients by physical examination. There were only minimal differences found in the functional outcome, comparing the conservatively and operatively treated groups (Lysholm functional scale, average scores: Type I: 97, Type II: 95 and Type III: 94 points). The range of motion (ROM) of the injured knees was identical with healthy sides on the postoperative 6th week. Our results indicate that the presented method can successfully be applied in the treatment of displaced tibial spine fractures; providing excellent stability and preserving the function of the injured knee in the short-term. Copyright © 2013 Elsevier B.V. All rights reserved.
Karaarslan, Ahmet Adnan; Acar, Nihat; Aycan, Hakan; Sesli, Erhan
Nailing of tibial shaft fractures is considered the gold standard surgical method by many surgeons. The aim of this retrospective study was to investigate and compare the clinical outcome of tibial shaft fractures treated with intramedullary nails compressed by proximal tube and conventional intramedullary interlocking nails. Fifty-seven patients with tibial shaft fractures, treated with intramedullary nails compressed by proximal tube (n = 32) and the conventional interlocking nails (n = 25), were reviewed. All fractures except for one were united without any additional surgical intervention in the proximal compression tube nail group, whereas in the conventional interlocking nail group, six patients needed dynamization surgery (p = 0.005) and three cases of nonunion were recorded. In the proximal compression tube nail group, faster union occurred in 20 ± 2 (16-24) weeks (mean ± SD; range) without failure of locking screws and proximal nail migration, whereas in the conventional interlocking nail group, union occurred in 22 ± 2.5 (17-27) weeks (p = 0.001) with two failures of locking screws and two proximal nail migration. The proximal compression tube nail system is safer than the conventional nailing methods for the treatment for transverse and oblique tibial shaft fractures with a less rate of nonunion, proximal locking screw failure and proximal nail migration.
Background Conversion of a knee arthrodesis to a Total Knee Arthroplasty is an uncommon procedure. Revision Total Knee Arthroplasty in this setting presents the surgeon with a number of challenges including the management of the extensor mechanism and patella. Case presentation We describe a unique case of a 69 years old Caucasian man who underwent a revision Total Knee Arthroplasty using a tibial tubercle osteotomy after a previous conversion of a knee arthrodesis without patella resurfacing. Unfortunately 9 months following surgery a tibial tubercle pseudarthrosis and spontaneous patella fracture occurred. Both were managed with open reduction and internal fixation. At 30 months follow-up the tibial tubercle osteotomy had completely consolidated while the patella fracture was still evident but with no signs of further displacement. The patient was completely satisfied with the outcome and had a painless range of knee flexion between 0-95°. Conclusions We believe that patients undergoing this type of surgery require careful counseling regarding the risk of complications both during and after surgery despite strong evidence supporting improved functional outcomes. PMID:24195600
Jang, Ki-Mo; Lee, Jong-Hee; Park, Hyung-Jun; Kim, Jeong Lae; Han, Seung-Beom
This study involved 35 knees undergoing biplane medial open-wedge high tibial osteotomy (OWHTO) to assess the axial rotation of the distal tibia. The distal tibiae were internally rotated by 3.0° ± 7.1° after OWHTO. The opening width showed a Pearson correlation coefficient of -0.743 (P < .001), and the tuberosity osteotomy angle showed that of -0.678 (P < .001) with distal tibial rotation. However, changes in hip-knee-ankle angle, medial proximal tibial angle, and posterior tibial slope were not significantly correlated with the change in distal tibial rotation. In conclusion, there was an unintended tendency of increasing internal rotation of the distal tibia after biplane medial OWHTO, and this tendency was positively related to the opening width and tuberosity osteotomy angle. Copyright © 2016 Elsevier Inc. All rights reserved.
Yaligod, Vishwanath; Rudrappa, Girish H.; Nagendra, Srinivas; Shivanna, Umesh M.
Background The complications of intramedullary nailing of distal third tibial shaft and metaphyseal fractures have a direct impact on ankle and hind foot function. Methods We retrospectively evaluated 28 patients. Unreamed nail was negotiated across the well reduced fracture till subchondral bone and fixed with 2 to 3 distal locking screws in different planes. Results Fracture union rate was 85%. Three out of 28 patients had malalignment. Mean ankle, hindfoot functional score was 85. Conclusion Complications can be minimized by impacting the unreamed nail till the subchondral bone while maintaining the fracture well reduced and by using multiple distal locking screws in different planes. PMID:24719527
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
Hoke, David; Jafari, S Mehdi; Orozco, Fabio; Ong, Alvin
The use of navigation during joint arthroplasty is believed to allow better placement of components. Gross fracture or stress fracture through navigation tracker pin placement is a complication reported in the literature. This case series presents details of stress fracture of tibial shaft through navigation pin track in 3 patients of 220 cases who underwent total knee arthroplasty at our institution. All the fractures eventually healed after a course of protected weight bearing. As a result, we use smaller-diameter self-tapping and self-drilling pins routinely and avoid placement of pins in the diaphysis and ensure that pins are inserted in different plains during insertion into metaphysis.
Lee, Dong Hoon; Ryu, Keun Jung; Kim, Jae Hwa; Kim, Hae Hwa; Soung, Sahyun; Shin, Soowan
limbs (18%) showed lateral cortical hinge fracture and three limbs out of 149 limbs (2%) showed soft tissue complications (two superficial infections, one wound hematoma). The overall completeness of reaching the target correction was excellent. In the coronal plane, the difference between the amount of real correction and the amount of target correction was 0.3° ± 0.7° (p < 0.001). In the sagittal plane, the difference between pre- and postoperative posterior proximal tibial angle was -0.1° ± 0.2° (p < 0.001). All osteotomies healed before 4 months. Fixator-assisted high tibial osteotomy is a valid option for medial opening-wedge high tibial osteotomy, which enables less invasive surgery with excellent coronal/sagittal/rotational alignment control. However, future studies should compare this approach with other approaches for proximal tibial osteotomy to ascertain whether indeed this procedure is less invasive or more reliable. Level IV, therapeutic study.
Background 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. Methods/Design 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. Discussion The primary outcome was re-operation to promote healing, treat infection, or preserve the limb (fasciotomy for compartment syndrome after nailing). The primary
Lee, Seung-Yup; Lim, Hong-Chul; Bae, Ji Hoon; Kim, Jae Gyoon; Yun, Se-Hyeok; Yang, Jae-Hyuk; Yoon, Jung-Ro
Unlike postoperative changes in posterior tibial slope after medial open-wedge high tibial osteotomy, sagittal osteotomy inclination has not been examined. It has been recommended that the osteotomy line in the sagittal plane be parallel to the medial posterior tibial slope. The purpose of this study was to determine the frequency of parallel osteotomy in medial open-wedge high tibial osteotomy. To determine the sagittal osteotomy inclination, the angle between the medial joint line and the osteotomy line was measured in the lateral radiograph. A positive angle value indicates that the osteotomy is anteriorly inclined relative to the medial posterior tibial slope. Correlation between the sagittal osteotomy inclination and posterior tibial slope was also evaluated. The mean sagittal osteotomy inclination was 15.1 ± 7.5°. The majority 87.1 % of knees showed an anterior-inclined osteotomy. There was a significantly positive correlation between the postoperative posterior tibial slope and the sagittal osteotomy inclination (r, 0.33; 95 % confidence interval (CI) 0.19-0.46; P < 0.001). The postoperative change in posterior tibial slope also showed a significantly positive correlation with the sagittal osteotomy inclination (r, 0.35; 95 % CI 0.21-0.47; P < 0.001). Although parallel osteotomy in the sagittal plane relative to the medial joint line was planned, only 12.9 % of cases achieved osteotomy parallel to the medial posterior tibial slope in the sagittal plane. Because of high rate of the anterior-inclined osteotomy and their correlations with posterior tibial slope, surgeons should make all efforts to perform parallel osteotomy relative to medial posterior tibial slope. IV.
Conesa, Xavier; Minguell, Joan; Cortina, Josep; Castellet, Enric; Carrera, Lluís; Nardi, Joan; Cáceres, Enric
We report an unusual case of anteromedial tibial plateau compression fracture following hyperextension and forced varus of the knee, resulting in an anterior bone fragment large enough to require osteosynthesis. This uncommon lesion was associated with posterolateral complex injury, diagnosed with magnetic resonance imaging (MRI), while both cruciate ligaments were preserved. After proceeding with tibial plateau osteosynthesis, a peroneal tendon allograft was used for supplementation repair of the lateral collateral ligament and biceps tendon in a single surgical intervention. Tibial plateau fractures are often associated with soft-tissue involvement, mainly of the anterior cruciate ligament and external meniscus. Posterolateral complex injuries also occur with a mechanism of forced varus and hyperextension. These lesions require an accurate diagnosis to avoid future knee instability; moreover, adequate treatment in the acute phase provides a better functional outcome. Physicians should suspect associated posterolateral complex injury when an anteromedial tibial plateau fracture is diagnosed. MRI allows adequate diagnosis and permits surgical treatment in one procedure. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Tomčovčík, L; Tomčovčíková, A
Stress fractures of the anterior cortex of the mid-tibial shaft in dancers are rare, with a 1.4 % incidence in injured eli- te dancers. Treatment can be difficult and long-lasting and can seriously influence the dancer's career. The authors pre- sent the case of a 26-year-old professional dancer of a folk dance ensemble who suffered rare simultaneous bilateral mid-tibial shaft stress fractures. A conservative method of treatment with avoiding exercise and dancing activities resulted in the resolution of symptoms and healing of the fractures after 6 months. The patient finished his dancing career because of the necessity of a prolonged therapy interfering with his dancing activities. Current options of the treatment are also presented.
Giordano, Vincenzo; Schatzker, Joseph; Kfuri, Mauricio
High-energy fractures of the proximal tibia with extensive fragmentation of the posterior rim of the tibial plateau are challenging. This technique aims to describe a method on how to embrace the posterior rim of the tibial plateau by placing a horizontal precontoured one-third tubular plate wrapped around its corners. This method, which we named "hoop plating," is mainly indicated for cases of crushed juxta-articular rim fractures, aiming to restore cortical containment of the tibial plateau. Through a lateral approach with a fibular head osteotomy (Lobenhoffer approach), both anterolateral and posterolateral fragments are directly reduced and supported by a one-third tubular plate of adequate length. The plate is inserted from lateral to medial deep to all soft tissues, and its position is checked with fluoroscopy. The implant sits exactly on the posterior cortex of the tibial plateau and provides containment for the reduced juxta-articular posterior cortex and rim. We begin with immediate range of motion. Toe-touch weight-bearing with crutches is allowed with the operated knee in full extension. Weight-bearing is gradually increased only after 6 weeks as bone healing is taking place. Clinical follow-up is performed at 1, 3, 6, and 12 weeks. If the radiological exam confirms that the fracture is healed, the patient is allowed to proceed to muscle strengthening and bear weight entirely. The "hoop plating" may be a good option for the management in cases of extensive posterior tibial plateau articular surface fracture and impaction with rim and posterior cortical wall fragmentation. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Background: Intramedullary nailing is an effective approach for treatment of diaphyseal tibial fractures. However, infrapatellar intramedullary nailing can easily cause angulation and rotation displacement at the fracture ends and increase risk of postoperative infection. Intramedullary nailing via the suprapatellar approach was proved with good reduction and fixation. We used locked intramedullary nailing for the treatment of tibial fractures via a suprapatellar approach in this study. Materials and Methods: 23 patients undergoing tibial fractures fixation by locked META intramedullary nailing via a suprapatellar approach were enrolled between June 2012 and October 2013. There were 18 males and 5 females. The average age was 35.5 years (range 18-60 years). The intraoperative data including operative time and blood loss and postoperative data consisting of hospital stays, fluoroscopy time, fracture healing time and complications were all recorded. Results: The average operative time, blood loss, fluoroscopy time and hospital stay were 78.2 ± 9.1 min, 90.4 ± 23.4 mL, 38.5 ± 6.5 s and 11 ± 3.4 days respectively. The mean followup period in all the patients was 15.5 months. Callus appeared in the patients at average 8 weeks after surgery. The mean knee and ankle range of motion were significantly improved at the last followup (P < 0.05). The average Hospital for Special Surgery and Olerud–Molander scores was 92 ± 4.3 points and 93.6 ± 3.9 points, respectively. No complications were observed. Conclusion: Locked META intramedullary nail fixation via a suprapatellar approach is safe and effective for patients suffering from tibial fractures and earlier functional recovery. PMID:27293289
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.
Richman, M H; Weltman, J K; Cole, A
Between 1970 and 1973 99 tibial fractures were treated by rigid internal fixation with ASIF plates. The fractures were all regarded as sufficiently stable for exercise without weight bearing, thus needing no additional external support during the healing period. Four of the plates broke late in the healing period, after the onset of weight bearing. These fractures had some degree of delayed union with slight resorption of the bone ends, resulting in cyclical bending of the plate. Examination of 2 of the fractured plates by scanning electron microscopy, electron microprobe analysis and optical metallography revealed that the primary cause of plate fracture was fatigue. There was no evidence that corrosion fatigue or inclusion content were factors leading to plate fracture.
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.
Liu, Yong; Liao, Zhengwen; Shang, Lei; Huang, Wenhua; Zhang, Dawei; Pei, Guoxian
The aim of this study was to investigate the characteristics of unilateral tibial plateau fractures among hospitalized adult patients in Xijing Hospital, to evaluate the accuracy of Schatzker classification system and AO/OTA classification system to tibial plateau fractures. We retrospectively analysed clinical data on 274 patients admitted to Xijing Hospital between September 2006 and August 2015. The patients’ demographic characteristics, admission periods and seasons, external causes and fracture types were recorded and summarized. Then the characteristics of tibial plateau fractures and the accuracy rate of these two classification systems were analysed. Schatzker type II fractures and AO/OTA type 41-B3 fractures were the most common types. The external causes differed between genders, types of employment, urban-rural residents and both two systems. In addition, some fractures were difficult to classify using Schatzker or AO/OTA classification system. Rural male physical labourers aged between 30–59 years-old were most likely to suffer from unilateral tibial plateau fractures, due to traffic accidents, falls and indoor activity injuries, or falls from height. We should pay more attention to the related people and professions, which contributed to the high occurrence of tibial plateau fractures. Besides that, further improvements are required for both Schatzker and AO/OTA classification systems. PMID:28074894
Jakma, Tijs; Reynders-Frederix, Peter; Rajmohan, Rai
Intramedullary nailing of proximal tibial fractures can be difficult when using the standard entry portal. We evaluated the suprapatellar portal, using a midline quadriceps tendon incision, to perform intramedullary nailing of the tibia. Seven patients were treated with this adaptation of the standard intramedullary nailing procedure. An arthroscopy was done before and after the nailing procedure. No special equipment was used to perform the intramedullary nailing. We evaluated the handling and necessary modifications of the standard intramedullary technique to introduce the locked tibial nail through the suprapatellar approach. We found this technique not necessarily more difficult than the standard intramedullary nailing of the tibia through the infrapatellar entry portal. Although the patients did not complain of patellofemoral discomfort after the suprapatellar nailing, definitive scuffing of the cartilage in the lower part of the femoral trochlea was visible. Introduction of a locked tibial nail via the suprapatellar approach was found to be possible and even advantageous for some complex upper tibial shaft fractures in compromised limbs. Some possible downsides of this approach need to be taken into account but, in some cases, they can be outweighed by the benefits.
Tsai, Chuan-En; Su, Yu-Ping; Feng, Chi-Kuang; Chen, Chuan-Mu; Chiu, Fang-Yao; Liu, Chien-Lin
Concomitant tibial shaft and posterior malleolar fractures (PMFs) are often encountered in clinical settings. Plain films were reviewed for concomitant PMF, and fracture patterns were analyzed by focusing on the integrity of the fibula and the location of the fibular fracture. A retrospective review of patients who presented with tibial shaft fractures between January 2005 and January 2010 was performed. Patients were included if they were at least 18 years of age and had a tibial diaphyseal fracture. Exclusion criteria were age less than 18 years, previous surgery on the same leg, and pathological fractures. Medical records were reviewed for information on injury mechanisms. Pre- and post-operative radiographs were analyzed for PMFs, tibial fracture pattern, fibular integrity, fibular fracture pattern, treatment type, and time to fracture union. Descriptive statistical tests were used. Among 240 patients, there were 20 cases (15 male and 5 female) of concomitant PMF, all detected in lateral radiograph views. The incidence of PMF was 8.3%. Most patients had a motorcycle injury (n = 15, 75%). Distal tibia spiral fracture was the most common fracture pattern (85%) and there was no proximal tibia fracture (0%). Combined fibular fractures were found in 17 patients (85%). There were nine proximal fibular fractures (45%). Intact fibulas were found in three patients (15%). Only one PMF was treated with screw fixation. All PMFs showed radiographic evidence of healing within 5 months post-operatively. We recommend careful radiographic examination to evaluate PMF, especially in patients with distal tibial spiral fractures combined with proximal fibular fractures or intact fibulas. Copyright © 2013. Published by Elsevier B.V.
Yoon, Yong-Cheol; Oh, Jong-Keon; Oh, Chang-Wug; Sahu, Dipit; Hwang, Jin-Ho; Cho, Jae-Woo
With the introduction of 3.5 anatomically pre-shaped plates, the rafting screw technique is gaining popularity in recent years for the management of lateral tibial plateau fractures with articular depression. To gain access to the depressed articular fragments, the split fragment is hinged open laterally. We elevate the depressed articular fragments to the normal level. The defect below is filled with bone graft or its substitutes. We then close the split fragment and apply rafting screws either through the screw holes of the plate or separately above the plate rather in a blind fashion. We therefore cannot be sure that the rafting screws are supporting the specific elevated fragments. For this reason some surgeons place the rafting screws from within and then close the lateral fragment over the screws. This so-called embedded rafting screw technique carries the risk of difficulty in removal, especially in case of an infection. Here we describe the inside out rafting technique to tackle this problem.
Popkov, A. V.; Kononovich, N. A.; Gorbach, E. N.; Tverdokhlebov, S. I.; Irianov, Y. M.; Popkov, D. A.
Purpose. Our research was aimed at studying the radiographic and histological outcomes of using flexible intramedullary nailing (FIN) combined with Ilizarov external fixation (IEF) versus Ilizarov external fixation alone on a canine model of an open tibial shaft fracture. Materials and Methods. Transverse diaphyseal tibial fractures were modelled in twenty dogs. Fractures in the dogs of group 1 (n = 10) were stabilized with the Ilizarov apparatus while it was combined with FIN in group 2 (n = 10). Results. On day 14, a bone tissue envelope started developing round the FIN wires. Histologically, we revealed only endosteal bone union in group 1 while in group 2 the radiographs revealed complete bone union on day 28. At the same time-point, the areas of cancellous and mature lamellar bone tissues were observed in the intermediary area in group 2. The periosteal layers were formed of the trabeculae net of lamellar structure and united the bone fragments. The frame was removed at 30 days after the fracture in group 2 and after 45 days in group 1 according to bone regeneration. Conclusion. The combination of the Ilizarov apparatus and FIN accelerates bone repair and augments stabilization of tibial shaft fractures as compared with the use of the Ilizarov fixation alone. PMID:25379523
muscle forces after eccentric exercise . American College of Sports Medicine Annual Meeting, Baltimore, MD, May, 1989. 20. Hamill, J., Freedson, P. S...McKeown, K.A. (2002). Kinetic variables in subjects with previous lower extremity stress fractures. Medicine and Science in Sports and Exercise , 34(1...and without lower extremity stress fractures. Medicine and Science in Sports and Exercise , 34(1), s991. 19 4) Degrees obtained that are supported by
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.
Thaunat, Mathieu; Nourissat, Geoffroy; Gaudin, Pascal; Beaufils, Philippe
We report a case of tibial plateau fracture after previous anterior cruciate ligament (ACL) reconstruction using patellar tendon autograft and bioabsorbable screws 4 years previously. The fracture occurred through the tibial tunnel. The interference screw had undergone complete resorption and the tunnel widening had increased. The resorption of the interference screw did not simultaneously promote and foster the growth of surrounding bone tissue. Therefore, the area of reactive tissue left by the screw resorption in an enlarged bone tunnel may lead to vulnerability of the tibial plateau. Stress risers would occur following ACL reconstruction if either resorption is not complete or bony integration is not complete.
Konda, Sanjit R; Jordan, Charles J; Davidovitch, Roy I; Egol, Kenneth A
Standard techniques for immobilization of a tibia shaft fracture in the emergency department in a long-leg splint can be cumbersome, technically difficult, and often requires the use of an assistant. We have developed a novel technique for the reduction and splinting of tibial shaft fractures, which uses a "hammock" constructed of stockinette, which allows a single consulting orthopaedic physician to rapidly reduce and place a long-leg plaster splint or cast on a patient. This technique was performed on 12 consecutive patients with a total of 12 tibial shaft fractures. Translation, angulation, and shortening of the fracture were documented in anteroposterior and lateral views of the injured tibia and these parameters were compared against values measured after the hammock technique was used to reduce and splint the fracture. Pre-"hammock" average values for fracture displacement in the anteroposterior plane for translation, angulation, and shortening were 10.5 mm (53.1%), 12.0°, and 9.4 mm, respectively. Post-"hammock" average values for fracture displacement in the anteroposterior plane for the same parameters were 8.7 mm (44.4%), 4.2°, and 7.9 mm, respectively. Pre-"hammock" average values for fracture displacement in the lateral plane for translation and angulation were 4.9 mm and 8.7°. Post-"hammock" average values for fracture displacement in the lateral plane for the same parameters were 4.9 mm and 2.0°, respectively. These results show that this technique is able to achieve the goals of fracture reduction and immobilization in a rapid fashion when help is not available.
Ballard, Brooke L.; Antonacci, Jennifer M.; Temple-Wong, Michele M.; Hui, Alexander Y.; Schumacher, Barbara L.; Bugbee, William D.; Schwartz, Alexandra K.; Girard, Paul J.; Sah, Robert L.
Background: Intra-articular fractures may hasten posttraumatic arthritis in patients who are typically too active and too young for joint replacement. Current orthopaedic treatment principles, including recreating anatomic alignment and establishing articular congruity, have not eliminated posttraumatic arthritis. Additional biomechanical and biological factors may contribute to the development of arthritis. The objective of the present study was to evaluate human synovial fluid for friction-lowering function and the concentrations of putative lubricant molecules following tibial plateau fractures. Methods: Synovial fluid specimens were obtained from the knees of eight patients (twenty-five to fifty-seven years old) with a tibial plateau fracture, with five specimens from the injured knee as plateau fracture synovial fluid and six specimens from the contralateral knee as control synovial fluid. Each specimen was centrifuged to obtain a fluid sample, separated from a cell pellet, for further analysis. For each fluid sample, the start-up (static) and steady-state (kinetic) friction coefficients in the boundary mode of lubrication were determined from a cartilage-on-cartilage biomechanical test of friction. Also, concentrations of the putative lubricants, hyaluronan and proteoglycan-4, as well as total protein, were determined for fluid samples. Results: The group of experimental samples were obtained at a mean (and standard deviation) of 11 ± 9 days after injury from patients with a mean age of 45 ± 13 years. Start-up and kinetic friction coefficients demonstrated similar trends and dependencies. The kinetic friction coefficients for human plateau fracture synovial fluid were approximately 100% higher than those for control human synovial fluid. Hyaluronan concentrations were ninefold lower for plateau fracture synovial fluid compared with the control synovial fluid, whereas proteoglycan-4 concentrations were more than twofold higher in plateau fracture synovial
Parikh, Shital N; Myer, David; Eismann, Emily A
Arthrofibrosis is a major complication of tibial spine fracture treatment in children, potentially resulting in knee pain, quadriceps weakness, altered gait, decreased function, inability to return to sports, and long-term osteoarthritis. Thus, prevention rather than treatment of arthrofibrosis is desirable. The purpose of this study was to evaluate an aggressive postoperative rehabilitation and early intervention approach to prevent permanent arthrofibrosis after tibial spine fracture treatment and to compare epiphyseal and transphyseal screws for fixation. A consecutive series of 24 patients younger than age 18 with displaced type II and III tibial spine fractures who underwent arthroscopic reduction and screw fixation between 2006 and 2011 were retrospectively reviewed. Final range of motion was compared between patients with epiphyseal (n=12) and transphyseal (n=9) screws. One-third (4 of 12) of patients with epiphyseal screws underwent arthroscopic debridement and screw removal approximately 3 months postoperatively; 3 patients lacked 5° to 15° of extension, 1 experienced pain with extension, and 1 had radiographic evidence of screw pullout, loss of reduction, and resultant malunion. In the transphyseal screw group, 3 patients had 10° loss of extension, and all corrected after arthroscopic debridement and screw removal. The two groups did not significantly differ in time to hardware removal or return to sports or final range of motion. No growth disturbances were identified in patients after transphyseal screw removal. An aggressive approach of postoperative rehabilitation and early intervention after arthroscopic reduction and screw fixation of tibial spine fractures in children was successful in preventing permanent arthrofibrosis.
Loriaut, Philippe; Moreau, Pierre-Emmanuel; Loriaut, Patrick; Boyer, Patrick
Background: Avulsion fractures of the tibial intercondylar eminence are fairly common injuries requiring surgery for the optimal functional outcome. The purpose of this study was to assess the clinical and radiological outcomes of an arthroscopic treatment of displaced tibial intercondylar eminence fractures using a suspensory device. Material and Methods: Five patients with type 2 and 3 displaced tibial intercondylar eminence fractures who received an arthroscopically assisted fixation using a double button device were enrolled from 2011 to 2012. Clinical assessment included the patient demographics, cause of injury, the delay before surgery, time for surgery, time to return to work and sport, the International Knee Documentation Committee (IKDC) and Lysholm knee scores. Stability was measured with the KT-2000 arthrometer with a force of 134 N. A side to side difference on the KT-2000 examination superior to 3 mm was considered as a significant and abnormal increase in the anterior translation. Radiological examination consisted of anteroposterior and lateral radiographs, as well as computed tomography (CT) scan of the affected knee. Clinical and radiological followup was done at 1, 2, 3, 6, and 12 months postoperatively and at final followup. CT-scan was performed before surgery and at 3 months followup. Results: The median age of patients was 31 years. Mean followup was 27 ± 5.1 months. The average delay before surgery was 3 days. At final followup, the mean IKDC and Lysholm knee scores were, 93.9 and 94.5 respectively. All patients had a complete functional recovery and were able to return to work and to resume their sport activities. No secondary surgeries were required to remove hardware. No complication was noted. Bony union was achieved in all patients. Conclusion: The arthroscopic treatment of displaced tibial intercondylar eminence fractures using a suspensory system provided a satisfactory clinical and radiological outcome at a followup of 2 years. PMID
Scott, C E H; Davidson, E; MacDonald, D J; White, T O; Keating, J F
Radiological evidence of post-traumatic osteoarthritis (PTOA) after fracture of the tibial plateau is common but end-stage arthritis which requires total knee arthroplasty is much rarer. The aim of this study was to examine the indications for, and outcomes of, total knee arthroplasty after fracture of the tibial plateau and to compare this with an age and gender-matched cohort of TKAs carried out for primary osteoarthritis. Between 1997 and 2011, 31 consecutive patients (23 women, eight men) with a mean age of 65 years (40 to 89) underwent TKA at a mean of 24 months (2 to 124) after a fracture of the tibial plateau. Of these, 24 had undergone ORIF and seven had been treated non-operatively. Patients were assessed pre-operatively and at 6, 12 and > 60 months using the Short Form-12, Oxford Knee Score and a patient satisfaction score. Patients with instability or nonunion needed total knee arthroplasty earlier (14 and 13.3 months post-injury) than those with intra-articular malunion (50 months, p < 0.001). Primary cruciate-retaining implants were used in 27 (87%) patients. Complication rates were higher in the PTOA cohort and included wound complications (13% vs 1% p = 0.014) and persistent stiffness (10% vs 0%, p = 0.014). Two (6%) PTOA patients required revision total knee arthroplasty at 57 and 114 months. The mean Oxford knee score was worse pre-operatively in the cohort with primary osteoarthritis (18 vs 30, p < 0.001) but there were no significant differences in post-operative Oxford knee score or patient satisfaction (primary osteoarthritis 86%, PTOA 78%, p = 0.437). Total knee arthroplasty undertaken after fracture of the tibial plateau has a higher rate of complications than that undertaken for primary osteoarthritis, but patient-reported outcomes and satisfaction are comparable. Cite this article: Bone Joint J 2015;97-B:532-8.
Beslikas, Theodoros; Christodoulou, Andreas; Chytas, Anastasios; Gigis, Ioannis; Christoforidis, John
Salter-Harris type V fracture is a very rare injury in the immature skeleton. In most cases, it remains undiagnosed and untreated. We report a case of genu recurvatum deformity in a 15-year-old boy caused by a Salter-Harris type V fracture of the proximal tibial physis. The initial X-ray did not reveal fracture. One year after injury, genu recurvatum deformity was detected associated with significant restriction of knee flexion and limp length discrepancy (2 cm) as well as medial and posterior instability of the joint. Further imaging studies revealed anterior bone bridge of the proximal tibial physis. The deformity was treated with a high tibial dome osteotomy combined with a tibial tubercle osteotomy stabilized with malleolar screws and a cast. Two years after surgery, the patient gained functional knee mobility without clinical instability. Firstly, this case highlights the importance of early identification of this rare lesion (Salter-Harris type V fracture) and, secondly, provides an alternative method of treatment for genu recurvatum deformity.
Beslikas, Theodoros; Christodoulou, Andreas; Chytas, Anastasios; Gigis, Ioannis; Christoforidis, John
Salter-Harris type V fracture is a very rare injury in the immature skeleton. In most cases, it remains undiagnosed and untreated. We report a case of genu recurvatum deformity in a 15-year-old boy caused by a Salter-Harris type V fracture of the proximal tibial physis. The initial X-ray did not reveal fracture. One year after injury, genu recurvatum deformity was detected associated with significant restriction of knee flexion and limp length discrepancy (2 cm) as well as medial and posterior instability of the joint. Further imaging studies revealed anterior bone bridge of the proximal tibial physis. The deformity was treated with a high tibial dome osteotomy combined with a tibial tubercle osteotomy stabilized with malleolar screws and a cast. Two years after surgery, the patient gained functional knee mobility without clinical instability. Firstly, this case highlights the importance of early identification of this rare lesion (Salter-Harris type V fracture) and, secondly, provides an alternative method of treatment for genu recurvatum deformity. PMID:23259115
Kang, Jong Yeal; Lee, Yong Seuk
The authors report a case of failure fracture of the tibial metal tray and polyethylene insert at the same level in a 73-year-old woman 10 years after total knee arthroplasty using the AMK Total Knee System (DePuy, Warsaw, Indiana). Causes of this fracture are analyzed and discussed, with the focus on the importance of component design, position, and size. The overall aim of this case report is for orthopedic surgeons to avoid this complication in total knee arthroplasty by paying attention to these controllable factors. [Orthopedics. 2016; 39(4):e787-e789.]. Copyright 2016, SLACK Incorporated.
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
Gali, Julio Cesar; Sansanovicz, Dennis; Ventin, Fernando Carvalho; Paes, Rodrigo Henrique; Quevedo, Francisco Carlos; Caetano, Edie Benedito
OBJECTIVE: To evaluate the effect of dipyrone on healing of tibial fractures in rats. METHODS: Fourty-two Wistar rats were used, with mean body weight of 280g. After being anesthetized, they were submitted to closed fracture of the tibia and fibula of the right posterior paw through manual force. The rats were randomly divided into three groups: the control group that received a daily intraperitoneal injection of saline solution; group D-40, that received saline injection containing 40mg/Kg dipyrone; and group D-80, that received saline injection containing 80mg/Kg dipyrone. After 28 days the rats were sacrificed and received a new label code that was known by only one researcher. The fractured limbs were then amputated and X-rayed. The tibias were disarticulated and subjected to mechanical, radiological and histological evaluation. For statistical analysis the Kruskal-Wallis test was used at a significance level of 5%. RESULTS: There wasn't any type of dipyrone effect on healing of rats tibial fractures in relation to the control group. CONCLUSION: Dipyrone may be used safely for pain control in the treatment of fractures, without any interference on bone healing. Level of Evidence II, Controlled Laboratory Study. PMID:25246852
Gwinner, Clemens; Hoburg, Arnd; Wilde, Sophie; Schatka, Imke; Krapohl, Björn Dirk; Jung, Tobias M.
Background: The posterior cruciate ligament (PCL) avulsion fracture from its tibial insertion is a rare condition. Despite the further technical advent in refixation of avulsion fractures, the reported failure rate of current approaches remains high and the optimal surgical technique has not been elucidated yet. The purpose of the current study is to present an all-inside arthroscopic reconstruction technique for bony tibial avulsion fractures of the PCL and initial clinical outcomes. Methods: Patients underwent a thorough clinical and radiological examination of both knees at 3, 6, 12, 18, and if possible also at 24 months. Clinical evaluation included subjective and objective IKDC 2000, Lysholm score, and KOOS score. Radiographic imaging studies included CT scans for assessment of osseous integration and anatomic reduction of the bony avulsion. In addition to that posterior stress radiographs of both knees using the Telos device (Arthrex, Naples, USA) were conducted to measure posterior tibial translation. Results: A total of four patients (1 female, 3 male; ø 38 (± 18) years), who underwent arthroscopic refixation of a PCL avulsion fracture using the Tight Rope device were enrolled in this study. Mean follow up was 22 [18–24] months. The mean subjective IKDC was 72.6% (± 9.9%). Regarding the objective IKDC three patients accounted for grade A, one patient for grade C. The Lysholm score yielded 82 (± 6.9) points. The KOOS score reached 75% (± 13%; symptoms 76%, pain 81%, function 76%, sports 66%, QoL 64%). All patients showed complete osseous integration and anatomic reduction of the bony avulsion. The mean posterior tibial translation at final follow up was 2.8 [0–7] mm. Conclusions: All-arthroscopic treatment of tibial avulsion fractures of the posterior cruciate ligament provides satisfactory clinical results in a preliminary patient cohort. It is a reproducible technique, which minimizes soft tissue damage and obviates a second surgery for hardware
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.
Pornrattanamaneewong, Chaturong; Numkanisorn, Surin; Chareancholvanich, Keerati; Harnroongroj, Thossart
Medial opening wedge high tibial osteotomy (MOWHTO) has proven to be an effective treatment for varus osteoarthritic knees. Various methods of fixation with different implant types and using either bone grafts or bone substitutes have been reported. We performed non-locking T-buttress plate fixation with autologous iliac bone graft augmentation, which is defined here as the traditional method, and locking compression plate fixation without any bone graft or bone substitute. We aimed to compare bone union and complications of these two MOWHTO techniques. Between June 2005 and December 2007, 50 patients who underwent MOWHTO (a total of 60 knees) were retrospectively reviewed and classified into two groups: group A, which consisted of 26 patients (30 knees) was treated using T-buttress plate fixation with autologous iliac bone graft augmentation and group B, which consisted of 24 patients (30 knees) was operated upon using a medial high tibial locking compression plate without any augmentation. Demographic characteristics and radiographic outcomes, including union rate, time to union, medial osteotomy defects, and complications, were collected and compared between the two groups. The progress of all patients was followed for at least 2 years. All osteotomies united within 12 weeks after surgery. Group B had slightly longer time to union than group A (10.3 weeks and 9.5 weeks, respectively; P = 0.125). A significantly higher incidence of medial defects after osteotomy was reported in the locking compression plate group (P = 0.001). A total of 5 (8.3%) knees had complications. In group A, one knee had a superficial wound infection and another knee had a lateral tibial plateau fracture without significant loss of correction. In group B, one knee had screw penetration into the knee joint and two knees had local irritation that required the removal of the hardware. Locking compression plate fixation without the use of bone grafts or bone substitutes provides a satisfactory
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
Asada, Shigeki; Akagi, Masao; Mori, Shigeshi; Matsushita, Tetsunao; Hashimoto, Kazuki; Hamanishi, Chiaki
The purpose of this study was to clarify the causes of the increase in the posterior tibial slope during open-wedge high tibial osteotomy (HTO) and to investigate whether its changes influenced the correction angle in frontal plane. We retrospectively reviewed 20 patients (26 knees) treated with open-wedge HTO. They were divided into the following two groups. Group A consisted of the knees whose opening gaps were fixed using a spacer plate having the trapezoidal block with a 2° posterior slope. In Group B, anterior and posterior opening gaps were fixed separately. The posterior tibial slope and the hip-knee-ankle angle were measured based on CT data. The relationship between the correction rate in frontal plane and the changes of posterior tibial slope was investigated. Increase in the posterior tibial slope was 2.1 ± 2.5° in Group A and 0.2 ± 1.2° in Group B, which showed a statistical difference (P = 0.02). The difference between the hip-knee-ankle angles before and after operation was 5.2 ± 2.3° in Group A and 5.5 ± 2.5° in Group B. The correction rate was statistically correlated with the changes of posterior tibial slope (R = -0.55, P = 0.003). To avoid increase in the posterior tibial slope, the trapezoidal block with a only 2° posterior slope in a spacer plate was not sufficient, and it was necessary to fix anterior and posterior gaps separately. The correction angle in frontal plane had a trade-off relationship with the changes in posterior tibial slope. Thus, we thought that increase in the posterior tibial slope might result in correction loss. Therapeutic study, Retrospective comparative study, Level III.
Donohue, David; Sanders, Drew; Serrano-Riera, Rafa; Jordan, Charles; Gaskins, Roger; Sanders, Roy; Sagi, H Claude
To determine whether ketorolac administered in the immediate perioperative period affects the rate of nonunion in femoral and tibial shaft fractures. Retrospective comparative study. Single Institution, Academic Level 1 Trauma Center. Three hundred and thirteen skeletally mature patients with 137 femoral shaft (OTA 32) and 191 tibial shaft (OTA 42) fractures treated with intramedullary rod fixation. Eighty patients with 33 femoral shaft and 52 tibial shaft fractures were administered ketorolac within the first 24 hours after surgery (group 1-study group). Two-hundred thirty-three patients with 104 femoral shaft and 139 tibial shaft fractures were not (group 2-control group). Rate of reoperation for repair of a nonunion and time to union. Average time to union of the femur was 147 days for group 1 and 159 days for group 2 (P = 0.57). Average time to union of the tibia was 175 days for group 1 and 175 days for group 2 (P = 0.57). There were 3 femoral nonunions (9%) in group 1 and eleven femoral nonunions (11.6%) in group 2 (P = 1.00). There were 3 tibial nonunions (5.8%) in group 1 and 17 tibial nonunions (12.2%) in group 2 (P = 0.29). The average dose of ketorolac for patients who healed their fracture was 85 mg, whereas it was 50 mg for those who did not (P = 0.27). All patients with a nonunion in the study group were current smokers. Ketorolac administered in the first 24 hours after fracture repair for acute pain management does not seem to have a negative impact on time to healing or incidence of nonunion for femoral or tibial shaft fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Bryant, H; Dearden, P M C; Harwood, P J; Wood, T J; Sharma, H K
Total radiation exposure accumulated during circular frame treatment of distal tibial fractures was quantified in 47 patients treated by a single surgeon from February 2007 until Oct 2010. The radiation exposures for all relevant radiology procedures for the distal tibial injury were included to estimate the radiation risk to the patient. The median time of treatment in the frame was 169 days (range 105-368 days). Patients underwent a median of 13 sets of plain radiographs; at least one intra operative exposure and 16 patients underwent CT scanning. The median total effective dose per patient from time of injury to discharge was 0.025mSv (interquartile range 0.013-0.162 and minimum to maximum 0.01-0.53). The only variable shown to be an independent predictor of cumulative radiation dose on multivariate analysis was the use of CT scanning. This was associated with a 13-fold increase in overall exposure. Radiation exposure during treatment of distal tibial fractures with a circular frame in this group was well within accepted safe limits. The fact that use of CT was the only significant predictor of overall exposure serves as a reminder to individually assess the risk and utility of radiological investigations on an individual basis. This is consistent with the UK legal requirements for justification of all X-ray imaging, as set out in the Ionising Radiation (Medical Exposure) Regulations 2000 .
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
Bartoníček, Jan; Rammelt, Stefan; Kostlivý, Karel; Vaněček, Václav; Klika, Daniel; Trešl, Ivo
The aim of this study was to analyze the pathoanatomy of the posterior fragment on the basis of a comprehensive CT examination, including 3D reconstructions, in a large patient cohort. One hundred and forty one consecutive individuals with an ankle fracture or fracture-dislocation of types Weber B or Weber C and evidence of a posterior tibial fragment in standard radiographs were included in the study. The mean patient age was 49 years (range 19-83 years). The exclusion criteria were patients below 18 years of age, inability to provide written consent, fractures of the tibial pilon, posttraumatic arthritis and pre-existing deformities. In all patients, post-injury radiographs were obtained in anteroposterior, mortise and lateral views. All patients underwent CT scanning in transverse, sagittal and frontal planes. 3D CT reconstruction was performed in 91 patients. We were able to classify 137 cases into one of the following four types with constant pathoanatomic features: type 1: extraincisural fragment with an intact fibular notch, type 2: posterolateral fragment extending into the fibular notch, type 3: posteromedial two-part fragment involving the medial malleolus, type 4: large posterolateral triangular fragment. In the 4 cases it was not possible to classify the type of the posterior tibial fragment. These were collectively termed type 5 (irregular, osteoporotic fragments). It is impossible to assess the shape and size of the posterior malleolar fragment, involvement of the fibular notch, or the medial malleolus, on the basis of plain radiographs. The system that we propose for classification of fractures of the posterior malleolus is based on CT examination and takes into account the size, shape and location of the fragment, stability of the tibio-talar joint and the integrity of the fibular notch. It may be a useful indication for surgery and defining the most useful approach to these injuries.
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: firstname.lastname@example.org.
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.
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.
Gamulin, Axel; Lübbeke, Anne; Belinga, Patrick; Hoffmeyer, Pierre; Perneger, Thomas V; Zingg, Matthieu; Cunningham, Gregory
The aim of the study was to evaluate the relation between demographic, injury-related, clinical and radiological factors of patients with tibial plateau fractures and the development of acute compartment syndrome. All consecutive adult patients with intra-articular tibial plateau fractures admitted in our urban academic medical centre between January 2005 and December 2009 were included in this retrospective cohort study. The main outcome measurement was the development of acute compartment syndrome. The charts of 265 patients (mean age 48.6 years) sustaining 269 intra-articular tibial plateau fractures were retrospectively reviewed. Acute compartment syndrome occurred in 28 fractures (10.4%). Four patients presented bilateral tibial plateau fractures; of them, 2 had unilateral, but none had bilateral acute compartment syndrome. Non-contiguous tibia fracture or knee dislocation and higher AO/OTA classification (type 41-C) were statistically significantly associated with the development of acute compartment syndrome in multivariable regression analysis, while younger age (<45 years), male sex, higher Schatzker grade (IV-V-VI), higher tibial widening ratio (≥1.05) and higher femoral displacement ratio (≥0.08) were significantly associated in the analysis adjusted for age and sex. Two parameters related to the occurrence of ACS in tibial plateau fractures were highlighted in this study: the presence of a non-contiguous tibia fracture or knee dislocation, and higher AO/OTA classification. They may be especially useful when clinical findings are difficult to assess (doubtful clinical signs, obtunded, sedated or intubated patients), and should rise the suspicion level of the treating surgeon. In these cases, regular clinical examinations and/or intra-compartmental pressure measurements should be performed before and after surgery, even if acute compartment syndrome seemed unlikely during initial assessment. However, larger studies are mandatory to confirm and
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.
Mellema, Jos J; Doornberg, Job N; Molenaars, Rik J; Ring, David; Kloen, Peter
Tibial plateau fracture classification systems have limited interobserver reliability and new systems emerge. The purpose of this study was to compare the reliability of the Luo classification and the Schatzker classification for two-dimensional computed tomography (2DCT) and to study the effect of adding three-dimensional computed tomography (3DCT). Eighty-one observers, orthopedic surgeons and residents, were randomized to either 2DCT or 2D- and 3DCT evaluation of a spectrum of 15 complex tibial plateau fractures using web-based platforms in order to classify according to the Schatzker and according to Luo's Three Column classification. Reliability was calculated with the use of Siegel and Castellan's multirater kappa measure. Kappa values were interpreted according to the categorical rating by Landis and Koch. Overall interobserver reliability of the Schatzker classification was significantly better compared to the Luo classification (kSchatzker=0.32 and kLuo=0.28, P=0.021), however, 'fair' for both fracture classification systems. For the Schatzker classification observers agreed significantly better on 2DCT compared to 2D- and 3DCT (k2DCT=0.37 and k2D+3DCT=0.29, P<0.001). The addition of 3DCT did not improve the overall interobserver reliability for the Luo classification as well, as kappa values were not significantly different on 2DCT and 2D- and 3DCT (k2DCT=0.31 and k2D+3DCT=0.25, P=0.096). The agreement between observers was significantly better for the Schatzker classification compared to Luo's Three Column classification, however agreement was fair for both classification systems. Furthermore, the addition of 3DCT reconstructions did not improve the reliability of CT-based evaluation of tibial plateau fractures. Considering that new classification systems and 3DCT do not seem to improve agreement between surgeons, other efforts are needed that lead to more reliable diagnosis of complex tibial plateau fractures. Copyright © 2015 Elsevier Ltd. All rights
Zelle, Boris A
Intramedullary nail fixation remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point remains a crucial step in the surgical procedure. Tibial nailing using an infrapatellar starting point with the knee flexed over a radiolucent triangle has been established as a widely-used standard technique. Tibial nail insertion with the knee in the semi-extended position was introduced with the goal to counteract post-operative procurvatum deformities that frequently have been reported as a common problem in proximal third tibial shaft fractures. Early reports on tibial nailing in the semi-extended position used a knee arthrotomy in order to establish the proximal tibial starting point. Recent technological advances have provided the surgical community with instrumentation systems that allow for tibial nailing in the semi-extended position using a suprapatellar portal with nail insertion through the patellofemoral joint. Preliminary clinical studies have suggested favorable outcomes that can be achieved with this technique. This article provides a description of the surgical technique and a review of the currently available evidence.
Background Currently, antegrade intramedullary nailing and minimally invasive plate osteosynthesis (MIPO) represent the main surgical alternatives in distal tibial fractures. However, neither choice is optimal for all bony and soft tissue injuries. The Retrograde Tibial Nail (RTN) is a small-caliber prototype implant, which is introduced through a 2-cm-long incision at the tip of the medial malleolus with stab incisions sufficient for interlocking. During this project, we investigated the feasibility of retrograde tibial nailing in a cadaver model and conducted biomechanical testing. Methods Anatomical implantations of the RTN were carried out in AO/OTA 43 A1-3 fracture types in three cadaveric lower limbs. Biomechanical testing was conducted in an AO/OTA 43 A3 fracture model for extra-axial compression, torsion, and destructive extra-axial compression. Sixteen composite tibiae were used to compare the RTN against an angle-stable plate osteosynthesis (Medial Distal Tibial Plate, Synthes®). Statistical analysis was performed by Student's t test. Results Retrograde intramedullary nailing is feasible in simple fracture types by closed manual reduction and percutaneous reduction forceps, while in highly comminuted fractures, the use of a large distractor can aid the reduction. Biomechanical testing shows a statistically superior stability (p < 0.001) of the RTN during non-destructive axial loading and torsion. Destructive extra-axial compression testing resulted in failure of all plate constructs, while all RTN specimens survived the maximal load of 1,200 N. Conclusions The prototype retrograde tibial nail meets the requirements of maximum soft tissue protection by a minimally invasive surgical approach with the ability of secure fracture fixation by multiple locking options. Retrograde tibial nailing with the RTN is a promising concept in the treatment of distal tibia fractures. PMID:24886667
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. PMID:26274757
Goyal, Saumitra; Naik, Monappa A; Tripathy, Sujit Kumar; Rao, Sharath K
AIM To measure single baseline deep posterior compartment pressure in tibial fracture complicated by acute compartment syndrome (ACS) and to correlate it with functional outcome. METHODS Thirty-two tibial fractures with ACS were evaluated clinically and the deep posterior compartment pressure was measured. Urgent fasciotomy was needed in 30 patients. Definite surgical fixation was performed either primarily or once fasciotomy wound was healthy. The patients were followed up at 3 mo, 6 mo and one year. At one year, the functional outcome [lower extremity functional scale (LEFS)] and complications were assessed. RESULTS Three limbs were amputated. In remaining 29 patients, the average times for clinical and radiological union were 25.2 ± 10.9 wk (10 to 54 wk) and 23.8 ± 9.2 wk (12 to 52 wk) respectively. Nine patients had delayed union and 2 had nonunion who needed bone grafting to augment healing. Most common complaint at follow up was ankle stiffness (76%) that caused difficulty in walking, running and squatting. Of 21 patients who had paralysis at diagnosis, 13 (62%) did not recover and additional five patients developed paralysis at follow-up. On LEFS evaluation, there were 14 patients (48.3%) with severe disability, 10 patients (34.5%) with moderate disability and 5 patients (17.2%) with minimal disability. The mean pressures in patients with minimal disability, moderate disability and severe disability were 37.8, 48.4 and 58.79 mmHg respectively (P < 0.001). CONCLUSION ACS in tibial fractures causes severe functional disability in majority of patients. These patients are prone for delayed union and nonunion; however, long term disability is mainly because of severe soft tissue contracture. Intra-compartmental pressure (ICP) correlates with functional disability; patients with relatively high ICP are prone for poor functional outcome. PMID:28567342
Goyal, Saumitra; Naik, Monappa A; Tripathy, Sujit Kumar; Rao, Sharath K
To measure single baseline deep posterior compartment pressure in tibial fracture complicated by acute compartment syndrome (ACS) and to correlate it with functional outcome. Thirty-two tibial fractures with ACS were evaluated clinically and the deep posterior compartment pressure was measured. Urgent fasciotomy was needed in 30 patients. Definite surgical fixation was performed either primarily or once fasciotomy wound was healthy. The patients were followed up at 3 mo, 6 mo and one year. At one year, the functional outcome [lower extremity functional scale (LEFS)] and complications were assessed. Three limbs were amputated. In remaining 29 patients, the average times for clinical and radiological union were 25.2 ± 10.9 wk (10 to 54 wk) and 23.8 ± 9.2 wk (12 to 52 wk) respectively. Nine patients had delayed union and 2 had nonunion who needed bone grafting to augment healing. Most common complaint at follow up was ankle stiffness (76%) that caused difficulty in walking, running and squatting. Of 21 patients who had paralysis at diagnosis, 13 (62%) did not recover and additional five patients developed paralysis at follow-up. On LEFS evaluation, there were 14 patients (48.3%) with severe disability, 10 patients (34.5%) with moderate disability and 5 patients (17.2%) with minimal disability. The mean pressures in patients with minimal disability, moderate disability and severe disability were 37.8, 48.4 and 58.79 mmHg respectively (P < 0.001). ACS in tibial fractures causes severe functional disability in majority of patients. These patients are prone for delayed union and nonunion; however, long term disability is mainly because of severe soft tissue contracture. Intra-compartmental pressure (ICP) correlates with functional disability; patients with relatively high ICP are prone for poor functional outcome.
Al-Sayyad, Mohammed J
The Taylor Spatial Frame (TSF) is a modern multiplanar external fixator that combines ease of application plus computer accuracy in the reduction of fractures. A retrospective review of our experience in using this device for treating unstable tibia fractures in pediatric and adolescent patients was carried out to determine the effectiveness and complications of TSF in the treatment of these fractures. Ten tibia fractures were included. All patients were boys with an average age of 12 years (range 8-15 years). Mean duration of follow-up was 3.1 years. These fractures included 5 open fractures. All fractures healed over a mean of 18 weeks. All patients were doing well and involved in sports when last seen. Postoperative complications included pin tract infection in 5 patients. TSF is an effective definitive method of tibia fracture care with the advantage of early mobilization and ability to postoperatively manipulate fracture into excellent alignment.
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.
Rozell, Joshua C; Connolly, Keith P; Mehta, Samir
The optimal treatment of open fractures continues to be an area of debate in the orthopedic literature. Recent research has challenged the dictum that open fractures should be debrided within 6 hours of injury. However, the expedient administration of intravenous antibiotics remains of paramount importance in infection prevention. Multiple factors, including fracture severity, thoroughness of debridement, time to initial treatment, and antibiotic administration, among other variables, contribute to the incidence of infection and complicate identifying an optimal time to debridement.
Ho, Kelvin Lor Kah; Sing, Nicholas Yeoh Ching; Wong, Khai Phang; Huat, Andy Wee Teck
To measure the intracompartmental pressures surrounding tibial fractures not exhibiting any clinical evidence of compartment syndrome. Our hypothesis was that pressures often exceed the recommended threshold of fasciotomy despite the absence of compartment syndrome, and hence diagnosis based on pressure measurements alone is unreliable. Thirteen consecutive patients with closed tibial shaft fractures without clinical suspicion of compartment syndrome, and who were planned for intramedullary nailing, were prospectively enrolled. Compartment pressures ( P) in all four compartments of the affected leg were measured at the start of surgery and immediately after tibial reaming, and differential pressures (delta P) were calculated based on the diastolic blood pressure prior to induction of anaesthesia. No patients required reoperation in the post-operative period, as a result of an undiagnosed compartment syndrome. Using commonly quoted threshold pressure criteria, 62% (using P > 30 mmHg) and 23% of patients (using delta P < 30 mmHg) have been incorrectly diagnosed with compartment syndrome. We conclude that raised compartment pressures are frequently seen in patients with tibial shaft fractures; but in most cases, it does not equate to the presence of compartment syndrome. Diagnosis of compartment syndrome based on intracompartmental pressure measurements alone may result in unnecessary fasciotomies in a sizeable number of patients. Compartment syndrome remains a clinical diagnosis, and one which always needs to be considered when managing tibial fractures.
Kumar, Nishikant; Yadav, Chandrashekhar; Raj, Rishi; Yadav, Sanjay
We report a case of fracture of tibial polyethylene post fracture from base in a 56 year old lady 10 years from posterior stabilized total knee arthroplasty following trivial trauma. There have been signs of wear at the base especially anteriorly. After revision of tibial polyethylene component patient developed complete relief of symptom.
Clansey, Adam C; Hanlon, Michael; Wallace, Eric S; Lake, Mark J
The purpose of this study was to investigate the acute effects of progressive fatigue on the parameters of running mechanics previously associated with tibial stress fracture risk. Twenty-one trained male distance runners performed three sets (Pre, Mid, and Post) of six overground running trials at 4.5 m.s(-1) (± 5%). Kinematic and kinetic data were collected during each trial using a 12-camera motion capture system, force platform, and head and leg accelerometers. Between tests, each runner ran on a treadmill for 20 min at their corresponding lactate threshold (LT) speed. Perceived exertion levels (RPE) were recorded at the third and last minute of each treadmill run. RPE scores increased from 11.8 ± 1.3 to 14.4 ± 1.5 at the end of the first LT run and then further to 17.4 ± 1.6 by the end of the second LT run. Peak rearfoot eversion, peak axial head acceleration, peak free moment and vertical force loading rates were shown to increase (P < 0.05) with moderate-large effect sizes during the progression from Pre to Post tests, although vertical impact peak and peak axial tibial acceleration were not significantly affected by the high-intensity running bouts. Previously identified risk factors for impact-related injuries (such as tibial stress fracture) are modified with fatigue. Because fatigue is associated with a reduced tolerance for impact, these findings lend support to the importance of those measures to identify individuals at risk of injury from lower limb impact loading during running.
Zhang, Xing-zhou; Yu, Wei-zhong; Li, Yun-feng; Liu, Yan-hui
To summarize application of rafting K-wires technique for tibial plateau fractures. From January 2013 to January 2015,45 patients with tibial plateau fractures were treated by locking plate with rafting K-wires, including 33 males and 12 females with an average of 44.2 years old ranging from 22 to 56 years old. According to Schatzker classification, 6 cases were type II, 8 were type Ill, 4 were type IV, 4 were type V, and 5 were type VI. Allogeneic bone graft were performed for bone defects. All patients were fixed with two to five K-wires. Part of weight loading were encouraged at 3 months after operation,and full weight-loading were done at 5 months after operation. Postoperative complications were observed,and Rasmussen clinical and radiological assessment were used to evaluate clinical results. All Patients were followed up from 10 to 23 months with average of 14 months. According to Rasmussen clinical and radiological assessment, clinical scores 23.58 ± 6.33, radiological scores were 14.00 ± 6.33; and excellent and good rates were 82.2% and 77.8% respectively. Four patients occurred severe osteoporosis and collapse of articular surface; 5 patients occurred traumatic arthritis. Rafting K-wires technique with anatomized armor plate could effective fix and support platform collapse and joint bone fragments, increase support surface area and reduce postoperative reduction loss rate.
Hardy, A; Casabianca, L; Grimaud, O; Meyer, A
In comminuted fractures of the intercondyloid eminence of the tibial spine, the quality of the reduction and the arthroscopic fixation, notably adjustable suture button fixation, is sometimes disappointing with reduction defects of the anterior bone block. In the Speed-Bridge technique, the two traction sutures of the adjustable button fixation are replaced with two braided sutures of different colors. After the button is placed above the eminence, reduction is obtained by tightening the loop of the button. The accessory communitive fragments are then packed in the depression around the main fragment. A second row provides bone suturing for these accessory fragments; traction sutures of the button are attached anteromedially and laterally with knotless anchors to obtain a Speed-Bridge-type inverted-V bone suture. The Speed-Bridge arthroscopic reinsertion technique of the tibial eminence effectively completes the adjustable button bone suture technique for communitive fractures to obtain better reduction and good stability. Copyright © 2016 Elsevier Masson SAS. All rights reserved.
Kuhn, Sebastian; Appelmann, Philipp; Pairon, Philip; Mehler, Dorothea; Rommens, Pol M
Displaced distal tibia fractures require stable fixation while minimizing secondary damage to the soft tissues by the surgical approach and implants. Antegrade intramedullary nailing has become an alternative to plate osteosynthesis for the treatment of distal metaphyseal fractures over the past two decades. While retrograde intramedullary nailing is a standard procedure in other long bone fractures, only few attempts have been made on retrograde nailing of tibial fractures. The main reasons are difficulties of finding an ideal entry portal and the lack of an ideal implant for retrograde insertion. The Retrograde Tibial Nail (RTN) is a prototype intramedullary implant developed by our group. The implant offers double proximal and triple distal interlocking with an end cap leading to an angle-stable screw-nail construct of the most distal interlocking screw. Its design meets the requirements of a minimally invasive surgical approach, with a stable fracture fixation by multiple locking options. The 8mm diameter curved nail, with a length of 120 mm, is introduced through an entry portal at the medial malleolus. We see possible indications for the RTN in far distal tibial shaft fractures, distal extraarticular metaphyseal tibial fractures and in distal tibia fractures with simple extension into the ankle joint when the nail is combined lag screw fixation. A biomechanical comparison of the current RTN prototype against antegrade nailing (Expert Tibial Nail, Synthes(®), ETN) was performed. Both implants were fixed with double proximal and triple distal interlocking. Seven biomechanical composite tibiae were treated with either osteosynthesis techniques. A 10mm defect osteotomy 40 mm proximal to the joint line served as an AO 43-A3 type distal tibial fracture model. The stiffness of the implant-bone constructs was measured under low and high extra-axial compression (350 and 600 N) and under torsional load (8 Nm). Results show a comparable stability during axial loading
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.
Smith, Ralph; Moghal, M; Newton, J L; Jones, N; Teh, J
Anterior mid-tibial cortex stress fractures (ATCSF) are uncommon and notoriously challenging to treat. They are termed high risk due to their predilection to prolonged recovery, nonunion and complete fracture. Early diagnosis is essential to avoid progression and reduce fracture complications. Imaging plays a key role in confirming the diagnosis. Magnetic resonance imaging (MRI) is accepted as the gold standard modality due to its high accuracy and nonionizing properties. This report describes three cases of ATCSFs in recreational athletes who had positive radiographic findings with no significant MRI changes. Two athletes had multiple striations within their tibias. Despite the radiographic findings, their severity of symptoms were low with mild or no tenderness on examination. Clinicians should be mindful that the ATCSFs may not present with typical acute stress fracture symptoms. We recommend that plain radiographs should be used as the first line investigation when suspecting ATCSFs. Clinicians should be aware that despite MRI being considered the gold standard imaging modality, we report three cases where the MRI was unremarkable, whilst radiographs and computed tomography confirmed the diagnosis. We urge clinicians to continue to use radiographs as the first line imaging modality for ATCSFs and not to directly rely on MRI. Those who opt directly for MRI may be falsely reassured causing a delay in diagnosis.
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.
Background Bone repair is dependent on the presence of osteocompetent progenitors that are able to differentiate and generate new bone. Muscle is found in close association with orthopaedic injury, however its capacity to make a cellular contribution to bone repair remains ambiguous. We hypothesized that myogenic cells of the MyoD-lineage are able to contribute to bone repair. Methods We employed a MyoD-Cre+:Z/AP+ conditional reporter mouse in which all cells of the MyoD-lineage are permanently labeled with a human alkaline phosphatase (hAP) reporter. We tracked the contribution of MyoD-lineage cells in mouse models of tibial bone healing. Results In the absence of musculoskeletal trauma, MyoD-expressing cells are limited to skeletal muscle and the presence of reporter-positive cells in non-muscle tissues is negligible. In a closed tibial fracture model, there was no significant contribution of hAP+ cells to the healing callus. In contrast, open tibial fractures featuring periosteal stripping and muscle fenestration had up to 50% of hAP+ cells detected in the open fracture callus. At early stages of repair, many hAP+ cells exhibited a chondrocyte morphology, with lesser numbers of osteoblast-like hAP+ cells present at the later stages. Serial sections stained for hAP and type II and type I collagen showed that MyoD-lineage cells were surrounded by cartilaginous or bony matrix, suggestive of a functional role in the repair process. To exclude the prospect that osteoprogenitors spontaneously express MyoD during bone repair, we created a metaphyseal drill hole defect in the tibia. No hAP+ staining was observed in this model suggesting that the expression of MyoD is not a normal event for endogenous osteoprogenitors. Conclusions These data document for the first time that muscle cells can play a significant secondary role in bone repair and this knowledge may lead to important translational applications in orthopaedic surgery. Please see related article: http
Kampa, John; Dunlay, Ryan; Sikka, Robby; Swiontkowski, Marc
Tibial plateau fractures may result in significant limitations postoperatively. Studies have described outcomes of arthroscopic-assisted percutaneous fixation (AAPF) of these injuries but have rarely reported postoperative activity levels. Between 2009 and 2013, patients who sustained a lateral split, split depression, or pure depression type tibial plateau fracture (Schatzker types I-III fractures) and underwent outpatient AAPF were eligible for the study. Outcomes were assessed using Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm score, and Marx activity score. Twenty-five consecutive patients were eligible for the study, and 22 (88%) were included in the final analysis, with average follow-up of 2.5 years (range, 1-5.2 years). Thirteen women and 9 men with an average age of 48.3 years (range, 23-65 years) comprised the study population. Average number of screws used for fixation was 2 (range, 1-4). The average depression was 8 mm preoperatively and 0.9 mm (range, 0-3 mm) postoperatively. Four patients (18%) had complications: 2 with hardware removal and 2 with postoperative deep venous thrombosis. Average postoperative Marx activity score was 5.7. Average postoperative KOOS Symptoms, Sports, and Quality of Life scores were 88 (range, 68-100), 85 (range, 45-100), and 77 (range, 50-100), respectively. Average IKDC and Lysholm scores were 81 (range, 55-97) and 87 (range, 54-100), respectively. The AAPF surgical technique, which was performed in an outpatient setting, facilitated excellent postoperative range of motion, outcomes, and activity scores with minimal complications. [Orthopedics. 2016; 39(3):e486-e491.].
PIPINO, GENNARO; INDELLI, PIER FRANCESCO; TIGANI, DOMENICO; MAFFEI, GIUSEPPE; VACCARISI, DAVIDE
Purpose medial opening-wedge osteotomy is a widely performed procedure used to treat moderate isolated medial knee osteoarthritis. Historically, the literature has contained reports showing satisfactory mid-term results when accurate patient selection and precise surgical techniques were applied. This study was conducted to investigate the clinical and radiographic seven- to twelve-year results of opening-wedge high tibial osteotomy in a consecutive series of patients affected by varus knee malalignment with isolated medial compartment degenerative joint disease. Methods we reviewed a case series of 147 medial opening-wedge high tibial osteotomies at an average follow-up of 9.5 years. Endpoints for evaluation included the reporting of adverse effects, radiographic evidence of bone union, radiographic changes in the correction angle during union, and clinical and functional final outcomes. Results good or excellent results were obtained in 94% of the cases: the patients reported no major complications related to the opening-wedge high tibial osteotomy surgical technique, bone graft resorption, implant choice or postoperative rehabilitation protocol. At final follow-up, the average hip-knee angle was 4° of valgus without major loss of correction during the healing process. A statistically significant change in the patellar height was detected postoperatively, with a trend towards patella infera. Conclusions medial opening-wedge high tibial osteotomy is still a reliable method for correcting varus deformity while producing stable fixation, thus allowing satisfactory stability, adequate bone healing and satisfactory mid- to long-term results. Level of evidence Level IV, therapeutic cases series. PMID:27386441
Cisneros, Luis Natera; Gómez, Mireia; Alvarez, Carlos; Millán, Angélica; De Caso, Julio; Soria, Laura
Background: Tibial platfond fractures are usually associated with massive swelling of the foot and ankle, as well as with open wounds. This swelling may cause significant decrease of the blood flow, so the state of the soft tissue is determinant for the surgical indication and the type of implant. This retrospective study compares the union times in cases of tibial plafond fractures managed with a hybrid external fixation as a definitive procedure versus those managed with a two stage strategy with final plate fixation. Materials and Methods: A retrospective study in a polytrauma referral hospital was performed between 2005 and 2011. Patients with a tibial plafond fracture, managed with a hybrid external fixation as a definitive procedure or managed with a two stage strategy with the final plate fixation were included in the study. Postoperative radiographs were evaluated by two senior surgeons. Fracture healing was defined as callus bridging of one cortex, seen on both lateral and anteroposterior X-ray. The clinical outcome was evaluated by means of 11 points Numerical Rating Scale for pain and The American Orthopedic Foot and Ankle Society ankle score, assessed at the last followup visit. Thirteen patients had been managed with a hybrid external fixation and 18 with a two-stage strategy with the final plate fixation. There were 14 males and 17 females with a mean age of 48 years (range 19–82 years). The mean followup was 24 months (range 24–70 months). Results: The mean time from surgery to weight bearing was 7 ± 6.36 days for the hybrid fixation group and 57.43 ± 15.46 days for the plate fixation group (P < 0.0001); and the mean time from fracture to radiological union was 133.82 ± 37.83) and 152.8 ± 72.33 days respectively (P = 0.560). Conclusion: Besides the differences between groups regarding the baseline characteristics of patients, the results of this study suggest that in cases of tibial plafond fractures, the management with a hybrid external
Veins from from cracks. As such, a stage of brittle failure and fracturing is to be set apart from a stage of opening and sealing. The process of fracture opening requires distortion of the host rocks to create space for the evolving vein. To keep a crack arrested and, at the same time, to widen or stabilize the cavity, the stress intensity factor K_I=(P-S3)(πa) must remain below the fracture toughness K_IC of the host rock, and P-S3 >0 (P and S3 denote pore fluid pressure and absolute minimum principal stress, respectively and 'a' refers to the half-length of the fracture). For purely elastic distortion of the host rocks, maximum aperture W0=K_IC (1-ν^2)/(E(π/8)^1/2))(2a)^1/2 depends on on K_IC, Poisson's ratio ν, and Young's modulus E of the host rocks. Owing to the low values for rock K_IC typically ranging between 0.1 and 1 MPa m^1/2, veins formed by purely elastic distortion of the host rocks are restricted to high aspect ratios 2a/W. In metamorphic rocks, veins with low aspect ratios are common; inelastic deformation and viscous creep in the host rocks must have contributed to final vein shapes. In the present study, I use finite element models to simulate fracture opening and cavity formation supported by viscous creep distributed in the host rock. Simulations are carried out on 2D plate models containing elliptical fractures. The walls of the fractures are coated by thin layers simulating incipient sealing; a residual cavity prevails in the centre of the model veins. Constant displacement is applied to the plate boundaries oriented normal to the cracks. I run a series of models with various viscosity contrasts between the rocks and the sealing. The results of these models indicate the following. (1) Fracture opening is most effective when the viscosity of the sealing ηs exceeds the viscosity of the host rocks ηr (2) The rate of fracture opening increases with increasing values for ηs/ηr . (3) An increase in the thickness of the sealing layer causes
Iundusi, Riccardo; Gasbarra, Elena; D'Arienzo, Michele; Piccioli, Andrea; Tarantino, Umberto
Reduction of tibial plateau fractures and maintain a level of well aligned congruent joint is key to a satisfactory clinical outcome and is important for the return to pre-trauma level of activity. Stable internal fixation support early mobility and weight bearing. The augmentation with bone graft substitute is often required to support the fixation to mantain reduction. For these reasons there has been development of novel bone graft substitutes for trauma applications and in particular synthetic materials based on calcium phosphates and/or apatite combined with calcium sulfates. Injectable bone substitutes can optimize the filling of irregular bone defects. The purpose of this study was to assess the potential of a novel injectable bone substitute CERAMENT™|BONE VOID FILLER in supporting the initial reduction and preserving alignment of the joint surface until fracture healing. From June 2010 through May 2011 adult patients presenting with acute, closed and unstable tibial plateau fractures which required both grafting and internal fixation, were included in a prospective study with percutaneous or open reduction and internal fixation (ORIF) augmented with an injectable ceramic biphasic bone substitute CERAMENT™|BONE VOID FILLER (BONESUPPORT™, Lund, Sweden) to fill residual voids. Clinical follow up was performed at 1, 3, 9 and 12 months and any subsequent year; including radiographic analysis and Rasmussen system for knee functional grading. Twenty four patients, balanced male-to-female, with a mean age of 47 years, were included and followed with an average of 44 months (range 41-52 months). Both Schatzker and Müller classifications were used and was type II or 41-B3 in 7 patients, type III or 41-B2 in 12 patients, type IV or 41-C1 in 2 patients and type VI or 41-C3 in 3 patients, respectively. The joint alignement was satisfactory and manteined within a range of 2 mm, with an average of 1.18 mm. The mean Rasmussen knee function score was 26.5, with 14
Otsuka, Makoto; Hasue, Fumio; Fujiyoshi, Takayuki; Kamiya, Koushirou; Kiuchi, Hitoshi; Ohara, Ken; Yunde, Atsushi; Toki, Yasunori; Tanaka, Tadashi; Nakamura, Junichi
Patellar tendon rupture in children is especially rare. The fact that the area of traumatic rupture has wide variations makes surgical treatment difficult. We present an 11-year-old boy with acute traumatic patellar tendon rupture at the tibial tuberosity attachment without avulsion fracture. Primary end-to-end repair and reinforcement using 1.5 mm stainless steel wires as a surgical strategy were undertaken. Early range of motion began with a functional knee brace and the reinforced stainless wire was removed 3 months after surgery. Knee function at the final follow-up was satisfactory. We suggest that this strategy may provide a useful option for surgical treatment. PMID:28856026
Cerqueira, Italo Scanavini; Petersen, Pedro Araujo; Júnior, Rames Mattar; Silva, Jorge dos Santos; Reis, Paulo; Gaiarsa, Guilherme Pelosini; Morandi, Massimo
Objective: Intramedullary nails are the gold standard for treating tibial shaft fractures. Knee pain is a frequent complication after the procedure. Alternative routes such as the suprapatellar approach for nail insertion are seen as an option for avoiding late postoperative knee pain. The question is whether this approach might give rise to any injury to intra-articular structures of the knee. Methods: This study analyzed the suprapatellar approach and the risk to adjacent structures by reproducing it in 10 knees of five cadavers. Results: This approach was seen to make it easy to locate the entry point, with lesions only occurring in the Hoffa fat. In three of our cases, there were lesions of the chondral surface, which is an obstacle that is difficult to overcome. Conclusion: There is a need to develop specific material to minimize injury to intra-articular structures when using this route. PMID:27042617
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.
Xia, Liheng; Zhou, Jian; Zhang, Yongtao; Mei, Gang; Jin, Dan
Controversy exists regarding the clinical outcomes of reamed vs unreamed intramedullary nailing in the treatment of closed tibial fractures. This study assessed the effects of reamed vs unreamed intramedullary nailing for closed tibial fractures. The authors searched PubMed, EMBASE, BIOSIS, and the Cochrane Controlled Trials Register for randomized and quasi-randomized controlled clinical trials from January 1980 to June 2012 comparing reamed with unreamed intramedullary nailing for closed tibial fracture in adults. Primary outcomes were nonunion, delayed union, malunion, secondary procedure, failure of implants, compartment syndrome, infection, and knee pain. Eight randomized and 1 quasi-randomized clinical trials (1229 fractures) were included. No statistically significant differences were found between reamed and unreamed nailing groups in delayed union (P=.20), malunion (P=.28), infection (P=.36), compartment syndrome (P=.36), and knee pain (P=.93). The unreamed group had a higher rate of fracture nonunion than the reamed group (P=.02). The subgroup analysis of implant failures (broken screws vs broken nails) indicated that reamed nailing significantly reduced the risk of screw breakage (P<.001); however, there was no significant difference between reamed and unreamed intramedullary nailing in nail breakage (P=.94). The subgroup analysis of a secondary procedure showed that the reamed intramedullary nailing resulted in significantly lower risks of implant exchange (P=.01) and dynamization (P=.04); however, there was no significant difference in bone grafting rate (P=.73). Evidence comparing reamed with unreamed intramedullary nailing for closed tibial fractures indicates that reamed intramedullary nailing may lead to significantly lower risks of nonunion, screw failure, implant exchange, and dynamization without increasing operative complications.
Xie, Zong-Ping; Zhang, Chang-Qing; Yi, Cheng-Qing; Qiu, Jian-Jun; Wang, Jian-Qiang; Zhou, Juan
There are many in vitro experiments showing that particulate bioactive glasses have a broad and certain antibacterial effect, but there is no report about this antibacterial effect in vivo so far. The aim of this study is to examine the efficacy of particulate Bioglass in reducing the rate of infection with Staphylococcus aureus after the fixation of open tibial fractures in rabbits. The test in vivo was carried out with male rabbits split into two groups infected with Staphylococcus aureus at the right tibial fracture sites fixed with plate and screw, either with or without bioactive glass respectively. Culture results show that six of ten rabbits from the control group had a positive culture for the strain of Staphylococcus aureus ATCC25923, compared with six of the nine rabbits from the Bioglass group. The median radiographic score is 4.5 points for the rabbits from the control group and 4 points for the rabbits from the Bioglass group. The median histopathological score was 2.5 points for the rabbits in the control group and 3 points for the rabbits in the Bioglass group. In conclusion, this study showed no significant difference between the rates of infection of two groups. Particulate Bioglass did not reduce the rate of infection with Staphylococcus aureus after the fixation of open tibial fractures in rabbits.
El-Azab, Hosam; Glabgly, Parpakorn; Paul, Jochen; Imhoff, Andreas B; Hinterwimmer, Stefan
Valgus high tibial osteotomy (HTO) may be associated with changes in the patellar height and posterior tibial slope. Patellar height increases and posterior tibial slope decreases after closed-wedge HTO, whereas patellar height decreases and tibial slope increases after open-wedge osteotomy. Cohort study; Level of evidence, 3. Lateral radiographs of 100 knees were assessed for patellar height (PH) (Insall-Salvati index [ISI], Caton-De Champ index [CDI], and Blackburne-Peel index [BPI]) as well as posterior tibial slope. Measurements were done before HTO (50 closed wedge [CW], 50 open wedge [OW]), direct postoperatively, and before removal of the hardware. In the CW group, all 3 PH indices were increased direct postoperatively and at removal of the hardware, with changes in CDI and BPI being significant (P<.05). The effect size (ES) for the direct postoperative PH increase was medium (ES = 0.48) according to CDI. In the OW group, all 3 indices showed a significant (P <.05) PH decrease direct postoperatively and at hardware removal. The ES for the direct postoperative PH decrease was large according to CDI (ES = 0.92) and BPI (ES = 0.80). There were no significant changes between the 2 follow-up measurements (P > .05) with a small ES each. Posterior tibial slope showed a significant (P <.05) decrease of 3.1 degrees +/- 3.4 degrees after CW HTO and a significant (P <.05) increase of 2.1 degrees +/- 3.6 degrees after OW HTO direct postoperatively. These changes did not change at the second follow-up. In CW HTO, the correlations between frontal plane correction and PH changes were moderate (CDI: r = .57; BPI: r = .64). In OW HTO, these correlations were weak (CDI: r = .44; BPI: r = .46). According to ISI, there was no correlation (CW: r = .11; OW: r = .16). There was no correlation between PH changes and slope changes (CDI) and no correlation between frontal plane HTO correction and slope changes in both CW and OW HTO. The results confirm our hypothesis for PH and
Lavallé, F; Pascal-Mousselard, H; Rouvillain, J L; Ribeyre, D; Delattre, O; Catonné, Y
The aim of this radiological study was to evaluate the use of a biphasic ceramic wedge combined with plate fixation with locked adjustable screws for open wedge tibial osteotomy. Twenty-six consecutive patients (27 knees) underwent surgery between December 1999 and March 2002 to establish a normal lower-limb axis. The series included 6 women and 20 men, mean age 50 years (16 right knees and 11 left knees). Partial weight-bearing with crutches was allowed on day 1. A standard radiological assessment was performed on day 1, 90, and 360 (plain AP and lateral stance films of the knee). A pangonogram was performed before surgery and at day 360. Presence of a lateral metaphyseal space, development of peripheral cortical bridges, and osteointegration of the bone substitute-bone interface were evaluated used to assess bone healing. The medial tibial angle between the line tangent to the tibial plateau and the anatomic axis of the tibia (beta) was evaluated to assess preservation of postoperative correction. The HKA angle was determined. Three patients were lost to follow-up and 23 patients (24 knees) were retained for analysis. At last follow-up, presence of peripheral cortical bridges and complete filling of the lateral metaphyseal space demonstrated bone healing in all patients. Good quality osteointegration was achieved since 21 knees did not present an interface between the bone substitute and native bone (homogeneous transition zone). The beta angle was unchanged for 23 knees. A normal axis was observed in patients (16 knees) postoperatively. Use of a biphasic ceramic wedge in combination with plate fixation with locked adjustable screws is a reliable option for open wedge tibial osteotomy. The bone substitute fills the gap well. Tolerance and integration are optimal. Bone healing is achieved. Plate fixation with protected weight bearing appears to be a solid assembly, maintaining these corrections.
Myers, S. C.; Pitarka, A.; Matzel, E.; Aguiar, A. C.
Injection of high-pressure fluid into the subsurface is proven to stimulate geothermal, oil, and gas production by opening cracks that increase permeability. The effectiveness of increasing permeability by high-pressure injection has been revolutionized by the introduction of "proppants" into the injected fluid to keep cracks open after the pressure of the stimulation activity ends. The network of fractures produced during stimulation is most commonly inferred by the location of micro-earthquakes. However, existing (closed) fractures may open aseismically, so the whole fracture network may not be imaged by micro-seismic locations alone. Further, whether all new fractures remain open and for how long remains unclear. Open cracks, even fluid-filled cracks, scatter seismic waves because traction forces are not transmitted across the gap. Numerical simulation confirms that an open crack with dimensions on the order of 10 meters can scatter enough seismic energy to change the coda of seismic signals. Our simulations show that changes in seismic coda due to newly opened fractures are only a few percent of peak seismogram amplitudes, making signals from open cracks difficult to identify. We are developing advanced signal processing methods to identify candidate signals that originate from open cracks. These methods are based on differencing seismograms that are recorded before and after high-pressure fluid injection events to identify changes in the coda. The origins of candidate signals are located using time-reversal techniques to determine if the signals are indeed associated with a coherent structure. The source of scattered energy is compared to micro-seismic event locations to determine whether cracks opened seismically or aseismically. This work performed under the auspices of the U.S. Department of Energy by Lawrence Livermore National Laboratory under Contract DE-AC52-07NA27344. LLNL-ABS-675612.
Goff, Thomas; Kanakaris, Nikolaos K; Giannoudis, Peter V
The current available evidence for the use of bone graft substitutes in the management of subchondral bone defects associated with tibial plateau fractures as to their efficiency and safety has been collected following a literature review of the Ovid MEDLINE (1948-Present) and EMBASE (1980-Present). Nineteen studies were analysed reporting on 672 patients (674 fractures), with a mean age of 50.35 years (range 15-89), and a gender ratio of 3/2 males/females. The graft substitutes evaluated in the included studies were calcium phosphate cement, hydroxyapatite granules, calcium sulphate, bioactive glass, tricalcium phosphate, demineralised bone matrix, allografts, and xenograft. Fracture healing was uneventful in over 90% of the cases over a variant period of time. Besides two studies reporting on injectable calcium phosphate cement excellent incorporation was reported within 6 to 36 months post-surgery. No correlation was made by any of the authors between poor incorporation/resorption and adverse functional or radiological outcome. Secondary collapse of the knee joint surface ≥ 2 mm was reported in 8.6% in the biological substitutes (allograft, DBM, and xenograft), 5.4% in the hydroxyapatite, 3.7% in the calcium phosphate cement, and 11.1% in the calcium sulphate cases. The recorded incidence of primary surgical site and donor site infection (3.6%) was not statistically significant different, however donor site-related pain was reported up to 12 months following autologous iliac bone graft (AIBG) harvest. Shorter total operative time, greater tolerance of early weight bearing, improved early functional outcomes within the first year post-surgery was also recorded in the studies reporting on the use of injectable calcium phosphate cement (Norian SRS). Despite a lack of good quality randomised control trials, there is arguably sufficient evidence supporting the use of bone graft substitutes at the clinical setting of depressed plateau fractures.
Barros, Marcos Alexandre; Cervone, Gabriel Lopes de Faria; Costa, André Luis Serigatti
Objective To objectively and subjectively evaluate the functional result from before to after surgery among patients with a diagnosis of an isolated avulsion fracture of the posterior cruciate ligament who were treated surgically. Method Five patients were evaluated by means of reviewing the medical files, applying the Lysholm questionnaire, physical examination and radiological examination. For the statistical analysis, a significance level of 0.10 and 95% confidence interval were used. Results According to the Lysholm criteria, all the patients were classified as poor (<64 points) before the operation and evolved to a mean of 96 points six months after the operation. We observed that 100% of the posterior drawer cases became negative, taking values less than 5 mm to be negative. Conclusion Surgical methods with stable fixation for treating avulsion fractures at the tibial insertion of the posterior cruciate ligament produce acceptable functional results from the surgical and radiological points of view, with a significance level of 0.042. PMID:27218073
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
Mighell, Mark A; Stephens, Brent; Stone, Geoffrey P; Cottrell, Benjamin J
Distal humerus fractures are challenging injuries for the upper extremity surgeon. However, recent techniques in open reduction internal fixation have been powerful tools in getting positive outcomes. To get such results, the surgeon must be aware of how to properly use these techniques in their respective practices. The method of fixation depends on the fracture, taking the degree of comminution and the restoration of the columns and articular surface into account. This article helps surgeons understand the concepts behind open reduction internal fixation of the distal humerus and makes them aware of pitfalls that may lead to negative results. Copyright © 2015 Elsevier Inc. All rights reserved.
Milner, Clare E; Davis, Irene S; Hamill, Joseph
Stress fractures are a common and serious overuse injury in runners, particularly female runners. They may be related to loading characteristics of the lower extremity during running stance. Some tibial stress fractures (TSFs) are spiral in nature and, therefore, may be related to torque. Free moment (FM) is a measure of torque about a vertical axis at the interface with the shoe and ground. Increases in FM variables may be related to a history of TSF in runners. The purpose of this cross-sectional study was to investigate differences in FM between female distance runners with and without a history of TSF and, additionally, to investigate the relationship between absolute FM and the occurrence of TSF. A group of 25 currently uninjured female distance runners with a history of TSF (28+/-10 years, 46+/-15 km week(-1)) and an age- and mileage-matched control group of 25 healthy runners with no previous lower extremity fractures (26+/-9 years, 46+/-19 km week(-1)) participated in this study. Ground reaction forces and foot placement on the force platform were recorded during running at 3.7 ms(-1) (+/-5%). Peak adduction, braking peak and absolute peak FM and impulse were compared between groups using one-tailed t-tests. The predictive value of absolute peak FM was investigated via a binary logistic regression. All variables, except impulse, were significantly greater in runners with a history of TSF. Absolute peak FM had a significant predictive relationship with history of TSF. There is a significant relationship between higher values for FM variables and a history of TSF.
da Cunha Luciano, Roberto; de Moura Souza, Getúlio Danival; Rispoli, Juliano; Cardoso, Rodrigo Galvão; do Nascimento, Marcus Vinícius Martins; Domingos, Gustavo Gontijo; Luciano, Dyego Vilela
Objective: Radiographic assessment of lower limb alignment, in the frontal and sagittal planes, after high tibial osteotomy. To stabilize the osteotomy, a tricortical iliac graft was used, along with a positioning screw. Methods: Prospective study on 46 patients with ages ranging from 17 to 61 years. Among them, 42 patients presented genu varum secondary to knee osteoarthritis and four from other causes. Teleradiography was performed for surgical planning, using the Frank Noyes method, as modified by Fugizawa. A conventional surgical access of 3 cm was made to harvest a tricortical iliac graft. Osteotomy was performed under radioscopic control, by means of an anteromedial incision of 3 cm with release of the superficial portion of the medial collateral ligament. The graft was placed in the posterior portion of the osteotomy, to maintain an unaltered tibial slope. The screw crossed the osteotomy orthogonally to protect the lateral cortex. Pre and postoperative radiographic criteria were established to assess the results. Results: There was consolidation in 100% of the cases and maintenance of the mechanical axis, obtained intraoperatively, in 94% of the cases. The posterior slope of the tibial plateau in the sagittal plane ranged from 7° to 12°. Joint mobility was restored in all the patients. Eleven patients presented temporary pain at the site of graft harvesting, but none had paresthesia. The incidence of complications was 8% (infection, loss of correction and joint fracture). Conclusion: The technique was shown to be reproducible, simple, biological, accurate and low-cost, and it may be an alternative to the existing techniques. PMID:27026961
antibiotics than oral ingestion or the sub-cutaneous route that was used in this model to avoid the morbidity from repeated venipuncture in a small mammal. With...open tibial frac- tures in children and similarly found that surgery after six hours correlated with increased infection, but their results did not...J Bone Joint Surg [Am] 1976;58-A:453–458. 18. Kreder HJ, Armstrong P. A review of open tibia fractures in children . J Pediatr Orthop 1995;15:482–488
Background Tibial plateau fracture (TPF) includes different fracture patterns with varied degrees of articular depression and displacement. Many kinds of fixators, including newly designed plate with locking screws, were applied to treat these complicated fractures. We intended to follow up the surgical outcomes of (1) unilateral locking plate, (2) classic dual plates, or (3) hybrid dual plates for TPF. Materials and methods We retrospectively reviewed 76 patients with TPF, Schatzker types V and VI, who we operated from June 2006 to May 2009 in our institute. Excluding patients who expired due to other medical conditions and without complete follow-up, 45 patients were sorted out in this series. The scheme of surgical intervention was designed by visiting staff, and 15 patients, as group I, were treated with unilateral locking plate. The other 19 patients, as group II, were treated with classic dual plates. The residual 11 patients, as group III, were treated with hybrid dual plates (one lateral approach locking compression plate (LCP) + medial anti-gliding plate). All patients were under periodic F/U at about 6 weeks interval for at least 18 months postoperatively. Results In group I, 13 cases achieved solid bony union without obvious traumatic OA change, limitation of ROM, or malalignment. In groups II and III, 15 and 10 patients reached the same goal, respectively. By analysis of the recorded parameters with statistical software (SPSS 12.0), there were five parameters with significant difference, including Schatzker classification, operation time, staged treatment or not, hospitalization period, and hardware impingement. Conclusions There was no significant statistical difference of union rate between these three groups in our series. Based on our clinical follow-up, several key points were emphasized: (1) Soft tissue problems should be kept in mind, and usage of locking plate can reduce the discomfort of hardware impingement effectively. (2) The single
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
Jung, Kwang Am; Lee, Su Chan; Hwang, Seung Hyun; Song, Moon Bok
High tibial osteotomy (HTO) is an accepted surgical technique for the treatment of medial compartmental arthrosis of the knee in younger patients. Compared to total knee arthroplasty, HTO may be a good choice in patients who wish to continue with heavy labor and/or impact sports. Based on the rehabilitation protocol after HTO, impact sports, such as running, jumping rope, and full sports activities, are generally permitted 6 months postoperatively. Jumping rope is an excellent form of aerobic exercise, and when done properly, jumping rope can lead to a dramatic improvement in rehabilitation and full sports activities. However, an adequate evaluation should be performed prior to initiating impact sports. We present the case of a ruptured anterior cruciate ligament that occurred in a patient with an unintended increase in the tibial slope after an opening wedge HTO who was jumping rope.
Jasqui-Remba, Salomon; Rodriguez-Corlay, Ruy Ernesto
In this case report, we present an acute rupture in the muscular tendinous junction of a posterior tibialis muscle in a bimalleolar closed ankle fracture after a high-energy trauma in a 30-year-old patient with no significant medical history. Fracture was confirmed by simple X-rays, and was treated with an open reduction in which both of the fractures were treated with osteosynthesis material and reparation of the syndesmosis. If left untreated, this uncommon finding can result in a bad postsurgical outcome; we believe this injury is more common but under-reported in the literature. The surgeon should be aware and look specifically for this type of lesion during the procedure. Finding and treating this injury requires special postoperative care, non-weight-bearing instructions and balanced physiotherapy. 2016 BMJ Publishing Group Ltd.
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.
Triantafillou, Konstantinos; Barcak, Eric; Villarreal, Arturo; Collinge, Cory; Perez, Edward
measured on both the AP and mortise ankle radiographs using both the plafond and talus as a reference, while sagittal nail placement was measured on the lateral ankle radiographs. In the coronal plane, the mean passive distal position of the nail when referenced from the lateral cortex was 45.2% of the tibia plafond and 45.5% the width of the talus, or just lateral to the center of each. In the sagittal plane passive nail placement was 40% the sagittal width of the joint measured from the anterior cortex, or just anterior to the center of the joint. This is the first patient series that defines optimal tibial nail placement in the treatment of distal tibia fractures. Distal placement of the nail just lateral to the center of the talus and plafond, or along mechanical axis of the tibia, results in significantly reduced rates of malalignment on the coronal plane when compared to nail placement medial to the center of the talus or plafond. Fluoroscopic judgment of distal nail trajectory was improved on the mortise view using the talus as a reference when compared to using the AP view. On the sagittal plane, anatomic passive nail placement is just anterior to the center of the plafond. However, non-anatomic nail placement just posterior to the center of the plafond had a lower incidence of malalignment compared to nails placed anterior to the center of the plafond. Further study of appropriate nail positioning on the sagittal plane is needed. Prognostic Level II.
Jung, Woon-Hwa; Takeuchi, Ryohei; Chun, Chung-Woo; Lee, Jung-Su; Ha, Jae-Hun; Kim, Ji-Hyae; Jeong, Jae-Heon
The purposes of this study were to evaluate regeneration of the articular cartilage after medial opening-wedge high tibial osteotomy for knees with medial-compartment osteoarthritis and to assess the clinical outcome and cartilage regeneration according to the postoperative limb alignment at 2 years postoperatively. The study involved 159 knees in 159 patients. For evaluation of cartilage degeneration, the International Cartilage Repair Society grading system was used for arthroscopic grading on initial arthroscopy during high tibial osteotomy. The patients underwent a second-look arthroscopic evaluation of the articular cartilage at the time of removal of the plate, an average of 2 years after the initial osteotomy. For evaluation of cartilage regeneration, the articular cartilage was classified into 2 stages as no regenerative change (grade 1) or white scattering with fibrocartilage, partial coverage with fibrocartilage, or even coverage with fibrocartilage (grade 2) on second-look arthroscopy. Maturation of the cartilage regeneration was defined as even coverage with fibrocartilage. "Immaturation" of the cartilage regeneration was defined as white scattering with fibrocartilage or partial coverage with fibrocartilage. Clinical evaluations were performed by use of Knee Society scores preoperatively and at 2 years postoperatively. We divided the knees into 3 groups according to the postoperative limb alignment. Group A comprised knees with a mechanical tibiofemoral angle of 0° or less. Group B comprised knees with a mechanical tibiofemoral angle greater than 0° and less than 6°. Group C comprised knees with a mechanical tibiofemoral angle of 6° or greater. Grade 2 regeneration was achieved in the medial femoral condyle articular cartilage in 92% of knees and in the medial tibial plateau articular cartilage in 69% of knees. Maturation of the cartilage regeneration was found in the medial femoral condyle articular cartilage in 4% of knees and in the medial
Li, Wendy; Anderson, Donald D; Goldsworthy, Jane K; Marsh, J Lawrence; Brown, Thomas D
The role of altered contact mechanics in the pathogenesis of posttraumatic osteoarthritis (PTOA) following intraarticular fracture remains poorly understood. One proposed etiology is that residual incongruities lead to altered joint contact stresses that, over time, predispose to PTOA. Prevailing joint contact stresses following surgical fracture reduction were quantified in this study using patient-specific contact finite element (FE) analysis. FE models were created for 11 ankle pairs from tibial plafond fracture patients. Both (reduced) fractured ankles and their intact contralaterals were modeled. A sequence of 13 loading instances was used to simulate the stance phase of gait. Contact stresses were summed across loadings in the simulation, weighted by resident time in the gait cycle. This chronic exposure measure, a metric of degeneration propensity, was then compared between intact and fractured ankle pairs. Intact ankles had lower peak contact stress exposures that were more uniform and centrally located. The series-average peak contact stress elevation for fractured ankles was 38% (p = 0.0015; peak elevation was 82%). Fractured ankles had less area with low contact stress exposure than intact ankles and a greater area with high exposure. Chronic contact stress overexposures (stresses exceeding a damage threshold) ranged from near zero to a high of 18 times the matched intact value. The patient-specific FE models represent substantial progress toward elucidating the relationship between altered contact stresses and the outcome of patients treated for intraarticular fractures.
Di Giorgio, Luigi; Touloupakis, Georgios; Theodorakis, Emmanouil; Sodano, Luca
The anterolateral approach to the tibia has been popularized for the management of tibial pilon fractures. For complex fracture patterns a combined anterolateral/anteromedial approach is suitable but a high rate of complication has been reported. In our retrospective study a two-choice strategy adopting a medial tibial approach was proposed for the treatment of pilon fractures with anterior or posterior fragmentation. Based on an anatomic study of tibial pilon fractures, we retrospectively analyzed the fractures with primary posterior, posterior-lateral or anterior, anterior-lateral (Tillaux-Chaput) involvement of the distal tibia. This retrospective study consisted of 18 patients with a closed tibial plafond fracture. The inclusion criteria were: (1) pre- sence of an anterior/anterolateral type fragment or a posterior (Volkmann) type fragment involving larger than 25% of the articular surface, (2) a minimum follow-up of 12 months, (3) a fibula fracture associated with a medial column fracture of the distal tibia, and (4) soft tissue conditions at the time of operation that did not compromise the choice of surgical access (Tscherne classification for closed fractures: grade 0 and grade 1). Tibial plafond fractures were classified into two groups: one presenting anterior and the other with posterior rim (Volkmann) fragments. Most patients achieved a good clinical recovery in terms of range of motion and Olerud-Molander scale scores. Only three patients presented a grade 2 osteoarthritis at the 12 month follow-up. Our two-choice strategy highlights concepts which have been previously debated and described in the literature. But a new extended protocol for surgical approach to the distal tibia, including more fracture patterns and their association should be further investigated.
Sautet, Pierre; Choufani, Elie; Petit, Philippe; Launay, Franck; Jouve, Jean-Luc; Pesenti, Sébastien
Pseudoaneurysms of the lower limb are rare and frequently iatrogenics complications. Closed traumas are likely to generate lesions of the arterial wall, which generally become symptomatic at a later stage. The diagnosis of such vascular lesion is difficult because the symptomatology and the onset can be delayed. We herein report the case of a 15-year-old patient in whom the diagnosis of pseudoaneurysm of the anterior tibial artery was made 5 months after a non-displaced closed fracture of the tibial shaft. The radiographs were evocative of a malignant bone tumor. The study of vessels by a contrast-enhanced CT-scan enabled us to diagnose the pseudoaneurysm. Before the occurrence of late onset swelling, a history of trauma must be sought, even old.
Giordano, Vincenzo; Koch, Hilton Augusto; Gasparini, Savino; Serrão de Souza, Felipe; Labronici, Pedro José; do Amaral, Ney Pecegueiro
Background: Open pelvic fractures are rare but usually associated with a high incidence of complications and increased mortality rates. The aim of this study was to retrospectively evaluate all consecutive open pelvic fractures in patients treated at a single Level-1 Trauma Center during a 10-year interval. Patients and Methods: In a 10-year interval, 30 patients with a diagnosis of open pelvic fracture were admitted at a Level-1 Trauma Center. A retrospective analysis was conducted on data obtained from the medical records, which included patient’s age, sex, mechanism of injury, classification of the pelvic lesion, Injury Severity Score (ISS), emergency interventions, surgical interventions, length of hospital and Intensive Care Unit stay, and complications, including perioperative complications and death. The Jones classification was used to characterize the energy of the pelvic trauma and the Faringer classification to define the location of the open wound. Among the survivors, the results were assessed in the last outpatient visit using the EuroQol EQ-5D and the Blake questionnaires. It was established the relationship between the mortality and morbidity and these classification systems by using the Mann-Whitney non-parametric test, with a level of significance of 5%. Results: Twelve (40%) patients died either from the pelvic lesion or related injuries. All of them had an ISS superior to 35. The Jones classification showed a direct relationship to the mortality rate in those patients (p = 0.012). In the 18 (60%) other patients evaluated, the mean follow-up was 16.3 months, ranging from 24 to 112 months. Eleven (61%) patients had a satisfactory outcome. The Jones classification showed a statistically significant relationship both to the objective and subjective outcomes (p < 5%). The Faringer classification showed a statistically significant relationship to the subjective, but not to the objective outcome. In addition, among the 18 patients evaluated at the
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.
Zhim, Fouad; Ayers, Reed A; Moore, John J; Moufarrège, Richard; Yahia, L'Hocine
In this work a new generation of bioceramic personalized implants were developed. This technique combines the processes of solid freeform fabrication (SFF) and combustion synthesis (CS) to create personalized bioceramic implants with tricalcium phosphate (TCP) and hydroxyapatite (HA). These porous bioceramics will be used to fill the tibial bone gap created by the opening wedge high tibial osteotomy (OWHTO). A freeform fabrication with three-dimensional printing (3DP) technique was used to fabricate a metallic mold with the same shape required to fill the gap in the opening wedge osteotomy. The mold was subsequently used in a CS process to fabricate the personalized ceramic implants with TCP and HA compositions. The mold geometry was designed on commercial 3D CAD software. The final personalized bioceramic implant was produced using a CS process. This technique was chosen because it exploits the exothermic reaction between P₂O₅ and CaO. Also, chemical composition and distribution of pores in the implant could be controlled. To determine the chemical composition, the microstructure, and the mechanical properties of the implant, cylindrical shapes were also fabricated using different fabrication parameters. Chemical composition was performed by X-ray diffraction. Pore size and pore interconnectivity was measured and analyzed using an electronic microscope system. Mechanical properties were determined by a mechanical testing system. The porous TCP and HA obtained have an open porous structure with an average 400 µm channel size. The mechanical behavior shows great stiffness and higher load to failure for both ceramics. Finally, this personalized ceramic implant facilitated the regeneration of new bone in the gap created by OWHTO and provides additional strength to allow accelerated rehabilitation.
Zhang, Hai-ning; Zhang, Jie; Lv, Cheng-yu; Leng, Ping; Wang, Ying-zhen; Wang, Xiang-da; Wang, Chang-yao
Objective: To introduce and characterize the modified biplanar opening high tibial osteotomy with rigid fixation to treat varus knee in young and active patients. Methods: Between June 2001 to July 2008, 18 patients with monocompartmental degeneration of the knee combined with a varus malalignment of the leg had the modified biplanar opening high tibial osteotomy and the osteotomy was fixed with the locking plates (Locking Compression Plate System). The mean varus deformity before operation was 11.5° (5°~19°) and no degenerative changes were found in other departments. Stability of the knee was normal in 15 patients, but ruptures in anterior cruciate ligaments or lateral collateral ligament were presented in the remaining 3 patients. Preoperative symptom was mainly limited in the pain of medial compartment. The preoperative and follow-up data for the range of motion and Lysholm score were determined. Subjective satisfactory examination was also applied to the patients for the operation they selected. Results: All of the patients were followed up with an average of 32.5 months (12~82 months). There was no ununion or delayed union in this group during the follow-up period. No complications like broken plate, nerve injury, or blood vessel injury occurred. The postoperative average corrected degree was 9.5° (5.5°~18°). No degenerations developed in the three departments of the knee. The Lysholm scores before and after surgery were 42.5 and 77.5, respectively (P<0.01). The overall fineness rate was 83.3%. The subjective satisfactory survey demonstrated that about 83.3% patients showed satisfactory on the operation. There was no obvious difference in the range of motion before and after operation, but significant changes were found in the Lysholm score and varus degree from preoperative to follow-up. Conclusion: Proximal opening high tibial osteotomy performed in conjunction with the special rigid locking plate yielded good results for symptomatic genu varum. This
Background The role of low-intensity pulsed ultrasound (LIPUS) in the management of fractures remains controversial. The purpose of this study was to assess the feasibility of a definitive trial to determine the effect of LIPUS on functional and clinical outcomes in tibial fractures managed operatively. Methods We conducted a multicenter, concealed, blinded randomized trial of 51 skeletally mature adults with operatively managed tibial fractures who were treated with either LIPUS or a sham device. All participating centers were located in Canada and site investigators were orthopedic surgeons specializing in trauma surgery. The goals of our pilot study were to determine recruitment rates in individual centers, investigators’ ability to adhere to study protocol and data collection procedures, our ability to achieve close to 100% follow-up rates, and the degree to which patients were compliant with treatment. Patients were followed for one year and a committee (blinded to allocation) adjudicated all outcomes. The committee adjudicators were experienced (10 or more years in practice) orthopedic surgeons with formal research training, specializing in trauma surgery. Results Our overall rate of recruitment was approximately 0.8 patients per center per month and site investigators successfully adhered to the study protocol and procedures. Our rate of follow-up at one year was 84%. Patient compliance, measured by an internal timer in the study devices, revealed that 39 (76%) of the patients were fully compliant and 12 (24%) demonstrated a greater than 50% compliance. Based on patient feedback regarding excessive questionnaire burden, we conducted an analysis using data from another tibial fracture trial that revealed the Short Musculoskeletal Function Assessment (SMFA) dysfunction index offered no important advantages over the SF-36 Physical Component Summary (PCS) score. No device-related adverse events were reported. Conclusions Our pilot study identified key issues
Ramprasath, D R; Thirunarayanan, V; David, J; Anbazhagan, S
Acute Compartment Syndrome is a limb-threatening emergency and it occurs most commonly after fractures. The aim of our study is to find out the effectiveness of serial measurement of differential pressure in closed tibial diaphyseal fractures, in diagnosing acute compartment syndrome, using Whiteside's technique. A total of 52 cases in the age group of 15 to 55 years admitted with closed fractures were studied for serial compartment pressure as well as serial differential pressure. Eight patients had persistent compartment pressure > 40mmHg, out of which only two patients had persistent differential pressure < 30mmHg and these two patients underwent fasciotomy. Thus, by measuring the compartment pressure serially and calculating differential pressure serially, acute compartment syndrome can be diagnosed or ruled out with higher precision, so that unnecessary fasciotomies can be avoided.
Bagherifard, Abolfazl; Ghandhari, Hassan; Jabalameli, Mahmoud; Rahbar, Mohammad; Hadi, Hosseinali; Moayedfar, Mehdi; Sajadi, Mohammadreza Minatour; Karimpour, Alireza
There is no consensus regarding the use of filling agent in the re-elevation of depressed tibial plateau fracture (TPF). Although autograft is considered as the gold standard approach of such reconstructions, its limitation has led to a recent attraction toward allograft substitution. In this study, we compare the complications and outcome of autograft and allograft in TPF reconstruction, in order to address the existing controversy. A total of 81 patients with acute TPF were included in this study. Allograft and autograft were applied in 58 and 23 cases, respectively. The mean age of the patients was 40.26 years, and the mean follow-up period of patients was 19.1 months. Clinical and radiological assessment of the outcome was conducted, employing the modified Rasmussen clinical criteria. A total of three infections were observed in our patients, from which two infections occurred in allograft received patients. Articular surface collapse was seen in two cases, including one allograft and one autograft receiving patient. The mean clinical score was 18.65 and 18.55 in autograft and allograft received patients, respectively (p = 0.09). The mean radiological score was 15.65 and 15.68 in autograft and allograft received patients (p = 0.3). With respect to the comparable complication rate, clinical and radiological outcome of allogenic versus autologous reconstruction of TPF, freeze-dried allograft could be recommended as an appropriate substitute of autograft in this treatment. Nevertheless, the longer follow-up period of the patients could further extend our understanding of the clinical outcome of each component.
Hoffmann, Martin F; Sietsema, Debra L; Jones, Clifford B
Different reasons for lost to follow-up are assumed. Besides "objective" reasons, "subjective" reasons and satisfaction contribute to treatment adherence. Retrospective studies usually lack the possibility of acquisition of additional outcome information. Purpose of this study was to determine outcome and factors for patients not returning for follow-up. Between 2002 and 2009, 380 patients underwent internal fixation for tibial plateau fractures. Short Musculoskeletal Function Assessment (SMFA) was collected at 6, 12, and 24 months as long as patients returned for follow-up. Pain and range of motion were measured. Records were studied for reasons of termination of follow-up. Statistical analysis was performed comparing lost to follow-up versus continued office visits regarding demographics, contributing factors, and SMFA. Two hundred fifty-nine patients were followed until treatment was completed (PRN), while 120 patients (32 %) terminated further follow-up. Patients in the 12- and 24-month follow-up groups were older (p = 0.02; p < 0.01, respectively). Pain (VAS ≥ 3) was noticed in 22 % of the patients terminating follow-up before the 6-month survey and 41 % of the patients returning for the 24-month SMFA survey (χ (2) = 0.06). Improvements were found with time in SMFA subscores but arm and hand. No differences in SMFA subscores at 6 or 12 months were found between those leaving treatment untimely and those being released from office visits. Follow-up remains important to obtain as much up-to-date information as possible. The current study does not support the assumption that patients lost to follow-up have a different SMFA outcome than patients returning until PRN. III.
YAO, Jian-fei; SHEN, Jia-zuo; LI, Da-kun; LIN, Da-sheng; Li, Lin; LI, Qiang; Qi, Peng; LIAN, Ke-jian; DING, Zhen-qi
Background Lower tibial bone fracture may easily cause bone delayed union or nonunion because of lacking of dynamic mechanical load. Objective Research Group would design a new instrument as Rap System of Stress Stimulation (RSSS) to provide dynamic mechanical load which would promote lower tibial bone union postoperatively. Methods This clinical research was conducted from January 2008 to December 2010, 92 patients(male 61/female 31, age 16-70years, mean 36.3years) who suffered lower tibial bone closed fracture were given intramedullary nail fixation and randomly averagely separated into experimental group and control group(according to the successively order when patients went for the admission procedure). Then researchers analysed the clinical healing time, full weight bearing time, VAS (Visual Analogue Scales) score and callus growth score of Lane-Sandhu in 3,6,12 months postoperatively. The delayed union and nonunion rates were compared at 6 and 12 months separately. Results All the 92 patients had been followed up (mean 14 months). Clinical bone healing time in experimental group was 88.78±8.80 days but control group was 107.91±9.03days. Full weight bearing time in experimental group was 94.07±9.81 days but control group was 113.24±13.37 days respectively (P<0.05). The delayed union rate in 6 months was 4.3% in experimental group but 10.9% in control group(P<0.05). The nonunion rate in 12 months was 6.5% in experimental group but 19.6% in control group(P<0.05). In 3, 6, 12 months postoperatively, VAS score and Lane-Sandhu score in experimental group had more significantly difference than them in control group. Conclusions RSSS can intermittently provide dynamic mechanical load and stimulate callus formation, promote lower tibial bone union, reduce bone delayed union or nonunion rate. It is an adjuvant therapy for promoting bone union after lower tibial bone fracture. PMID:22859907
Yao, Jian-fei; Shen, Jia-zuo; Li, Da-kun; Lin, Da-sheng; Li, Lin; Li, Qiang; Qi, Peng; Lian, Ke-jian; Ding, Zhen-qi
Lower tibial bone fracture may easily cause bone delayed union or nonunion because of lacking of dynamic mechanical load. Research Group would design a new instrument as Rap System of Stress Stimulation (RSSS) to provide dynamic mechanical load which would promote lower tibial bone union postoperatively. This clinical research was conducted from January 2008 to December 2010, 92 patients(male 61/female 31, age 16-70 years, mean 36.3 years) who suffered lower tibial bone closed fracture were given intramedullary nail fixation and randomly averagely separated into experimental group and control group(according to the successively order when patients went for the admission procedure). Then researchers analysed the clinical healing time, full weight bearing time, VAS (Visual Analogue Scales) score and callus growth score of Lane-Sandhu in 3,6,12 months postoperatively. The delayed union and nonunion rates were compared at 6 and 12 months separately. All the 92 patients had been followed up (mean 14 months). Clinical bone healing time in experimental group was 88.78±8.80 days but control group was 107.91±9.03 days. Full weight bearing time in experimental group was 94.07±9.81 days but control group was 113.24±13.37 days respectively (P<0.05). The delayed union rate in 6 months was 4.3% in experimental group but 10.9% in control group(P<0.05). The nonunion rate in 12 months was 6.5% in experimental group but 19.6% in control group(P<0.05). In 3, 6, 12 months postoperatively, VAS score and Lane-Sandhu score in experimental group had more significantly difference than them in control group. RSSS can intermittently provide dynamic mechanical load and stimulate callus formation, promote lower tibial bone union, reduce bone delayed union or nonunion rate. It is an adjuvant therapy for promoting bone union after lower tibial bone fracture.
Sadighi, Ali; Elmi, Asghar; Jafari, Mohamad Ali; Sadeghifard, Vahid; Goldust, Mohamad
Tibia fractures are the most common type of long bone fractures in US. This study aimed at comparing the therapeutic results of closed tibial shaft fracture with intramedullary nails inserted with and without reaming. In this randomized clinical trial study, 60 patients with a fracture of the tibia were examined. The patients were randomly divided into two groups. Thirty patients treated through inserting intramedullary nail with reaming technique (group A). The other 30 patients treated through inserting intramedullary nail without reaming technique (group B). After operation physical examination and control radiography were taken up to 6 month and results were compared. Sixty patients suffering from closed tibial diaphysis fractures were studied. Mean age of the group A and B were 40.24 +/- 12.32 and 38.42 +/- 14.28, respectively. Group A consisted of 24 (80%) males and 6 (20%) females while group B consisted of 24% females and 76% males. Considering fracture based on OTA criteria (p = 0.4) and severity of soft tissue damage based on Tscherne classification (p = 0.6), there was no statistically meaningful difference between groups A and B. The study demonstrated that degree of horizontal displacement, mean time of surgery, post-operation infection, organ shortness at the end of the follow-up period, organ deviation in patients of the group A was significantly more than that of the group B. Time required for callus formation (mean time of union), mean time of full weight bearing time and mean time of return to normal activities in group B was significantly more than that of the group A.
Thomas, Alasdair; Kimber, Cheryl; Bramwell, Donald; Jaarsma, Ruurd
Look, feel, move is a simple and widely taught sequence to be followed when undertaking a clinical examination in orthopaedics (Maher et al., 1994; McRae, 1999; Solomon et al., 2010). The splinting of an acute tibial fracture with a posterior back-slab is also common practice; with the most commonly taught design involving covering the dorsum of the foot with bandaging (Charnley, 1950; Maher et al., 1994; McRae, 1989). We investigated the effect of the visual cues provided by exposing the dorsum of the foot and marking the dorsalis pedis pulse. We used a clinical simulation in which we compared the quality of the recorded clinical examination undertaken by 30 nurses. The nurses were randomly assigned to assess a patient with either a traditional back-slab or one in which the dorsal bandaging had been cut back and the dorsalis pedis pulse marked. We found that the quality of the recorded clinical examination was significantly better in the cut-back group. Previous studies have shown that the cut-back would not alter the effectiveness of the back-slab as a splint (Zagorski et al., 1993). We conclude that all tibial back-slabs should have the bandaging on the dorsum of the foot cut back and the location of the dorsalis pedis pulse marked. This simple adaptation will improve the subsequent clinical examinations undertaken and recorded without reducing the back-slab's effectiveness as a splint. Copyright © 2015 Elsevier Ltd. All rights reserved.
Kuhn, Sebastian; Greenfield, Julia; Arand, Charlotte; Jarmolaew, Andrey; Appelmann, Philipp; Mehler, Dorothea; Rommens, Pol M
In factures of the distal tibia with simple articular extension, the optimal surgical treatment remains debatable. In clinical practice, minimally invasive plate osteosynthesis and intramedullary nailing are both routinely performed. Comparative biomechanical studies of different types of osteosynthesis of intraarticular distal tibial fractures are missing due to the lack of an established model. The goal of this study was first to establish a biomechanical model and second to investigate, which are the biomechanical advantages of angle-stable plate osteosynthesis and intramedullary nailing of distal intraarticular tibial fractures. Seven 4(th) generation biomechanical composite tibiae featuring an AO 43-C2 type fracture were implanted with either osteosynthesis technique. After primary lag screw fixation, 4-hole Medial Distal Tibial Plate (MDTP) with triple proximal and quadruple distal screws or intramedullary nailing with double proximal and triple 4.0mm distal interlocking were implanted. The stiffness of the implant-bone constructs and interfragmentary movement were measured under non-destructive axial compression (350 and 600 N) and torsion (1.5 and 3Nm). Destructive axial compression testing was conducted with a maximal load of up to 1,200 N. No overall superior biomechanical results can be proclaimed for either implant type. Intramedullary nailing displays statistically superior results for axial loading in comparison to the MDTP. Torsional loading resulted in non-statistically significant differences for the two-implant types with higher stability in the MDTP group. From a biomechanical view, the load sharing intramedullary nail might be more forgiving and allow for earlier weight bearing in patients with limited compliance.
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.
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°.
Takashi Kojima; Yasuhiko Nakagawa; Koji Matsuki; Toshiyuki Hashida
Hydraulic fracturing with constant fluid injection rate was numerically modeled for a pair of rectangular longitudinal fractures intersecting a wellbore in an impermeable rock mass, and numerical calculations have been performed to investigate the relations among the form of pressure-time curves, fracture opening/propagation behavior and permeability of the mechanically closed fractures. The results have shown that both permeability of the fractures and fluid injection rate significantly influence the form of the pressure-time relations on the early stage of fracture opening. Furthermore it has been shown that wellbore pressure during fracture propagation is affected by the pre-existing fracture length.
Schlatterer, Daniel R; Hirschfeld, Adam G; Webb, Lawrence X
Grade IIIB open tibia fractures are devastating injuries. Some clinicians advocate wound closure or stable muscle flap coverage within 72 hours to limit complications such as infection. Negative pressure wound therapy was approved by the FDA in 1997 and has become an adjunct for many surgeons in treating these fractures. Opinions vary regarding the extent to which negative pressure wound therapy contributes to limb salvage. Evidence-based practice guidelines are limited for use of negative pressure wound therapy in Grade IIIB tibia fractures. This systematic literature review of negative pressure wound therapy in Grade IIIB tibia fractures may substantiate current use and guide future studies. We sought to answer the following: (1) Does the use of negative pressure would therapy compared with gauze dressings lead to fewer infections? (2) Does it allow flap procedures to be performed safely beyond 72 hours without increased infection rates? (3) Is it associated with fewer local or free flap procedures? We conducted a systematic review of six large databases (through September 1, 2013) for studies reporting use of negative pressure wound therapy in Grade IIIB open tibia fractures, including information regarding infection rates and soft tissue reconstruction. The systematic review identified one randomized controlled trial and 12 retrospective studies: four studies compared infection rates between negative pressure wound therapy and gauze dressings, 10 addressed infection rates with extended use, and six reported on flap coverage rates in relation to negative pressure wound therapy use beyond 72 hours. None of the 13 studies was eliminated owing to lack of study quality. Negative pressure wound therapy showed a decrease in infection rates over rates for gauze dressings in two of four studies (5.4% [two of 35] versus 28% [seven of 25], and 8.4% [14 of 166] versus 20.6% [13 of 63]), an equivalent infection rate in one study (15% [eight of 53] versus 14% [five of 16
Wirbel, R; Weber, A; Heinzmann, J; Meyer, C; Pohlemann, T
Background: Dislocation fractures of the tibial plateau often lead to functional restrictions and subjective complaints from the patients. Besides functional and radiological results, criteria to determine the quality of life are of increasing importance. Intermediate term restriction in quality of life was evaluated and correlated with objective radiological results in patients with Moore type V dislocation fracture of the tibial plateau. Patients and Methods: From 2003 to 2012, a multicentre retrospective cohort study in three hospitals was used to register 36 patients with 38 Moore type V dislocation fractures of the tibial plateau. The injury mechanism, the surgical treatment (one step or two step surgery, single or double plate fixation) the complication rate, the radiological result (Kellgren/Lawrence osteoarthritis score, loss of reduction, secondary deviation of the axis) after a mean follow-up of 37 months, and the quality of life (pain and function by NRS, IKDC form, EQ 5D score) after a mean follow-up of 68 months (range, 15-128 months), were analysed. Results: The mean age of the 27 men and the 9 women was 50.8 years. There were 30 cases of high impact injury. An external fixator was used for primary fracture stabilisation in 24 knees; definitive internal fixation was performed in a second step. Internal fixation using a single plate was used in 12 knees, and double plate fixation in 25 knees; one patient was treated definitively with an external fixator. Early complications (3 × infection, 2 × compartment syndrome, 4 × implant failure) were seen in 21.1 % of patients; all could be cured surgically. The function of the affected knee joint gave a mean NRS of 4.53; the IKDC score was 50.46, and the EQ 5D 7.47. Only two patients (5 %) were free of pain, 27 (75 %) reported mild to moderate pain, and 7 patients (20 %) reported severe pain. Four patients are retired or have applied for a pension. Altogether, the quality of life was calculated
Yoo, Moon-Jib; Shin, Yong-Eun
Purpose To evaluate the radiologic and functional outcomes of medial open wedge high tibial osteotomy (HTO) combined with arthroscopic procedure in patients with medial osteoarthritis. Materials and Methods From June 1996 to March 2010, 26 patients (32 knees) who underwent medial open wedge osteotomy and arthroscopic operation for medial osteoarthritis were retrospectively reviewed. Measurements included hip-knee-ankle (HKA) angle, femorotibial angle, medial proximal tibial angle, posterior tibial slope angle, and Kellgren-Lawrence grade. Clinical evaluation was performed using Lysholm knee scoring scale and knee and function score of the American Knee Society. Results Differences between the mean preoperative and postoperative measurements were significant in all angles including the HKA angle (−5.7° and +5.5°), femorotibial angle (−1.9° and +9.8°), and medial proximal tibial angle (82.9° and 90.5°) (p<0.05). Mean Lysholm knee scoring scale was 63.6 preoperatively and 88.7 at the last follow-up, mean Knee Society knee score was 61.2 and 86.6, and mean function score was 59.3 and 87.2, respectively. All differences were significant (p<0.05). Conclusions Medial open wedge HTO in combination with arthroscopic procedure is an effective treatment method for medial osteoarthritis to treat varus deformity and an intra-articular lesion. PMID:27894173
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.
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
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.
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. PMID:27682431
Simunovic, Nicole; Walter, Stephen; Devereaux, P J; Sprague, Sheila; Guyatt, Gordon H; Schemitsch, Emil; Tornetta, Paul; Sanders, David; Swiontkowski, Marc; Bhandari, Mohit
To evaluate how the size of an outcome adjudication committee, and the potential for dominance among its members, potentially impacts a trial's results. We conducted a retrospective analysis of data from the six-member adjudication committee in the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) Trial. We modeled the adjudication process, predicted the results and costs if smaller committees had been used, and tested for the presence of a dominant adjudicator. Use of smaller committee sizes (one to five members) would have had little impact on the final study results, although one analysis suggested that the benefit in reduction of reoperations with reamed nails in closed tibial fractures would have lost significance if committee sizes of three or less were used. We identified a significant difference between adjudicators in the number of times their original minority decisions became the final consensus decision (χ(2)=9.67, P=0.046), suggesting that dominant adjudicators were present. However, their impact on the final study results was trivial. Reducing the number of adjudicators from six to four would have led to little change in the final SPRINT study results irrespective of the significance of the original trial results, demonstrating the potential for savings in trial resources. Copyright © 2011 Elsevier Inc. All rights reserved.
Levy, A S; Wetzler, M; Lewars, M; Bromberg, J; Spoo, J; Whitelaw, G P
To determine whether the accepted principles of management of open tibia fractures apply to children, 40 consecutive open fractures of the tibial shaft in skeletally immature patients were retrospectively reviewed. Attempts were made to evaluate the functional and social impact of open tibia fractures in children. All open fractures were initially treated by rapid irrigation and debridement which was repeated every 48 hours until soft tissues stabilized. The average age was 10.1 years and average follow up was 26 months (range: 18 to 84). There were 16 grade I, 10 grade II, and 14 grade III open fractures. The grade III fractures were further subdivided into 6 grade IIIA, 7 grade IIIB, and 1 grade IIIC. The average time to union was 7.5 and 11.0 weeks in the grade I and II fractures respectively, with no infections and no delayed unions. In grade III fractures, the average time to union was 15 weeks, with 1 infection and 3 delayed unions. Bone grafting using autogenous iliac crest was performed on 2 patients. The children surveyed missed an average of 4.1 months of school and 33% had to repeat a year. Twenty-five percent of the children complained of nightmares involving the events of the accident. Chronic pain despite solid union was found in 30% of patients. Forty percent of those surveyed (7 grade III fractures) complained of a limp. The low incidence of soft tissue complications and infections in the study population supports applying in children the same basic soft tissue management principles of open fracture treatment as used in adults. While bone stabilization options are limited in children, the rate of successful union without adjunctive bone grafting is much higher than that of adults treated under similar protocols. Routine early iliac crest bone grafting is unnecessary. The prevalence of gait abnormality despite fracture union should be taken into account during the patient's rehabilitation. The extensive time missed from school and resulting
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
Sang, Xi-Guang; Wang, Zhi-Yong; Cheng, Lin; Liu, Yan-Hong; Li, Yong-Gang; Qin, Tao; Di, Kai
The aim of the present study was to analyze the mechanism by which nerve growth factor (NGF) promotes callus formation in mice with tibial fracture. NGF transgenic homozygotic mice and NGF wild homozygotic mice were selected to construct non-stabilized fracture model of tibia. The mice were sacrificed on days 7, 14 and 21, respectively, and each group had a sample with 8 mice at each point in time. X-ray radiography and safranin fast green were used to observe fracture healing and in situ hybridization was used to examine the NGF mRNA expression of tibia at each phase of fracture healing. Tartrate-resistant acid phosphatase (TRAP) staining of callus tissue and the expression level of TRAP mRNA were combined to observe osteoclast formation. COL2A1, a chondrocyte differentiation-related gene in callus, and the mRNA level of SOX9 were combined to observe chondrocyte differentiation. It was found that under X-ray radiography, the fracture of NGF transgenic homozygotic mice healed in advance (P<0.05). Cartilage and bone tissue were identified by safranin and fast green staining. The residual cartilage on the callus tissue of NGF transgenic homozygotic mice had decreased significantly (P<0.05). The NGF mRNA expression level in each phase of callus formation of NGF transgenic homozygotic mice was significantly higher than that of the wild group (P<0.05). The number of positive cells in NGF-TRAP staining at each time point after fracture and the NGF mRNA expression level was markedly higher than that of the wild group, and the expression levels of COL2A1 and SOX9 mRNA were distinctively higher than that of the wild group. In conclusion, NGF potentially improves the healing of tibial fracture by osteoclast formation. Additionally, an increase in the number of osteoblasts in the NGF transgenic homozygotic mice compared with the wild-type mice may be achieved by cartilage differentiation due to NGF increasing the COL2A1 and SOX9 mRNA expression levels.
The paper evidently does not discuss several important problems of the management of open fractures, but it is confined to the exposition of some fundamental rules of their traitment. Nowadays, the treatment of open fractures is to be decided individually for all cases. A great number of patients with open fracture owe their recovery to the proper first aid care at scence of accident. This is also in respect of the further treatment in the hospital of great importance. Exagerated activity is usually superfluous in the treatment of open fractures. Less and more proper management is often more useful for the injured patient.
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
Kim, Tae Won; Kim, Byung Kag; Kim, Dong Whan; Sim, Jae Ang; Lee, Beom Koo; Lee, Yong Seuk
Purpose The purpose of this study was to evaluate compartmental changes using combined single-photon emission computerized tomography and conventional computerized tomography (SPECT/CT) after open wedge high tibial osteotomy (OWHTO) for providing clinical guidance for proper correction. Materials and Methods Analysis was performed using SPECT/CT from around 1 year after surgery on 22 patients who underwent OWHTO. Postoperative mechanical axis was measured and classified into 3 groups: group I (varus), group II (0°–3° valgus), and group III (>3° valgus). Patella location was evaluated using Blackburne-Peel (BP) ratio. On SPECT/CT, the knee joint was divided into medial, lateral, and patellofemoral compartments and the brighter signal was marked as a positive signal. Results Increased signal activity in the medial compartment was observed in 12 cases. No correlation was observed between postoperative mechanical axis and medial signal increase. Lateral increased signal activity was observed in 3 cases, and as valgus degree increased, lateral compartment’s signal activity increased. Increased signal activity of the patellofemoral joint was observed in 7 cases, and significant correlation was observed between changes in BP ratio and increased signal activity. Conclusions For the treatment of medial osteoarthritis, OWHTO requires overcorrection that does not exceed 3 valgus. In addition, the possibility of a patellofemoral joint problem after OWHTO should be kept in mind. PMID:27894172
Kim, Kug Jin; Song, Eun Kyoo; Seon, Jong Keun
Purpose The purpose of this study was to compare the mechanical stability of three types of plate systems for opening wedge high tibial osteotomy. Materials and Methods Forty-eight fresh frozen porcine tibia specimens were assigned to three different fixation device groups: Aescular group (16 specimens) was fixed with Aescular plates; Puddu group (16 specimens) with a Puddu plate, and TomoFix group (16 specimens) with a TomoFix plate. We compared axial displacements under compression loads from 200 to 2,000 N and maximal loads at failure among 8 specimens per group. We also compared displacements under cyclic load after 100 cycles at a compressive load of 2,000 N among 8 specimens per group. Results In all three groups, displacement under compression load increased with the increase in the axial compressive load; however, no significant intergroup differences were observed in the mean values under tested loading conditions. The mean maximal loads at failure were not significantly different (6,055, 6,798, and 6,973 N in the Aescular, Puddu, and TomoFix groups, respectively; p=0.41). While the TomoFix group showed less extension and strain during the cyclic load test, the mean values showed no significant differences among groups. Conclusions All three plate systems were found to provide fixation stability suitable for bearing axial compression and cyclic loads while walking. PMID:26389072
Moghtadaei, Mehdi; Otoukesh, Babak; Bodduhi, Bahram; Ahmadi, Keyvan; Yeganeh, Ali
Introduction: Genovarum is a common orthopedic problem. Its optimal prompt treatment is an issue of importance. Aim: This study was conducted to determine the radiographic changes in patella bone before and after open wedge high tibial osteotomy. Material and Methods: In this quasi-experimental study, 43 patients were enrolled and underwent open wedge high tibial osteotomy and the radiographic and CT-scan indices including Q-Angle, Congruence Angle, Insall-Salvati index, and TTTG were measured and compared before and after surgery. Results: The result revealed that all indices including Q-Angle, Congruence Angle, Insull-Salvati index, and TTTG were not significantly differed across the study (P > 0.05). There was no difference between DLFA values before and after the operation (P> 0.05), while MPTA values were significantly different before and after operation (p <0.001). Conclusions: Totally it may be concluded that imaging indices are not differed after open wedge high tibial osteotomy and monitoring for them is not necessary and they would have no prognostic role. PMID:27703292
Shivanna, Deepak; Aski, Bahubali; Manjunath, Dayanand; Bhatnagar, Abhinav
Introduction: The injury pattern of open fracture dislocation of elbow with fracture both bones forearm with radial nerve injury is very rare. Very few reports are there in literature related to this kind of injury. However this combination is first of its kind. This rare injury needs special attention by early intervention and biological fixation to achieve good results. Case Report: A 22 year old female presented to us with history of road traffic accident. On evaluation patient had combination of open fracture dislocation of elbow with open diaphyseal fracture of both forearm bones with radial nerve palsy. The patient was treated in emergency and followed for 2 years. Conclusion: Open fracture dislocation of elbow is a rare entity. Our case additionally had open fracture both the bones forearm with radial nerve palsy. Early intervention and biological fixation with minimal invasion gives good results in terms of range of movements and patient satisfaction. PMID:27298951
Metaphyseal screw augmentation of the LISS-PLT plate with polymethylmethacrylate improves angular stability in osteoporotic proximal third tibial fractures: a biomechanical study in human cadaveric tibiae.
Goetzen, Michael; Nicolino, Tomas; Hofmann-Fliri, Ladina; Blauth, Michael; Windolf, Markus
The incidence of osteoporotic proximal tibial fractures has increased during the last 2 decades. A promising approach in osteoporotic fracture fixation is polymethylmethacrylate-based cement augmentation of implants to gain better implant purchase in the bone. This study investigates the biomechanical benefits of screw augmentation in less invasive stabilization system-proximal lateral tibial (LISS-PLT) plates in cadaveric extraarticular comminuted proximal tibial fractures (OTA-41-A3.3). Standardized extraarticular proximal tibial fractures were stabilized with the LISS-PLT plate in 6 paired osteoporotic cadaveric tibiae. Bone mineral density was measured with high-resolution, quantitative computed tomography scans to identify bone quality. In the augmented group, the 5 proximal screws of the LISS-PLT plate were augmented with 1 mL of bone cement each, whereas the contralateral tibia was instrumented conventionally as the control. Cyclic axial loading was applied to each specimen with a starting load of 150 N, using a ramp of 0.05 N per cycle to 10-mm axial displacement. Varus displacement was identified from anterior-posterior radiographs. Bone mineral density showed no significant difference between the 2 groups (P = 0.47). The nonaugmented group reached 9417 load cycles (SD 753) until failure, compared with 14,792 load cycles (SD 2088) in the augmented group (P = 0.002). In the early-onset failure (deformation at 8250 load cycles), varus displacement was significantly smaller in the augmented group (0.46 degrees, SD 0.6) than in the nonaugmented group (3.23 degrees, SD 1.7) (P = 0.01). This biomechanical study showed that cement augmentation of the LISS-PLT plate screws in osteoporotic proximal extraarticular tibial fractures significantly lowers the propensity toward screw migration and secondary varus displacement.
Yasuda, Tomohiro; Obara, Shu; Hayashi, Junji; Arai, Masayuki; Sato, Kaoru
Intramedullary nail fixation is a common treatment for tibial-shaft fractures, and it offers a better functional prognosis than other conservative treatments. Currently, the primary approach employed during intramedullary nail insertion is the semiextended position is the suprapatellar approach, which involves a vertical incision of the quadriceps tendon Damage to the patellofemoral joint cartilage has been highlighted as a drawback associated with this approach. To avoid this issue, we perform surgery using the patellar eversion technique and a soft sleeve. This method allows the articular surface to be monitored during intramedullary nail insertion. We arthroscopically assessed the effect of this technique on patellofemoral joint cartilage. The patellar eversion technique allows a direct view and protection of the patellofemoral joint without affecting the patella. Thus, damage to the patellofemoral joint cartilage can be avoided.
Thomas, Thaddeus P.; Van Hofwegen, Christopher J.; Anderson, Donald D.; Brown, Thomas D.; Marsh, J. Lawrence
The pathophysiology of post-traumatic osteoarthritis (PTOA) after intra-articular fractures is poorly understood. Pursuit of a better understanding of this disease is complicated by inability to accurately monitor its onset, progression and severity. Common radiographic methods used to assess PTOA do not provide sufficient image quality for precise cartilage measurements. Double-contrast MDCT is an alternative method that may be useful, since it produces high-quality images in normal ankles. The purpose of this study was to assess this technique’s performance in assessing cartilage maintenance in ankles with an intra-articular fracture. Thirty-six tibial plafond fractures were followed over two years, with thirty-one MDCTs being obtained four months after injury, and twenty-two MDCTs after two years. Unfortunately, clinical results with this technique were unreliable due to pathology (presumed arthrofibrosis) and technical problems (pooling of contrast). The arthrofibrosis that developed in many patients inhibited proper joint access and contrast infiltration, although high-quality images were obtained in eleven patients. In this patient subset, in which focal regions of cartilage degeneration could be visualized, thickness could be measured with a high degree of fidelity. While thus useful in selected instances, double-contrast MDCT was too unreliable to be recommended to assess these particular types of injuries. PMID:20634971
de Lima Lopes, Clécio; da Rocha Cândido Filho, Carlos Antônio; de Lima e Silva, Thiago Almeida; Gonçalves, Marcelo Carvalho Krause; de Oliveira, Ricardo Lyra; de Lima, Paulo Rogério Gomes
Objectives To evaluate the concordance among knee surgery specialists regarding the classification and surgical technique indicated in cases of tibial plateau fracture, using conventional radiographs and computed tomography. Methods Forty-four patients with fractures of the tibial plateau shown on radiographic and tomographic images were selected. These were evaluated by specialists at two different times, with an interval of seven days. On the first occasion, the specialists only had access to the radiographs, while on the second occasion they had access to both radiographs and computed tomography images. Their concordance was evaluated by means of the kappa coefficient. Results The interobserver reliability of the Schatzker classification on the first occasion was 0.36 and on the second occasion, 0.35. This was considered to present low reproducibility. In evaluating the intra-observer reproducibility of this classification, the mean kappa index was 0.42, which was classified as moderate. From evaluating the choice of surgical access, the inter-observer reliability was 0.55 on the first occasion and 0.50 on the second, which was considered to present moderate reproducibility. Evaluation on the implant chosen showed that the interobserver reliability was 0.01 on the first occasion and −0.06 on the second, which was considered to be poor and discordant. In evaluating the classification of the three columns, the inter-observer reproducibility was 0.47 (p < 0.0001), which was classified as moderate concordance. Conclusion Use of computed tomography did not present any improvement in the inter-observer concordance, using the Schatzker classification, and did not produce any change in the preoperative planning. PMID:26229867
Han, Jae Hwi; Yang, Jae-Hyuk; Bhandare, Nikhl N; Suh, Dong Won; Lee, Jong Seong; Chang, Yong Suk; Yeom, Ji Woong; Nha, Kyung Wook
Medial opening wedge high tibial osteotomy (HTO) has become increasingly popular as an alternative to lateral closing wedge osteotomy for the treatment of medial compartment knee osteoarthritis with varus deformity. The present systematic review was conducted to provide an objective analysis of total knee arthroplasty (TKA) outcomes following previous knee osteotomy (medial opening wedge vs. lateral closing wedge). A literature search of online databases (MEDLINE, EMBASE, Cochrane Library database) was made, in addition to manual search of major orthopaedic journals. The methodological quality of each of the studies was assessed on the Newcastle-Ottawa Scale and Effective Practice and Organization of Care. A total of ten studies were included in the review. There were eight studies with Level IV and two studies with Level III evidence. Eight studies reported clinical and radiologic scores. Comparative studies between TKA following medial opening and lateral closing wedge HTO did not demonstrate statistically significant clinical and radiologic differences. The revision rates were similar. However, more technical issues during TKA surgery after lateral closing wedge HTO were mentioned than the medial open wedge group. The quadriceps snip, tibial tubercle osteotomy, and lateral soft tissue release were more frequently needed in the lateral closing wedge HTO group. In addition, because of loss of proximal tibia bone geometry in the lateral closing wedge HTO group, concerns such as tibia stem impingement in the lateral tibial cortex was noted. The present systematic review suggests that TKA after medial opening and lateral closing wedge HTO showed similar performance. Clinical and radiologic outcome including revision rates did not statistically differ from included studies. However, there are more surgical technical concerns in TKA conversion from lateral closing wedge HTO than from the medial opening wedge HTO group. IV.
Ranawat, Anil S; Nwachukwu, Benedict U; Pearle, Andrew D; Zuiderbaan, Hendrik A; Weeks, Kenneth D; Khamaisy, Saker
Lateral closing-wedge (LCW) and medial opening-wedge (MOW) high tibial osteotomies (HTOs) correct varus knee alignment and stabilize the anterior cruciate ligament (ACL)-deficient knee. Tibiofemoral and patellofemoral alignment and kinematics after HTO are not well quantified. To compare the effect of LCW and MOW HTO on tibiofemoral and patellofemoral alignment in the ACL-deficient knee. Controlled laboratory study. Anterior drawer, Lachman, and pivot-shift tests were performed on cadaveric specimens (N = 16), and anterior tibial translation and tibial rotation were measured for the native and ACL-sectioned knee. The right and left knee of each cadaveric specimen underwent an LCW and MOW HTO, respectively, and stability testing was repeated. All cadavers underwent pre- and postosteotomy computerized tomography with 3-dimensional computer modeling to determine the effect of HTO on posterior tibial slope, as well as tibial and patellofemoral axial plane alignment (tibial axial rotation and patellar axial tilt). Correction to neutral coronal alignment was obtained with both osteotomy techniques; however, larger posterior tibial slope neutralization was achieved with LCW compared with MOW (mean ± SD, 11° ± 3.8° vs 5° ± 5°). LCW demonstrated a greater decrease in anterior tibial translation (P < .05) during Lachman testing, with translation values approximating those of the native knee, especially for the lateral compartment. A similar decrease in anterior tibial translation with LCW was not found during anterior drawer testing. Anterior tibial translation did not improve for either the Lachman or the anterior drawer test after MOW. Osteotomy type did not affect tibial rotation with pivot shift. Relative to MOW, LCW resulted in greater tibial axial rotation and patellar axial tilt (7.7° ± 4° and 5.6° ± 3.9° [LCW], 2.8° ± 2.3° and 2.4° ± 0.9° [MOW], respectively; P < .05). LCW shows more reproducible posterior tibial slope neutralization and decreased
Khunda, A; Al-Maiyah, M; Eardley, W G P; Montgomery, R
We reviewed 40 complex tibial non-unions treated with Taylor Spatial Frames. 39 healed successfully. Using the ASAMI scoring, we obtained 33 excellent, 5 good, 1 fair and 1 poor bone results. The functional results were excellent in 29 patients, good in 8, fair in two and poor in one. Mean patient satisfaction score was 95%. All but one patient would have the same treatment again. 28 of the 36 patients in work when injured, returned to work at the time of their final review. Four patients had an adverse event requiring significant intervention. Average treatment cost was approximately £26,000/patient.
Nerhus, Tor Kjetil; Ekeland, Arne; Solberg, Geir; Sivertsen, Einar Andreas; Madsen, Jan Erik; Heir, Stig
The aim of the present study was to examine changes in radiological variables in a prospective randomized study comparing opening wedge (OW) and closing wedge (CW) techniques of high tibial osteotomy (HTO). Our hypothesis was that there would be no differences in joint line angles or correction accuracy between the two groups, that patellar height would increase after CW HTO and decrease after OW HTO, and that leg length and posterior tibial slope would decrease after CW HTO and increase after OW HTO. Radiological data were collected from 70 patients participating in an ongoing prospective randomized clinical trial comparing OW and CW HTOs. Digital standing hip-knee-ankle (HKA) radiographs as well as lateral radiographs in 30° of flexion were obtained preoperatively and at 6 months for each patient. Joint line angles, HKA angle, leg length, Insall-Salvati index, Miura-Kawamura index and posterior tibial slope were measured using medical planning software. The complete preoperative radiological examinations of the first 50 patients were used in a study of intra- and inter-rater reliability of the measurements. The mean posterior slope was reduced by 2.5° in CW HTO, whereas it remained unchanged in OW HTO (p < 0.001). Mean leg length decreased 5.7 mm in CW HTO and increased 3.1 mm in OW HTO (p < 0.001). Changes in joint line angles, patellar height indexes and the correction accuracy showed no significant differences comparing the two techniques. Frontal plane reliability measurement intra- and inter-rater intraclass correlation coefficient (ICC) varied from 0.81 to 0.99. Sagittal plane intra- and inter-rater ICC varied from 0.60 to 0.87. Posterior tibial slope intra- and inter-rater ICC showed the lowest values (0.70 and 0.60, respectively) corresponding to a smallest real difference of 4.5° and 5.5°, respectively. Posterior tibial slope and leg length changes were significantly different in CW compared to OW HTOs. We recommend that possible alterations
Hall, Michael P; Hergan, David M; Sherman, Orrin H
Graft fixation in anterior cruciate ligament (ACL) reconstruction is commonly performed with bioabsorbable devices. This article presents a case of a broken bioabsorbable tibial interference screw (Gentle Threads; Biomet, Warsaw, Indiana) that presented as an intra-articular loose body 4 months after ACL reconstruction with posterior tibialis tendon allograft. A 19-year-old man presented with symptoms of pain and catching for 1 week but reported no history of trauma. The broken screw tip was identified on magnetic resonance imaging examination, and the remaining screw appeared to be overinserted into the tibia. During arthroscopic removal, a 10-mm screw tip was found in the lateral gutter. The ACL graft was found to be well fixed, but small areas of chondral damage were found in the patellofemoral and medial compartment. The patient's symptoms resolved postoperatively. To our knowledge, this is the earliest report of a broken bioabsorbable interference screw and only the second report of subsequent chondral injury due to intra-articular migration. Although rare, late breakage and intra-articular migration of bioabsorbable interference screws should be considered during the postoperative evaluation of any patient with pain or mechanical symptoms, regardless of trauma. This case also supports the importance of both measurement of tibial tunnel length and inspection of the intercondylar notch following interference screw insertion. Orthopedic surgeons performing ACL reconstruction must be aware of this possible complication and its potential for devastating chondral injury.
Leblanc, Justin; Puloski, Shannon; Hildebrand, Kevin
Interprosthetic fractures of the humerus are rare. Revisions of total elbow arthroplasty components in these cases are difficult. We report the first case of a patient with hemophilia who underwent a revision with a tibial allograft prosthetic composite without the need for hardware augmentation. A 43-year-old Caucasian man with a history of hemophilia and transfusion-related human immunodeficiency virus and hepatitis B and C presented with an interprosthetic fracture of his humerus after months of pain between his total elbow and total shoulder arthroplasties. Because of the poor remaining bone stock available in his distal humerus, a revision using a barrel-staved tibial allograft prosthetic composite was performed. Our patients' factor VIII level was optimized before the operation and he suffered no major long-term complications at 28 months. His only complication was an incomplete radial nerve palsy that ultimately recovered and left him with some numbness on the dorsum of his hand. Careful use of an allograft prosthetic composite is a very reasonable option when a patient experiences an interprosthetic fracture. We have successfully performed revision total elbow arthroplasty for a patient with hemophilia with an interprosthetic fracture using a tibial allograft and no additional fixation, which resulted in his return to full activities of daily living, minimal pain and full incorporation of the allograft to host bone.
Ukar, Estibalitz; Laubach, Stephen E.; Fall, Andras; Eichhubl, Peter
Faults and networks of naturally open fractures can provide open conduits for fluid flow, and may play a significant role in hydrocarbon recovery, hydrogeology, and CO2 sequestration. However, sandstone fracture systems are commonly infilled, at least to some degree, by quartz cement, which can stiffen and occlude fractures. Such cement deposits can systematically reduce the overall permeability enhancement due to open fractures (by reducing open fracture length) and result in permeability anisotropies. Thus, it is important to identify the factors that control the precipitation of quartz in fractures in order to identify potential fluid conduits under the present-day stress field. In many sandstones, quartz nucleates syntaxially on quartz grain or cement substrate of the fracture wall, and extends between fracture walls only locally, forming pillars or bridges. Scanning electron microscope cathodoluminescence (SEM-CL) images reveal that the core of these bridges are made up of bands of broken and resealed cement containing wall-parallel fluid inclusion planes. The fluid inclusion-rich core is usually surrounded by a layer of inclusion-poor clear quartz that comprises the lateral cement. Such crack-seal textures indicate that this phase was precipitating while the fractures were actively opening (synkinematic growth). Rapid quartz accumulation is generally believed to require temperatures of 80°C or more. Fluid inclusion thermometry and Raman spectroscopy of two-phase aqueous fluid-inclusions trapped in crack-seal bands may be used to track the P-T-X evolution of pore fluids during fracture opening and crack-seal cementation of quartz. Quartz cement bridges across opening mode fractures in the Cretaceous Travis Peak Formation of the tectonically quiescent East Texas Basin indicate individual fractures opened over a 48 m.y. time span at rates of 16-23 µm/m.y. Similarly, the Upper Cretaceous Mesaverde Group in the Piceance Basin, Colorado contains fractures that
Miramini, Saeed; Zhang, Lihai; Richardson, Martin; Mendis, Priyan; Ebeling, Peter R
Mechano-regulation plays a crucial role in bone healing and involves complex cellular events. In this study, we investigate the change of mechanical microenvironment of stem cells within early fracture callus as a result of the change of fracture obliquity, gap size and fixation configuration using mechanical testing in conjunction with computational modelling. The research outcomes show that angle of obliquity (θ) has significant effects on interfragmentary movement (IFM) which influences mechanical microenvironment of the callus cells. Axial IFM at near cortex of fracture decreases with θ, while shear IFM significantly increases with θ. While a large θ can increase shear IFM by four-fold compared to transverse fracture, it also result in the tension-stress effect at near cortex of fracture callus. In addition, mechanical stimuli for cell differentiation within the callus are found to be strongly negatively correlated to angle of obliquity and gap size. It is also shown that a relatively flexible fixation could enhance callus formation in presence of a large gap but could lead to excessive callus strain and interstitial fluid flow when a small transverse fracture gap is present. In conclusion, there appears to be an optimal fixation configuration for a given angle of obliquity and gap size. Copyright © 2016 IPEM. Published by Elsevier Ltd. All rights reserved.
Liu, Zhi; Li, Gang; Yang, Yong; Gao, Chun-Hong; Luo, Yong-Quan; Luo, Jun-Jun
To study technique and clinical therapeutic effects of internal fixation with three-column plates for the treatment of complex tibial plateau fractures through antero-midline and postero-medial approaches. From January 2010 to December 2012, 28 patients with complex tibial plateau fractures were treated with internal fixation using three-column plates through antero-midline and postero-medial approaches. There were 17 males and 11 females, with an average age of 45.3 years old (ranged, 28 to 64 years old). Twelve patients had injuries in the left side and 16 patients had injuries in the right side. According to Schatzker classification, 12 patients were type V, 16 patients were type VI. According to three-column classification, all the patients had injuries of lateral, medial and posterior columns. The mean interval from injury to operation was 9.4 days (ranged, 6 to 15 days). The main clinical symptoms were knee joint swelling, deformity and limitation of motion before operation. The X-ray and CT showed all patients had complex tibial plateau fractures, which involved in the lateral, medial and posterior columns. The therapeutic effects were evaluated by fracture healing time, hospital for special surgery knee score (HSS) at one year after operation. The indexes such as tibial plateau-tibial shaft angle (TPA), posterior slope angle (PA) and femoral-tibial angle (FfA) were compared between immediate postoperation and one year after operation. All incisions primarily healed without postoperative complications such as infection and cutaneous necrosis. All the patients were followed up, and the duration ranged from 12 to 24 months, with a mean of 18.1 months. The bone union time ranged from 5 to 10 months (mean, 7.8 months) after operation. Knee joint swelling and pain disappeared after bony union, and joint function completely recovered. The results of hospital for special surgery knee score (HSS) was 27.81 ± 2.17 in pain, 19.52 ± 2.05 in function,15.82 ± 1.73 in
Kim, Kyungsoo; Feng, Jun; Nha, Kyung Wook; Park, Won Man; Kim, Yoon Hyuk
Accurate measurement of the center of rotation of the knee joint is indispensable for prediction of joint kinematics and kinetics in musculoskeletal models. However, no study has yet identified the knee center of rotations during several daily activities before and after high tibial osteotomy surgery, which is one surgical option for treating knee osteoarthritis. In this study, an estimation method for determining the knee joint center of rotation was developed by applying the optimal common shape technique and symmetrical axis of rotation approach techniques to motion-capture data and validated for typical activities (walking, squatting, climbing up stairs, walking down stairs) of 10 normal subjects. The locations of knee joint center of rotations for injured and contralateral knees of eight subjects with osteoarthritis, both before and after high tibial osteotomy surgery, were then calculated during walking. It was shown that high tibial osteotomy surgery improved the knee joint center of rotation since the center of rotations for the injured knee after high tibial osteotomy surgery were significantly closer to those of the normal healthy population. The difference between the injured and contralateral knees was also generally reduced after surgery, demonstrating increased symmetry. These results indicate that symmetry in both knees can be recovered in many cases after high tibial osteotomy surgery. Moreover, the recovery of center of rotation in the injured knee was prior to that of symmetry. This study has the potential to provide fundamental information that can be applied to understand abnormal kinematics in patients, diagnose knee joint disease, and design a novel implants for knee joint surgeries.
Kottmeier, Stephen A; Watson, J Tracy; Row, Elliot; Jones, Clifford B
A critical assessment of radiographic and clinical outcomes after complex articular fractures of the proximal tibia demonstrates several aspects worthy of reevaluation and potential modification. These include a refined understanding of fracture pathoanatomy, injury classification, operative exposure, surgical timing, and preferred fixation constructs in addition to implant design modifications. Evolving trends include increasing appreciation of the importance of the fracture morphology in the axial plane and the role that the fracture pattern has on the choice of surgical approach. This focused review will highlight the attributes and limitations of classification schemes (both conventional and contemporary) as well as the role that posterior surgical approaches performed in the prone position may offer in select clinical scenarios. The merits of staged fixation (prone followed by supine patient positioning), its technique, indications, and potential liabilities are described and case examples offered. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Ozalay, Metin; Sahin, Orcun; Akpinar, Sercan; Ozkoc, Gurkan; Cinar, Murat; Cesur, Necip
Biphasic calcium phosphate (BCP) has proved to be an effective bone substitute, but it's effectiveness and remodeling potential in open wedge high tibial osteotomy (OWHTO) has not been analyzed yet. This study sought to evaluate the bone healing and remodeling potentials of BCP granules using a radiographic rating system in biplanar OWHTO. Fifteen patients (15 knees) underwent biplanar OWHTO. Bone gaps were filled with BCP granules. For radiographic evaluation, remodeling was divided into four phases. Phase 1 was accepted as rounded osteotomy sites, with clear distinction between BCP and bone, phase 2 was accepted as whitened osteotomy sites, with distinction between BCP and bone still visible, phase 3 was accepted as distinction between BCP and bone not visible and cloudy bone formation and phase 4 was accepted as full reformation of BCP granules (4A-BCP visible, 4B-disappearence of BCP) with no sign of osteotomy. Bone union was confirmed with clinical (full weight bearing without pain) and radiographic evaluation (cortical bridging callus on radiographs and phase 3 or greater remodeling). The time to full remodeling and the starting point of the consolidation on anteroposterior radiographs were noted. Complications were also noted at each clinical follow-up. Mean follow-up was 27.2 months. The mean age was 55.8 years. At clinical follow-up, there were no wound healing problems, no loss of corrections, no infections, and no complications. All osteotomies successfully healed. According to the radiologic classification system, at the 6th week, 73.3% (11/15) of patients were in phase 1 and the remaining 26.7% (4/15) were in phase 2. At 12-month follow-up, 46.7 (7/15) of the patients were still in phase 3. After 2 years, all radiographs showed to be in phase 4A. Radiographic union was noted to progress from lateral to medial and finally central. BCP can be successfully used as a bone substitute. The radiographic remodeling and consolidation process of BCP was found to
Malocclusion is a serious complication of open reduction surgery for facial fractures. It is often caused by the lack of adequate consideration for the occlusal relationship before the trauma and intermaxillary fixation during the operation. This is a case report of postoperative malocclusion that occurred in a patient with a midfacial complex fracture. PMID:28280712
Thórhallsdóttir, Valdís Gudrún; Robertsson, Otto; W-Dahl, Annette; Stefánsdóttir, Anna
Background and purpose 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. Patients and methods 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. Results 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). Interpretation 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. PMID:25753311
Jubel, A; Andermahr, J; Mairhofer, J; Prokop, A; Hahn, U; Rehm, K E
Reduction of the depressed joint surface in tibial plateau fractures often leaves large cancellous bone defects. These metaphyseal voids are typically filled with autogenous bone grafts that can cause a significant donor site morbidity. The use of injectable bone cement offers the opportunity to support the reduced joint surface without bone grafting. The aim of this study was to evaluate the clinical and radiological outcome as well as the period of partial weight bearing after the use of Norian SRS in tibial plateau fractures. Twenty-one patients with a mean age of 48 years were included in this prospective trial. According to the AO/OTA Classification, there were seven fractures of type B2, ten B3, one C1, one C2, and two fractures of type C3. The period of partial weight bearing was 3.7 weeks. In 18 patients the follow-up was more than 24 months. After a mean follow-up of 30 months, the Lysholm score was 87.9 at mean. The radiological part of the Rasmussen score was excellent and good in eight cases each and fair in four cases. Soft tissue reactions due to the cement were not observed. On all radiographs taken 36 months after the operation the cement bloc was still visible. The results show that Norian SRS can be used to fill metaphyseal bone defects in tibial plateau fractures. Clinical and radiological results are comparable to those of fractures treated with autologous bone graft. The high compression strength allows early full weight bearing without the risk of secondary loss of reduction.
Ong, J C Y; Kennedy, M T; Mitra, A; Harty, J A
The goal of this study was to determine differences in fracture stability and functional outcome between synthetic bone graft and natural bone graft with internal fixation of tibia plateau metaphyseal defects. Hydroxyapatite calcium carbonate synthetic bone graft was utilised in 14 patients (six males and eight females). Allograft/autograft were utilised in the remaining 10 patients (six males and four females). All the 24 patients had clinical, radiological and subjective functional score assessments. There was no significant statistical difference between the groups for post-operative articular reduction, long-term subsidence, and WOMAC scores. The degree of subsidence was not related to age or fracture severity. Maintenance of knee flexion was found to be better in the allograft/autograft group (p = 0.048) when compared between the groups. Multivariate analysis compared graft type, fracture severity, post-operative reduction, subsidence rate, range of movement and WOMAC score. The only finding was a statistical significant association with the graft type related to the 6-month range of movement figures. Use of autologous or allogenic bone graft allows better recovery of long-term flexion, possibly due to reduced inflammatory response compared with synthetic bone composites. However, all other parameters, such as maintenance of joint reduction and subjective outcome measures were comparable with the use of hydroxyapatite calcium carbonate bone graft. This study shows that synthetic bone graft may be a suitable alternative in fixation of unstable tibia plateau fractures, avoiding risk of disease transmission with allograft and donor site morbidity associated with autograft.
Yoshioka, Tomokazu; Kubota, Shigeki; Sugaya, Hisashi; Hyodo, Kojiro; Ogawa, Kaishi; Taniguchi, Yu; Kanamori, Akihiro; Sankai, Yoshiyuki; Yamazaki, Masashi
Maintenance or restoration of a good range of motion of the knee is one of the most important outcomes following knee surgery. According to previous studies, opening wedge high tibial osteotomy enables better recovery of range of motion in knee flexion than that achievable after total knee arthroplasty or unicompartmental knee arthroplasty. However, few reports provide a detailed description of the postoperative recovery of knee extension range of motion after opening wedge high tibial osteotomy. We describe our experience with a knee extension training program using a single-joint hybrid assistive limb device (HAL-SJ; Cyberdyne Inc., Tsukuba, Japan) during the acute recovery phase after opening wedge high tibial osteotomy. The HAL-SJ is a wearable robotic device that facilitates voluntary control of knee joint motion. A 67-year-old Japanese woman who underwent opening wedge high tibial osteotomy for spontaneous osteonecrosis of the left medial femoral condyle received HAL-SJ-based knee extension training postoperatively. Our experience with this patient revealed that knee extension training with the HAL-SJ during the acute phase following opening wedge high tibial osteotomy is feasible. Furthermore, the patient's knee extension range of motion improved to values similar to those seen during the preoperative stage, and her flexion range of motion was improved at 3 months after the surgery. HAL-SJ-based knee extension training could be used as a novel post-opening wedge high tibial osteotomy rehabilitation modality. Further exploration of individualized optimal settings of the HAL-SJ is required to improve its safety and efficacy.
Frankle, M; Cordey, J; Sanders, R W; Koval, K; Perren, S M
Femoral shaft fractures with and without bony contact were simulated in cadaver specimens fixed with one of two different types of intramedullary locked nail systems; conventional antegrade nail fixation of the femur with the universal AO femoral nail or retrograde insertion in the femur with the universal tibial nail (a smaller diameter slotted nail) were utilized. Mechanical testing simulated one leg stance, and resultant deformation was measured in bending, torsion, and shortening. In stable fractures, fracture stability was similar to both devices, while in unstable fractures, the larger femoral nail was more stable. Furthermore, the simulation of single leg stance led to a coupled deformation of varus bending, axial shortening, and external rotation, which was dependent on bone geometry.
Lee, Wxp; Kyaw, M O
The optimal treatment for thoracolumbar fractures (TLF) without neurological deficit remains controversial. Majority of the systematic reviews and meta-analyses have evaluated open operative approaches but have yet to compare the outcomes of minimally invasive percutaneous pedicle fixation (MIPPF) versus non-operative treatment. A retrospective cohort study was performed to compare clinical and radiological outcomes between MIPPF and conservative groups for TLF AO Type A1 to Type B2 during a 2-year follow-up period. Pre-operative plain and CT films were evaluated and decision made for short segment (non-fusion) MIPPF. Patients who refused operation were treated conservatively with three months of body cast, brace, or corset. MIPPF group showed earlier Visual Analog Score(VAS) improvement at six months post-injury (0 vs 6.0- p<0.001), as well as better functional and radiological outcomes (p<0.050) at final follow-up. Progressions of regional kyphosis (RK) were noted in both groups but there was no significant difference within and between them(p>0.050). MIPPF as a method of internal bracing can be pursued in the treatment of TLF, with larger future cohorts and RCTs being called for to support and explore new findings.
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.
Branco, Paulo Sergio Martins Castelo; Cardoso Junior, Mauricio; Rotbande, Isaac; Ciraudo, José Antonio Fraga; Silva, Celso Ricardo Correa de Melo; Leal, Paulo Cesar Dos Santos
This article reports the use of elastic suture as an adjuvant in surgical wound closure caused by decompressive fasciotomy after compartment syndrome associated with a compound fracture of the tibia. Widely used in other medico-surgical specialties, this technique is unusual in orthopedics surgery, but the simplicity of the procedure and the successful outcome observed in this case allows for its consideration as indicated for situations similar to that presented in this study.
Polat, Gökhan; Karademir, Gökhan; Akgül, Turgut; Ceylan, Hasan Hüseyin
INTRODUCTION Elbow dislocations in children are rare injuries. These injuries are often in the form of complex injuries that is accompanied by the median nerve damage and medial epicondyle fracture in the pediatric age group. Open elbow dislocation without fracture in the pediatric age group has been reported very rarely in the literature. PRESENTATION OF CASE The purpose of this study is to present an 8-year-old patient who has open elbow dislocation without fracture accompanying with brachial artery injury. In the clinical examination of the patient, there was an open wound in the transverse antecubital region. After repair of brachial artery injury, open reduction was performed under general anesthesia. In the postoperative clinical examination at 6 months, left elbow flexion was 140°, extension was full and there were no deficit in the supination and pronation of the forearm. DISCUSSION Elbow dislocation without fracture in pediatric patients is a very rare injury. Usually the trauma mechanism of elbow dislocation is falling on outstretched hand with elbow in approximately 30° of flexion. However our patient had fallen on outstretched hand with elbow in full extension. Although this type of trauma mechanism is typical for supracondylar humerus fractures in pediatric age group, in our patient an open posterior elbow dislocation without fracture had occurred. CONCLUSION Pediatric elbow dislocations are rare injuries and the management of these injuries can be technically demanding due to concurrent neurovascular injuries. An open dislocation without fracture is very rare and it should be treated with immediate intervention, an effective teamwork and good rehabilitation. PMID:25460475
Seo, Seung-Suk; Kim, Ok-Gul; Seo, Jin-Hyeok; Kim, Do-Hoon; Kim, Youn-Gu; Lee, In-Seung
Purpose The purpose of this study was to investigate complications and radiologic and clinical outcomes of medial opening wedge high tibial osteotomy (MOWHTO) using a locking plate. Materials and Methods This study reviewed 167 patients who were treated with MOWHTO using a locking plate from May 2012 to June 2014. Patients without complications were classified into group 1 and those with complications into group 2. Medical records, operative notes, and radiographs were retrospectively reviewed to identify complications. Clinically, Oxford Knee score and Knee Injury and Osteoarthritis Outcome score (KOOS) were evaluated. Results Overall, complications were observed in 49 patients (29.3%). Minor complications included lateral cortex fracture (15.6%), neuropathy (3.6%), correction loss (2.4%), hematoma (2.4%), delayed union (2.4%), delayed wound healing (2.4%), postoperative stiffness (1.2%), hardware irritation (1.2%), tendinitis (1.2%), and hardware failure without associated symptoms (0.6%). Major complications included hardware failure with associated symptoms (0.6%), deep infection (0.6%), and nonunion (0.6%). At the first-year follow-up, there were no significant differences in radiologic measurements between groups 1 and 2. There were no significant differences in knee scores except for the KOOS pain score. Conclusions Our data showed that almost all complications of the treatment were minor and the patients recovered without any problems. Most complications did not have a significant impact on radiologic and clinical outcomes. PMID:27894176
Al-Sadek, Tabet A.; Niklev, Desislav; Al-Sadek, Ahmed
BACKGROUND: Open supracondylar fractures of the humerus are rare in children, and the treatment strategy for these fractures is yet to be standardised. AIM: We present the case of a 7-year-old boy with open supracondylar humerus fracture that was managed with an external wrist fixator. CASE PRESENTATION: A 7-year-boy was brought to our department with pain in the right arm after a fall from a height about 3 hours before admission. On examination, the elbow was found to be markedly swollen with restriction of movement of the right arm. A 4-cm-wide wound was also observed on the flexural aspect of the elbow, indicating severe contamination of the fractured site. Neurological examination revealed restriction of hand movement and decreased sensations, which suggested the possibility of nerve injuries. CONCLUSION: A good clinical outcome was achieved in this case, without the development of any complications over a 6-month follow-up period. PMID:28028413
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
Larrain, Mario; Rocco, Eduardo Di; Riatti, Patricio; Ferreyra, Facundo; Cianciosi, Juan Sebastián
Introduction: Given the infrequency and lack of consensus in the treatment of children and adolescents with these injuries, we decided to write this report with the aim of present a case of PCL tibial avulsion in a contact athlete teen with open physis and a review of the literature published. Materials and Methods: RF.male, 13 years, rugby, suffers French tackle and fall on knees flexed. 3 months post-trauma consultation with left knee pain, joint fluid and sport limitation. Whidout instability but "not feeling well". The posterior drawer test + + / ++++, gravitational test +. Rx posterior drawer: 8mm difference between the two nenes. MRI: tibial avulsion PCL. We interpreted as symptomatic PCL injury in athletes, surgery (arthroscopy + posterior approach) is decided reintegration of chondral fragment in 1 time P.OP: no load 4 Weeks . plaster wedge extension 6 weeks, then 3 months and passive immobilizer progressive mobility. Results: 0-90 mobility achieving in 8th week. The 3rd month drawer rx 4mm. MRI posterior translation of the 4th month reintegration of LCP with anchor . 6ª month later minimally elongated drawer with stop net. 11th month continuous strengthening recrearional and sports activities. Discussion and Conclusion: Most avulsion of PCL in patients with open physis probably be for greater strength and endurance ligament compared with the phisis and bone at this age. We suspected in patients with vague knee pain, with or without instability, history of trauma and normal Rx a correct examination and MRI to be essential for diagnosis. We beleave that athletes with open physis, because of the risk of joint degeneration, surgery is justified to restore kinematics, prevent osteoarthritis and resume activity prior to the injury.
Background Medial open wedge high tibial osteotomy is a well-established procedure for the treatment of unicompartmental osteoarthritis and symptomatic varus malalignment. We hypothesized that different fixation devices generate different fixation stability profiles for the various wedge sizes in a finite element (FE) analysis. Methods Four types of fixation were compared: 1) first and 2) second generation Puddu plates, and 3) TomoFix plate with and 4) without bone graft. Cortical and cancellous bone was modelled and five different opening wedge sizes were studied for each model. Outcome measures included: 1) stresses in bone, 2) relative displacement of the proximal and distal tibial fragments, 3) stresses in the plates, 4) stresses on the upper and lower screw surfaces in the screw channels. Results The highest load for all fixation types occurred in the plate axis. For the vast majority of the wedge sizes and fixation types the shear stress (von Mises stress) was dominating in the bone independent of fixation type. The relative displacements of the tibial fragments were low (in μm range). With an increasing wedge size this displacement tended to increase for both Puddu plates and the TomoFix plate with bone graft. For the TomoFix plate without bone graft a rather opposite trend was observed. For all fixation types the occurring stresses at the screw-bone contact areas pulled at the screws and exceeded the allowable threshold of 1.2 MPa for at least one screw surface. Of the six screw surfaces that were studied, the TomoFix plate with bone graft showed a stress excess of one out of twelve and without bone graft, five out of twelve. With the Puddu plates, an excess stress occurred in the majority of screw surfaces. Conclusions The different fixation devices generate different fixation stability profiles for different opening wedge sizes. Based on the computational simulations, none of the studied osteosynthesis fixation types warranted an intransigent full
Fuller, David A
The purpose of this video is to demonstrate the surgical repair of an intraarticular distal humerus fracture. A polytrauma patient with an intraarticular distal humerus fracture is shown. The patient is positioned laterally, with a posterior skin incision and olecranon osteotomy for exposure. An anatomic reduction is achieved, and internal fixation with perpendicular plating of the distal humerus is performed. The video is 18 minutes, 34 seconds duration in time and 2,048,752,000 bytes in size. Open reduction with internal fixation of a distal humerus fracture is demonstrated in this video.
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
Chen, Liang-Chin; Chan, Yi-Sheng; Wang, Ching-Jen
Injuries to the proximal tibial physis are among the least common epiphyseal injuries. We present a case of severe genu recurvatum deformity (45 degrees) with leg length discrepancy (4 cm) following a neglected proximal tibial physeal injury incurred 6 years previously. The 16-year-old patient was successfully treated by open-wedge osteotomy, allograft reconstruction, and dual buttress plate fixation. At 3 years' follow-up, the patient was asymptomatic, fully active with a full range of motion (0 - 140 degrees) of the leg, and equal leg lengths. There were no signs of genu recurvatum clinically.
Sadoni, Hanon; Arti, Hamidreza
Introduction: Femoral shaft fracture is one of the typical bone fractures due to high energy trauma and may occur as an open fracture. Some foreign materials may enter the fracture site such as sand, cloth particles and so on. Case Presentation: A 28-year-old motorcycle riding military member and his collaborator were received in the hospital because of multiple traumas due to a fall in a hollow during a surveillance mission. His collaborator died because of head trauma and multiple severe open fractures. When fixing the patients femoral fracture, a large femoral butterfly fragment was removed from the patient’s thigh as a foreign segment. The patient’s femur was fixed with a plate and screws. No femoral defect was detected during surgery or post-operative X-rays and CT scan. The removed segment was not a part of the patient’s femur. Conclusions: Surgical and post-surgical findings showed that this segment was not related to the patient’s femur. The foreign segment may have belonged to the other victim of this trauma. PMID:27218050
Kim, Ji Heui; Lee, Jun Ho; Hong, Seok Min; Park, Chan Hum
Open reduction through an intercartilaginous incision was useful for treating delayed-diagnosed nasal bone fractures because it resulted in a successful outcome with minimal complications. Nasal bone fractures are generally managed with closed reduction, which is usually inadequate and results in airway obstruction with a delayed diagnosis of nasal bone fracture when bone healing and fibrotic adhesions around the bone fragment have progressed. This study investigated the surgical outcome of open reduction through an intercartilaginous incision for delayed-diagnosis nasal bone fractures. The study enrolled 18 patients who underwent open reduction through an intercartilaginous incision to correct delayed-diagnosis nasal bone fractures. Three independent otorhinolaryngologists evaluated the outcomes 4-35 months (average 12.7 months) postoperatively as excellent, fair or poor. The time from injury to surgery was 11-39 days (20-39 days in adults and 11-30 days in children). The 18 cases included 16 primary repairs and two revisions. A Kirschner wire was inserted in six (33.3%) patients who had unstable reduced nasal bones. Postoperatively, l5 (83%) patients had excellent results, two (11%) had fair, and one (6%) had a poor outcome. No patient experienced any complication.
Zhang, F; Zhu, Y; Li, W; Chen, W; Tian, Y; Zhang, Y
There remains a controversy between unreamed intramedullary nailing and external fixation to treat Gustilo grade IIIB tibial fractures. To evaluate the comparative effectiveness and safeness of both methods for this type of fracture, we performed this meta-analysis. Relevant original studies were searched in MEDLINE, EMBASE, China National Knowledge Infrastructure, and Cochrane Central Database (all through February 2014). Studies included in this meta-analysis had to compare the effectiveness or complications and provided sufficient data of interest. The patients treated by both methods were similar statistically in demography and injury mechanism. The Stata 11.0 was used to analyze all data. Six studies involving 163 participants were included. Unreamed intramedullary nailing was associated with reduced time to union (standardized mean difference, -1.14; 95% confidence interval, -2.04 to -0.24) and lower rates of superficial infection (odds ratio: 0.39; 95% confidence interval: 0.17-0.87) and malunion (odds ratio: 0.27; 95% confidence interval: 0.09-0.78). However, there were no significant differences in other adverse events including delayed union, non-union, deep infection, and fixation failure. The existing evidence supports unreamed intramedullary nailing to be a better method for treating Gustilo grade IIIB tibial fractures, and this might aid in the management of this sever injury. © The Finnish Surgical Society 2015.
Vaca, Elbert E; Mundinger, Gerhard S; Kelamis, Joseph A; Dorafshar, Amir H; Christy, Michael R; Manson, Paul N; Rodriguez, Eduardo D
Treatment of facial fractures in the setting of open-globe injuries poses a management dilemma because of the often disparate treatment priorities of multidisciplinary trauma teams and the lack of prognostic data regarding visual outcomes. Patients in the University of Maryland Shock Trauma Registry sustaining facial fractures with concomitant open-globe injuries from January of 1998 to August of 2010 were identified. Odds ratios were calculated to identify demographic and clinical variables associated with blindness, and multivariate regression analysis was performed. A total of 99 patients were identified with 105 open-globe injuries. Seventy-nine percent of injuries were blinding, whereas 4.8 percent of globes achieved a final visual acuity greater than or equal to 20/400. Blindness was associated with penetrating injury, increasing number of facial fractures, zygomaticomaxillary complex fracture, admission Glasgow Coma Scale score less than or equal to 8, and globe injury spanning all three eye zones. Fracture repair was performed more frequently (62.5 percent) and more quickly (average time to fracture repair, 4.5 days) in cases of primary globe enucleation/evisceration when compared with complete (21.2 percent; 8 days; p=0.35) or incomplete (42.9 percent; 11 days; p=0.058) primary globe repair. Penetrating injury mechanism and zone of eye injury appear to be better indicators of visual prognosis than facial fracture patterns. Given the high rates of blindness, secondary enucleation, and delay of fracture repair in patients that were not primarily enucleated, the authors recommend that orbital fracture repair not be delayed in the hopes of eventual visual recovery in cases of high-velocity projectile trauma. Risk, III.
Leyes, Manuel; Torres, Raúl; Guillén, Pedro
This article discusses the complications after open reduction and internal fixation of ankle fractures. Complications are classified as perioperative (malreduction, inadequate fixation, and intra-articular penetration of hardware), early postoperative (wound edge dehiscence, necrosis, infection and compartment syndrome), and late (stiffness, distal tibiofibular synostosis, degenerative osteoarthritis, and hardware related complications). Emphasis is placed on preventive measures to avoid such complications.
Tulipan, Jacob E; Ilyas, Asif M
Open fractures of the hand are a common and varied group of injuries. Although at increased risk for infection, open fractures of the hand are more resistant to infection than other open fractures. Numerous unique factors in the hand may play a role in the altered risk of postinjury infection. Current systems for the classification of open fractures fail to address the unique qualities of the hand. This article proposes a novel classification system for open fractures of the hand, taking into account the factors unique to the hand that affect its risk for developing infection after an open fracture.
Gouin, F; Yaouanc, F; Waast, D; Melchior, B; Delecrin, J; Passuti, N
Valgus tibial osteotomy (VTO) is a well-known procedure for the treatment of medial compartment femoro-tibial osteoarthritis. Good and very good results have been reported with calcium phosphate wedges, which avoid the inconveniences of autologous grafts use. The hypothesis of this study is that with equivalent results in the treatment of osteoarthritis of the knee, the use of calcium phosphate wedges (BMCaPh) to fill the bone defect created by osteotomy would result in fewer specific complications and less pain associated with autologous grafts (AUTO) harvesting. This prospective, controlled, randomised study included one arm that received a macroporous, biphasic calcium phosphate wedge (BMCaPh group) and one arm that received an autologous tricortical graft (AUTO group) for filling. The same plate with locked screws was used for fixation in all cases. All patients underwent at least two years of clinical and radiographic post-operative follow-up. Forty patients were included. Loss of correction occurred in six of the twenty-two patients in the BMCaPh group (27%), resulting in three early surgical revisions, compared to one loss of correction in the AUTO group. Lateral cortical hinge tears were a risk factor for loss of correction for the entire cohort and in the BMCaPh group. (relative risk 13.3 [1.9-92]. Moreover, union took significantly longer and pain lasted significantly longer in the BMCaPh group, although results were comparable at 6 months. A significant number of undesirable events (loss of correction) occurred in this study, limiting the number of included patients. Nevertheless, the results show that although there was no difference in the two groups for overall complications, number of revisions all causes combined, or clinical results, filling with BMCaPh was less tolerated and increased the risk of loss of correction when local mechanical conditions of the knee were unfavourable (lateral cortical hinge tears). Moreover, although it is not possible
Mallee, Wouter H; Weel, Hanneke; van Dijk, C Niek; van Tulder, Maurits W; Kerkhoffs, Gino M; Lin, Chung-Wei Christine
To compare surgical and conservative treatment for high-risk stress fractures of the anterior tibial cortex, navicular and proximal fifth metatarsal. Systematic searches of CENTRAL, MEDLINE, EMBASE, CINAHL, SPORTDiscus and PEDro were performed to identify relevant prospective and retrospective studies. Two reviewers independently extracted data and assessed methodological quality. Main outcomes were return to sport and complication rate. 18 studies were included (2 anterior tibia (N=31), 8 navicular (N=200) and 8 fifth metatarsal (N=246)). For anterior tibial fracture, no studies on initial surgery were eligible. Conservative treatment resulted in high complication rates and few cases returned to sport. For navicular fracture, a weighted mean return to sport of 22 for conservative and 16 weeks for surgical treatment was found. Six weeks of non-weightbearing cast was mostly used as conservative treatment. Surgical procedures varied widely. For the fifth metatarsal fracture, weighted mean return to sport was 19 for conservative and 14 weeks for surgical treatment. Surgery consisted of intramedullary screw fixation or tension band wiring. For conservative methods, insufficient details were reported. Overall, there was a high risk of bias; sample sizes were small and GRADE level of evidence was low. Strong conclusions for surgical or conservative therapy for these high-risk stress fractures cannot be drawn; quality of evidence is low and subjected to a high risk of bias. However, there are unsatisfying outcomes of conservative therapy in the anterior tibia. The role of initial surgery is unknown. For the navicular, surgery provided an earlier return to sport; and when treated conservatively, weightbearing should be avoided. For the fifth metatarsal, surgery provided the best results. Treatment decision-making would greatly benefit from further prospective research. PROSPERO database of systematic reviews: CRD42013004201. Published by the BMJ Publishing Group Limited
Sharma, Pawan Kumar; Chugh, Ankush; Singh, Randhir
Background With i ncrease in elderly population, osteoarthritis has become major concern nowadays. Knee joint is most commonly affected joint. A number of methods have been developed in the last few years which help in treating the osteoarthritis knee, which includes non pharmacological, pharmacological and surgical methods. Among the most promising techniques with renewed interest for osteoarthritis knee with deformity is the use of high tibial osteotomy. Uni-compartmental osteoarthritis knee with deformity especially in relatively younger age group (less than 60 years) constitutes the main indication. Aim The aim of present study was to evaluate management of osteoarthritis knee by graduated open wedge high tibial osteotomy in 40-60 years age group using limb reconstruction system. Materials and Methods Medial Opening Wedge High Tibial Osteotomy leaving the lateral cortex intact which acts as a hinge, was done in 30 patients and stabilized by Limb Reconstruction System. Distraction was started at 7th day at the rate of 1 mm/day and continued till proper alignment was achieved. Results Medial Opening Wedge High Tibial Osteotomy stabilized by unilateral external fixator is a good method for unicompartmental osteoarthritis knee with deformity as it gives precise control over final limb alignment and its ability to perform a residual correction. Deformity correction can be quantified at the time of correction as it is not acute correction. Gradual deformity correction can be done over time by distraction histogenesis with the help of unilateral external fixator. It is also a good method in young patients requiring large correction. Conclusion Medial Opening Wedge High Tibial Osteotomy is having many benefits over closed wedge osteotomy and stabilization by unilateral external fixator also has its added benefits. It is less invasive, no internal hardware present and safer in terms of neurovascular complications. PMID:26557580
Cosman, Felicia; Nicpon, Kathleen; Nieves, Jeri W
We assessed osteoporosis management in patients admitted for rehabilitation of acute hip fracture to an open system community hospital before and after institution of a fracture liaison service (FLS). Pre-FLS, we surveyed 60 patients 4-6 months after hip fracture. Subsequently, the FLS program performed routine consultations, and recommended lab, bone density testing (BMD) and osteoporosis medication. FLS program outcomes were assessed by survey in 75 patients after hip fracture. In the pre-FLS population, after hip fracture, 55 % changed calcium intake, 48 % changed vitamin D intake, and 35 % obtained a BMD. Osteoporosis medication was taken by 38 % before and 33 % after hip fracture. Post-FLS, 56 % changed calcium intake, 68 % changed vitamin D intake and 65 % obtained a BMD. Post-FLS, osteoporosis medication was taken by 21 % of patients before and 19 % after hip fracture. Our FLS program in hip fracture patients improved non-pharmacologic measures, but not the use of osteoporosis medication.
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
Hennig, Alex C; Incavo, Stephen J; Beynnon, Bruce D; Abate, Joseph A; Urse, John S; Kelly, Stephen
Twenty opening wedge tibial osteotomies were performed using the Osteotrac plate, which consists of a two-piece plate with a one-way ratcheting mechanism with two degrees of freedom. A variety of concomitant procedures were performed including osteochondral transfer, tibial tubercle medialization, and anterior cruciate ligament reconstruction. The change in tibiofemoral alignment in the coronal plane and the shift in lower extremity mechanical axis were determined. The average lateral shift in the lower extremity mechanical axis was 24% of the tibial plateau width. The average change in the mechanical tibiofemoral angle was 7 degrees of valgus. Union rate at the osteotomy site was 95%. No deep infections, clinical deep venous thrombosis, or device failures occurred. The Osteotrac plate provides safe and effective fixation and intraoperative adjustability to achieve and maintain a lateral shift of the lower extremity mechanical axis and valgus correction of the tibiofemoral alignment in patients with varus knees undergoing proximal tibial opening wedge osteotomy and associated meniscal and chondral procedures.
Mack, Andrew W; Freedman, Brett A; Groth, Adam T; Kirk, Kevin L; Keeling, John J; Andersen, Romney C
Open proximal femoral fractures are rare injuries that often result from wartime high-energy causes. Limited data exist regarding the treatment and complications of these injuries. We retrospectively reviewed the records of combat casualties treated at two institutions between March 2003 and March 2008. The casualty patient databases, medical records, radiographs, and laboratory data were reviewed to determine time to union, complication rates, and patient outcomes. Forty-one patients (thirty-nine men and two women) with a mean age of 25.7 years were identified as receiving treatment for open proximal femoral fractures. The mechanisms of injury for these forty-one patients were blast (twenty-nine patients [71%]), gunshot wound (eight patients [20%]), motor vehicle crash (three patients [7%]), and helicopter crash (one patient [2%]). There were thirty Type-IIIA, six Type-IIIB, and five Type-IIIC open fractures. The predominant method of definitive fixation was a cephalomedullary or reconstruction nail in thirty-four patients (83%). Thirty-nine patients had at least two years of follow-up data available for assessment of complications and radiographic union. The mean time to union was 5.1 months (range, 2.8 to 16.0 months). Complications requiring reoperation occurred in twenty-two (56%) of thirty-nine patients. Wound infection (twelve patients [31%]) and symptomatic heterotopic ossification (ten patients [26%]) were the most common complications. Cephalomedullary nail fixation of open Type-III wartime subtrochanteric and pertrochanteric femoral fractures can be reliably used to effect fracture union in a timely manner. The most frequent complications of treatment are wound infection and symptomatic heterotopic ossification.
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.
Türkmen, Faik; Sever, Cem; Kacıra, Burkay K; Demirayak, Mehmet; Acar, Mehmet Ali; Toker, Serdar
Medial opening-wedge high tibial osteotomy (MOWHTO) is an effective surgical procedure for patients who have medial compartmental osteoarthritis of the knee with varus deformity of the limb. The abnormal load on the medial compartment of the knee is directed to the lateral compartment with this procedure. A gap occurs on the proximal tibia while providing adequate correction. Filling this gap with bone grafts or synthetic materials has gained wide acceptance for preventing bone union problems or osteotomy site collapse. The aim of this study is to report our results of MOWHTOs performed without any bone graft or any other synthetic materials. We evaluated 41 MOWHTOs that have been performed between 2009 and 2012 with no use of any grafts or synthetic materials and spacer. Age of the patients ranged from 43 to 67. Thirty-five of the patients were females and three of them were males. The follow-up time was 6 months. Seven knees had opening at the osteotomy site <10 mm, 26 knees had 10-12.5 mm, and eight knees had >12.5 mm (range 7.5-14 mm, mean 11.07 mm). All osteotomies united without loss of correction. The mean bone union time was 12.8 weeks. We did not have any major complication regarding the technique. The results of our study have shown that we can achieve satisfactory and good results by performing MOWHTO procedure without using any bone grafts or synthetic materials and spacer.
Lopes, C B; Pacheco, M T T; Silveira, L; Duarte, J; Cangussú, M C T; Pinheiro, A L B
Bone fractures are lesions of different etiology; may be associated or not to bone losses; and have different options for treatment, such as the use of biomaterials, guided bone regeneration, techniques considered effective on improving bone repair. Laser therapy has also been shown to improve bone healing on several models. The association of these three techniques has been well documented by our group using different models. This study aimed to assess, through Raman spectroscopy, the incorporation of calcium hydroxyapatite (CHA approximately 958 cm(-1)) on the repair of complete tibial fractures in rabbits treated with wire osteosynthesis (WO); treated or not with laser therapy; and associated or not with the use of BMPs and/or Guided Bone Regeneration. Complete tibial fractures were created in 12 animals that were divided into four groups: WO; WO+BMPs; WO+laser therapy; and WO+BMPs+laser therapy. Irradiation started immediately after surgery; was repeated at every other day during 2 weeks; and was carried out with lambda 790 nm laser light (4 J/cm(2) per point, 40 mW, phi approximately 0.5 cm(2), 16J per session). Animal death occurred after 30 days. Raman spectroscopy was performed at both the surface and the depth of the fracture site. Statistical analysis showed significant difference on the concentrations of CHA between surface and depth. The analysis in each of the areas showed at the depth of the fracture significant differences between all treatment groups (p<0.0001). Significant differences were also seen between WO+BMPs+laser therapy and WO (p<0.001) and WO+laser therapy (p<0.001). At the surface, significant difference was seen only between the treatment groups and the non-fractured subjects (p=0.0001). However, no significant difference was seen between the treatment groups (p=0.14). It is concluded that the use of NIR laser therapy associated to BMPs and GBR was effective in improving bone healing on the fractured bones as a result of the increasing
Lee, Dae-Hee; Park, Sung-Chul; Park, Hyung-Joon; Han, Seung-Beom
Open-wedge high tibial osteotomy (HTO) cannot always accurately correct limb alignment, resulting in under- or over-correction. This study assessed the relationship between soft tissue laxity of the knee joint and alignment correction in open-wedge HTO. This prospective study involved 85 patients (86 knees) undergoing open-wedge HTO for primary medial osteoarthritis. The mechanical axis (MA), weight-bearing line (WBL) ratio, and joint line convergence angle (JLCA) were measured on radiographs preoperatively and after 6 months, and the differences between the pre- and post-surgery values were calculated. Post-operative WBL ratios of 57-67 % were classified as acceptable correction. WBL ratios <57 and >67 % were classified as under- and over-corrections, respectively. Preoperative JLCA correlated positively with differences in MA (r = 0.358, P = 0.001) and WBL ratio (P = 0.003). Difference in JLCA showed a stronger correlation than preoperative JLCA with differences in MA (P < 0.001) and WBL ratio (P < 0.001). Difference in JLCA was the only predictor of both difference in MA (P < 0.001) and difference in WBL ratio (P < 0.001). The difference between pre- and post-operative JLCA differed significantly between the under-correction, acceptable-correction, and over-correction groups (P = 0.033). Preoperative JLCA, however, did not differ significantly between the three groups. Neither preoperative JLCA nor difference in JLCA correlated with change in posterior slope. Preoperative degree of soft tissue laxity in the knee joint was related to the degree of alignment correction, but not to alignment correction error, in open-wedge HTO. Change in soft tissue laxity around the knee from before to after open-wedge HTO correlated with both correction amount and correction error. Therefore, a too large change in JLCA from before to after open-wedge osteotomy may be due to an overly large reduction in JLCA following osteotomy, suggesting alignment over
Busse, Jason W.; Bhandari, Mohit; Guyatt, Gordon H.; Heels-Ansdell, Diane; Kulkarni, Abhaya V.; Mandel, Scott; Sanders, David; Schemitsch, Emil; Swiontkowski, Marc; Tornetta, Paul; Wai, Eugene; Walter, Stephen D.
Objective To explore the role of patients’ beliefs in their likelihood of recovery from severe physical trauma. Methods 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 post-surgical 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 (PCS) and mental component summary (MCS) scores. Results In our adjusted multivariable regression models that included pre-injury SF-36 scores, SPOC scores at 6-weeks post-surgery accounted for 18% of the variation in SF-36 PCS scores and 18% of SF-36 MCS 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 multi-trauma. 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% CI = 0.50 to 0.73). Conclusion The SPOC questionnaire is a valid measurement of illness beliefs in tibial fracture patients 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. PMID:22011635
Zhou, Kai-hua; Chen, Nong
Purpose: This study aimed to compare the clinical, radiologic, and cost-effectiveness results between locking and non-locking plates for the treatment of extra-articular type A distal tibial fractures. Methods: We performed a retrospective review of AO/OTA 42-A1, A2 distal tibial fractures treated by plates from January 2011 to June 2013. Patients were divided to the locking plate group or the non-locking plate group. Clinical outcomes, radiographic outcomes, and hospitalization fee were compared between the two plates groups. Results: 28 patients were treated with a locking plate and 23 patients were treated with a non-locking plate. The mean follow-up was 18.8 months (12-23 months). There were no significant differences between the groups in surgical time, bleeding, bone union time, or AOFAS scores. The cost of the locking plate was ¥24,648.41 ± 6,812.95 and the cost of the non-locking plate was ¥11,642 ± 3,162.57, p < 0.001. Each group had one patient that experienced superficial infection these wounds were readily healed by oral antibiotics and dressing changes. To date, five patients in the locking group and ten patients in the non-locking group had sensations of metal stimulation or other discomfort (X2 = 3.99, p < 0.05) Until the last follow-up, 14 patients in the locking plate group and 18 patients in the non-locking plate group had their plates removed or wanted to remove their plates (X2 = 4.31, p < 0.05). Conclusion: The use of locking or non-locking plates provides a similar outcome in the treatment of distal fractures. However the locking plate is much more expensive than the non-locking plate. PMID:28400874
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.
procedure. J Bone Joint Surg Am. 2001;83:239 246. 6. Burgess AR, Poka A, Brumback RJ , et al. Management of open grade III tibial fractures. Orthop Clin...extremities with failed free flaps: a single institution’s experience over 25 years. Ann Plast Surg. 2007;59:18 21. 19. Fix RJ , Vasconez LO...of lower extremity defects: anatomic considerations. Surg Clin North Am. 1974;54:1337 1354. 22. Shepherd LE, Costigan WM, Gardocki RJ , et al. Local or
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
Gäbel, G; Pyrc, J; Hinterseher, I; Zwipp, H; Saeger, H-D; Bergert, H
Vascular injuries are an uncommon finding. In times of peace vascular injuries occur in approximately 1-4 % during traffic accidents. Especially challenging is the treatment of open fractures combined with arterial lesions. These fractures are usually accompanied with severe soft tissue damage and injuries to neurological structures. The overall prognosis of these trauma patients is dependent on fast and sufficient diagnostics and therapy. In particular, for unstable patients time-consuming diagnostics can be dispensed and a primarily operative therapy should be targeted. Vascular reconstruction by direct suture is sometimes only possible with interposition and should be the primary goal. Interposition should be performed with autologous vein material because of the high risk of infection. Here we demonstrate on the basis of our patients the interdisciplinary -management of such trauma patients in our hospital.
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.
Wendsche, P; Kočiš, J; Chmelová, J; Kelbl, M; Stursa, V
Frozen tibial shaft bone allografts filled with autologous cancellous bone chips were used for anterior column reconstruction in Th12 and L1 fractures. The aim of this retrospective study was to evaluate the five-year results of the treatment on the basis of radiographic findings. Twenty-six patients treated in 2005 and 2006 for isolated Th12 or L1 fractures, with no neurological deficit, were evaluated. In all patients, the spine was stabilised from an isolated anterior approach or through a combined posterior and anterior approach, and angle-stable implants were used. On radiographic examination the loss of correction and lateral compression of the segment involved were measured on standard X-ray views. Data on bone union at graft-bone interfaces were obtained from spiral CT scans. For assessment of the stage of bone healing, a scale of 0-25-50-75-100 % was established, and each patient was evaluated by two independent radiologists. Based on the average results, bone union was defined as non-union, 0-24 %; incomplete union, 25-74 %; complete union, 75-100 %. The average loss of correction measured by Beck's method was 0.77 degree. In four patients, the lateral compression angle deteriorated on the average by 1.1 degree (range, 0.7°-1.8°) during the treatment. The proximal graft-bone interface showed complete union in 19 patients (73 %), and the distal interface was completely healed in 20 patients (77 %). Incomplete bone union at the proximal and the distal interface was found in seven (27 %) and six (23 %) patients, respectively. Nonunion was not recorded. No complications occurred. The use of tibial shaft bone allografts filled with autologous cancellous bone chips resulted in stable reconstruction of the anterior column of the thoracolumbar spine which showed a low loss of correction and good bone union.
Kraal, T; Mullender, M; de Bruine, J H D; Reinhard, R; de Gast, A; Kuik, D J; van Royen, B J
The open-wedge high tibial osteotomy (OWHTO) is a well accepted treatment modality for patients with osteoarthritis of the medial compartment associated with genu varum. To fill in the osteotomy gap 30% macroporosity rigid beta-tricalcium phosphate (beta-TCP) is frequently used as a stable resorbable bone substitute. However, the resorbability of these beta-TCP wedges is not known. The aim of this study was to investigate this. Twenty-one OWHTO procedures in seventeen patients were performed with the use of 30% macroporosity rigid beta-TCP wedges. The osteotomies were fixed using an angle-stable locking plate. Conventional AP and lateral radiographs were examined in order to assess the resorbability of the 30% macroporosity rigid beta-TCP wedges as a function of time. A radiological classification system consisting of five phases was used to monitor the resorption of the 30% macroporosity rigid beta-TCP wedges. The mean duration of follow-up was 62 months (+/-23 range of 28-99). In all 21 cases, remnants of the 30% macroporosity rigid beta-TCP wedges were still present at maximum follow-up. Although the boundaries between 30% macroporosity rigid beta-TCP wedges and bone remained slightly visible, all osteotomies were completely consolidated and full osseointegration took place. In 16 out of 21 knees the fixation system was removed after a mean duration of 32 months (+/-19 range of 6-62). In six out of 21 knees a conversion to a knee arthroplasty was performed after a mean duration of 56 months (+/-18 range of 37-82). The OWHTO did not interfere with the placement of knee prostheses. Complete resorption of 30% macroporosity rigid beta-TCP wedges did not take place up to 8 years after operation.
Seagrave, Richard A.; Sojka, John; Goodyear, Adam; Munns, Stephen W.
INTRODUCTION The lateral closing wedge high tibial osteotomy (HTO) was popularized by Coventry in the 1960s. In the 1990s the medial opening wedge osteotomy gained popularity because it could achieve greater valgus correction and it did not require dissociation of the fibula from the tibia, an important consideration when treating varus knees with lateral and posterolateral ligament deficiencies (Noyes’ double-varus and triple-varus knees). However, it has the disadvantage of requiring bone graft to fill bony defects. Recently, the reamer-irrigator-aspirator (RIA; Synthes, Paoli, PA) system was developed, and as a result of this procedure, a large amount of usable autogenous bone graft can be collected safely for use. To our knowledge, there is no published series combining opening wedge HTO with the use of RIA obtained autogenous bone graft. PRESENTATION OF CASE We present a novel technique in which a series of three patients underwent opening wedge HTO using ipsilateral, retrograde femur RIA graft to fill the bone defect. All patients had satisfactory clinical and radiologic outcomes following the new technique at latest follow up. DISCUSSION Opening wedge high tibial osteotomy is a well-documented and accepted orthopedic procedure, however, has the disadvantage of requiring varying amounts of bone graft. Traditionally, iliac crest or tricortical allograft have been the grafting modalities of choice, however both have inherent drawbacks to their use. In our series, the use of RIA autograft is a safe and reliable harvest technique for high tibial osteotomy, providing abundant and quality autogenous bone graft. CONCLUSION All three of our patients achieved radiographic union with high clinical patient satisfaction without any major complications. We feel this novel technique is a safe and acceptable operative solution grafting opening wedge osteotomies about the knee. PMID:24412805
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
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.
Hackett, William R.; Gleason, Gayle C.; Kappel, William M.
Open bedrock fractures were mapped in and near two brine field areas in Tully Valley, New York. More than 400 open fractures and closed joints were mapped for dimension, orientation, and distribution along the east and west valley walls adjacent to two former brine fields. The bedrock fractures are as much as 2 feet wide and over 50 feet deep, while linear depressions in the soil, which are 3 to 10 feet wide and 3 to 6 feet deep, indicate the presence of open bedrock fractures below the soil. The fractures are probably the result of solution mining of halite deposits about 1,200 feet below the land surface.
Karabila, Mohamed Amine; Azouz, Mohamed; Mhamdi, Younes; Hmouri, Ismail; Kharmaz, Mohamed; Bardouni, Ahmed; Lahlou, Abdou; Mahfoud, Mustapha; Berrada, Mohamed Saleh
Nous rapportons le cas d'une rupture post-traumatique du tendon tibial postérieur survenue lors d'une fracture bimalléolaire de la cheville. Le diagnostic a été posé lors de l'intervention chirurgicale. La réparation du tendon, non dégénératif, a été réalisée en même temps que l'ostéosynthèse. Bien que rare, cette possibilité de lésion tendineuse lors des fractures de la cheville ne doit pas êtreoubliée. Des douleurs résiduelles, un déficit de l'inversion active du pied, une modification de l'arche médiane du pied et à terme une évolution vers un pied plat valgus doivent faire évoquer rétrospectivement le diagnostic. PMID:27022431
Patil, Mahantesh Yellangouda; Gupta, Srinath Myadam; Agarwal, Saumya; Chandarana, Vishal
Introduction Open fractures are treated as surgical emergency and early administration of intravenous antibiotic coupled with early irrigation and debridement decreases the infection rate dramatically. Limb Reconstruction System (LRS) is a unilateral rail system which consists of Shanz pins, rail rods and sliding clamps. It is specifically designed to enable the surgeon to perform simple and effective surgery as it offers rigid fixation of fracture fragments, allowing early weight bearing and reduces economic burden. Aim To determine the efficacy of Limb Reconstruction System for treatment of compound tibia fractures. Materials and Methods A prospective study was carried out where in 54 cases out of 412 compound tibia fractures having Modified Gustilo Anderson Type IIIA and IIIB with a mean age of 42±5 years were treated using LRS over a period of 26 months. Limb reconstruction system was used in acute docking mode or with corticotomy and bone transport was done depending upon the bone loss. The soft tissue condition was assessed and split thickness skin grafting and flap repairs were done as per the need. Clinical and radiological assessment was done at every follow-up. Bony and functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. Results Among 54 patients, bony results as per ASAMI score were excellent in 36, good in 14, fair in 2 and poor in 2 patients. Functional results were excellent in 43, good in 7, fair in 4 patients. The average fracture union time was 8 months. Post-surgery patient satisfaction was excellent since fixation allowed weight bearing immediately. Average hospital stay was 7 days and financial burden was reduced by 40% as compared to multi staged surgery. The average time of return to work was 20 days. Conclusion LRS is an easy, simple and definitive surgical procedure that allows immediate full weight bearing walking. It reduces hospital stay, is cost effective with
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…
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…
Zhang, Xuebin; Liu, Yueju; Peng, Aqin; Wang, Haili; Zhang, Yingze
Background: Treatment of open calcaneal fractures remains to be a challenge for orthopaedic surgeons. The aim of this study is to assess factors affecting the treatment results of open calcaneal fractures. Methods: A total of 98 patients who have 101 open calcaneal fractures were recruited in our hospital, they were all treated with a standard protocol based on the appearance of the traumatic wound. Data on mechanism of injury, location and size of wound, classification, fixation methods and subsequent soft-tissue complications were collected and evaluated. AOFAS Ankle-Hindfoot Survey and physical examinations were performed to access outcomes. Results: No statistical difference was found in complication and AOFAS score in open calcaneal fractures treated with different fixation, and no statistical difference was found in AOFAS between gustilo I and II type open calcaneal fractures (P > 0.05). There was significant difference between gustilo I and III type or gustilo II and III type fractures (P < 0.05). The more serious soft tissue injury of open calcaneal fracture lead to the worse outcome and higher incidence of complications obtained. Conclusion: Open calcaneal fractures have a high propensity for soft-tissue complications no matter which fixation method was chose. There was no significant difference between patients who had been treated with different fixations in complication rates. Soft-tissue injury played an important role in outcomes of open calcaneal fractures. Deep infections and osteomyelitis were rare by means of emergency debridement and following repeated debridement. PMID:26064282
A fracture is a break, usually in a bone. If the broken bone punctures the skin, it is called an open ... falls, or sports injuries. Other causes are low bone density and osteoporosis, which cause weakening of the ...
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
Hermansen, Lars L; Freund, Knud G
This case report describes a 12-year-old boy, who suffered an injury to the right knee in a skateboard accident. Radiographs and surgery confirmed the extremely rare bifocal avulsion fracture including the distal patellar pole and tibial tuberosity. Open reduction and internal fixation was accomplished, and 4-month follow-up demonstrated a good outcome.
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
Millard, Ralph P; Weng, Hsin-Yi
To evaluate the proportion of and risk factors for open fractures of the appendicular skeleton in dogs and cats that were a result of acute trauma. Cross-sectional and case-control study. 84,629 dogs and 26,675 cats. Dogs and cats examined at Purdue University Veterinary Teaching Hospital from January 1993 through February 2013 were identified; the proportion of open fractures was estimated from the medical records. Additionally, all incident cases of open (77 dogs and 33 cats) and closed (469 dogs and 80 cats) fractures between January 1993 and February 2013 and a random sample of nonfracture patients (722 dogs and 330 cats) in 2010 were used to assess risk factors for open appendicular fractures. Proportion of open fractures for the 20-year period was 0.09% (95% confidence interval [CI], 0.07% to 0.11%) in dogs and 0.12% (95% CI, 0.09% to 0.17%) in cats. Seventy-seven of 546 (14.1%) and 33 of 113 (29.2%) traumatic fractures were classified as open in dogs and cats, respectively. Comminuted fractures were more likely than other configurations to be open in dogs (OR, 5.9; 95% CI, 2.9 to 12.2) and cats (OR, 3.5; 95% CI, 1.0 to 12.0). Vehicle-related trauma was a significant risk factor for open fractures in dogs (OR, 13.8; 95% CI, 3.1 to 61.8). The proportion of incident open fractures in dogs and cats was low. Age, body weight, affected bone or bone segment, fracture configuration, and method of trauma were associated with an open fracture.
Ferner, Felix; Dickschas, Joerg; Ostertag, Helmut; Poske, Ulrich; Schwitulla, Judith; Harrer, Joerg; Strecker, Wolf
Medial open-wedge high tibial osteotomy (MOWHTO) is an established method to treat unicompartimental osteoarthritis of the knee joint. However, augmentation of the created tibial gap after osteotomy is controversially discussed. We performed a prospective investigation of 49 consecutive cases of MOWHTO at our department. Patients were divided into two groups: group A consisted of 19 patients while group B consisted of 30 patients. In group A, the augmentation of the opening gap after osteotomy was filled with a synthetic bone graft, whereas group B received no augmentation. As an indicator for bone healing we investigated the non-union rate in our study population and compared the non-union-rate between the two groups. The non-union rate was 28% in group A (five of 19 patients had to undergo revision) which received synthetic augmentation, while it was 3.3% in group B (one of 30 patients had to undergo revision) which received no augmentation. The difference between the groups was statistically significant (p-value 0.027). With regard to bone healing after MOWHTO, synthetic augmentation was not superior to no augmentation in terms of non-union rates after surgery. In fact, we registered a significantly higher rate of non-union after augmentation with synthetic bone graft. III. Copyright © 2015 Elsevier B.V. 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.
Prinja, Aditya; Singh, Jagwant; Davis, Nwaka; Urwin, Gillian
An elderly gentleman presented with an open fracture of the calcaneum and ankle, following a boating accident. Despite treatment with repeated surgical debridement, delayed closure, prolonged antibiotics and strict adherence to national guidelines on the management of open fractures, he developed a wound infection with a rare organism, Shewanella putrefaciens, that appears to be increasing in prevalence.
Prinja, Aditya; Singh, Jagwant; Davis, Nwaka; Urwin, Gillian
An elderly gentleman presented with an open fracture of the calcaneum and ankle, following a boating accident. Despite treatment with repeated surgical debridement, delayed closure, prolonged antibiotics and strict adherence to national guidelines on the management of open fractures, he developed a wound infection with a rare organism, Shewanella putrefaciens, that appears to be increasing in prevalence. PMID:23417948
Gessmann, J; Baecker, H; Graf, M; Ozokyay, L; Muhr, G; Seybold, D
The operative management of open fractures of the lower limb requires a consistent treatment to avoid soft tissue complications. Acute angular shortening of the fracture enabling primary soft tissue closure is still an uncommon operative technique because of difficulties in correcting the secondary deformity. The case of a pediatric open fracture of the lower limb (Gustilo type IIIa) is described, which was treated with acute angular shortening followed by gradual correction using the Taylor spatial frame (TSF).
A fractured solid under stress loading (or unloading) can be viewed as behaving macroscopically as a medium with internal, hidden, degrees of freedom, wherein changes in fracture geometry (i.e. opening, closing and extension) and flow of fluid and gas within fractures will produce major changes in stresses and strains within the solid. Likewise, the flow process within fractures will be strongly coupled to deformation within the solid through boundary conditions on the fracture surfaces. The effects in the solid can, in part, be phenomenologically represented as inelastic or plastic processes in the macroscopic view. However, there are clearly phenomena associated with fracture growth and open fracture fluid flows that produce effects that can not be described using ordinary inelastic phenomenology. This is evident from the fact that a variety of energy release phenomena can occur, including seismic emissions of previously stored strain energy due to fracture growth, release of disolved gas from fluids in the fractures resulting in enhanced buoyancy and subsequent energetic flows of gas and fluids through the fracture system which can produce raid extension of old fractures and the creation of new ones. Additionally, the flows will be modulated by the opening and closing of fractures due to deformation in the solid, so that the flow process is strongly coupled to dynamical processes in the surrounding solid matrix, some of which are induced by the flow itself.
Sharma, Naveen; Singh, Varun; Agrawal, Ashish; Bhargava, Rakesh
Background: Proximal tibia fractures with compartment syndrome present a challenge for orthopedic surgeons. More often than not these patients are subjected to multiple surgeries and are complicated by infection osteomyelitis and poor rehabilitation. There is no consensus in the management of these fractures. Most common mode is to do early fasciotomy with external fixation, followed by second stage definitive fixation. We performed a retrospective study of proximal tibia fractures with impending compartment syndrome treated by single stage fasciotomy and internal fixation. Results in terms of early fracture union, minimum complications and early patient mobilization were very good. Materials and Methods: Fifteen patients who were operated between July 2011 and June 2012 were selected for the study. All documents from their admission until the last followup in December 2013 were reviewed, data regarding complications collected and results were evaluated using Oxford Knee scoring system. Results: At the final outcome, there was anatomical or near anatomical alignment with no postoperative problems with range of motion of near complete flexion (>120) in all patients within 3 months. 13 patients started full weight bearing walking at 3 months. Delayed union in two patients and skin necrosis in one patient was observed. Conclusions: Since the results are encouraging and the rehabilitation time is much less when compared to conventional approaches, it is recommended using this protocol to perform early fasciotomy with the definitive internal fixation as single stage surgery to obtain excellent followup results and to reduce rehabilitation time, secondary trauma, expense of treatment and infection rate. PMID:26538755
Wang, Haosen; Hao, Zhixiu; Wen, Shizhu
Intramedullary interlocking nailing is an effective technique used to treat long bone fractures. Recently, biodegradable metals have drawn increased attention as an intramedullary interlocking nailing material. In this study, numerical simulations were implemented to determine whether the degradation rate of magnesium alloy makes it a suitable material for manufacturing biodegradable intramedullary interlocking nails. Mechano-regulatory and bone-remodeling models were used to simulate the fracture healing process, and a surface corrosion model was used to simulate intramedullary rod degradation. The results showed that magnesium alloy intramedullary rods exhibited a satisfactory degradation rate; the fracture healed and callus enhancement was observed before complete dissolution of the intramedullary rod. Delayed magnesium degradation (using surface coating techniques) did not confer a significant advantage over the non-delayed degradation process; immediate degradation also achieved satisfactory healing outcomes. However, delayed degradation had no negative effect on callus enhancement, as it did not cause signs of stress shielding. To avoid risks of individual differences such as delayed union, delayed degradation is recommended. Although the magnesium intramedullary rod did not demonstrate rapid degradation, its ability to provide high fixation stiffness to achieve earlier load bearing was inferior to that of the conventional titanium alloy and stainless steel rods. Therefore, light physiological loads should be ensured during the early stages of healing to achieve bony healing; otherwise, with increased loading and degraded intramedullary rods, the fracture may ultimately fail to heal.
Shin, Young-Soo; Kim, Keong-Ho; Sim, Hyun-Bo; Yoon, Jung-Ro
An adequate stable fixation implant should be used for medial opening-wedge high tibial osteotomy (MOWHTO) to promote rapid bone healing without complications. This study compared the radiographic and clinical outcomes as well as plate-specific complications between two angular stable locking plates in patients following MOWHTO. This prospective study involved 97 patients (50 with DWL(®), group I; 47 with TomoFix™, group II) undergoing MOWHTO for primary medial compartment osteoarthritis between 2010 and 2013. Clinical and radiographic evaluations were performed by using the HSS and WOMAC scores, and calculating mechanical femorotibial angle (mFTA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), and posterior tibial slope (PTS) on radiographs both preoperatively and after 3 years. A statistically significant difference was observed for the MPTA at the last follow-up between the two groups (P = 0.033). Additionally, the last follow-up MPTA of group I was associated with the osteotomy technique (P = 0.004) and preoperative JLCA (P = 0.034) whereas the last follow-up MPTA of group II was associated with gender (P = 0.001) and BMI (P = 0.008). Furthermore, the results showed that group I had a higher rate of non-union (4%) compared to that in group II (0%). Both locking plates are useful tools in the treatment of medial compartment knee osteoarthritis with varus deformity in young, active patients. However, under special consideration of the complication we found in present study, the TomoFix™ seems to be a better alternative in using the MOWHTO for highly demanding patients. Copyright © 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
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.
O'Sullivan, S T; O'Sullivan, M; Pasha, N; O'Shaughnessy, M; O'Connor, T P
The patient with severe lower limb trauma presents a management dilemma; whether to amputate primarily or to attempt limb salvage. In recent years, many predictive indices have been published which purport to identify limbs which are non-viable. We retrospectively applied two recently described indices, the Mangled Extremity Severity Score (MESS) and the Limb Salvage Index (LSI), to 54 limbs in 50 patients with either Gustilo IIIB or IIIC complex tibial fractures. There were 22 amputations (40.7 per cent) in the series. The mean MESS score in the limb salvage group was 3.8 (range 2-10), and the mean MESS score in the amputation group was 7.7 (range 4-13) (P < 0.0001). The mean LSI score in the limb salvage group was 3.6 (range 3-8), and the mean LSI score in the amputation group was 6.9 (P < 0.01). However, in the group with MESS scores > 7 (which recommends amputation), there were three limbs which were salvaged with acceptable functional outcome. Similarly, in those with LSI scores > 6 (which recommends amputation), there were seven limbs successfully salvaged. A MESS > 7 offered a greater relative risk of amputation (9.2) than a LSI score > 6 (5.3). We found both indices of use in predicting limb salvage and functional outcome. However, neither is sufficiently accurate to be considered absolutely reliable in clinical practice.
Çabuk, H; Dedeoğlu, S S; Adaş, M; Tekin, A Ç; Seyran, M; Ayanoğlu, S
PURPOSE OF THE STUDY Although supracondylar humeral fractures represent a major part of the pediatric fractures, no classification system or radiological characteristics describes which supracondylar fractures require open reduction. We aim to evaluate the factors that lead us to perform open reduction during operation. MATERIAL AND METHODS We retrospectively evaluated 57 patients who underwent operation for type III supracondylar fracture, and divided them into two groups; those with open reduction and internal fixation, and those with closed reduction and percutaneous fixation. The two groups were compared based on age, gender, BMI by age, medial spike angle of the fracture, medial spike-skin distance and rotation angle between the fractured fragments. RESULTS Of all patients, 46 (81.71%) underwent closed reduction and percutaneous fixation (CRPF) and 11 (19.29%) were treated with open reduction and internal fixation (ORIF). BMI by age was remarkably higher in the ORIF group (p = 0.00). And medial spike angle was smaller in the ORIF group (p = 0.014). DISCUSSION Closed reduction and percutanous fixation is the main treatment of supracondylar humeral fractuers. Open reduction in supracondylar humeral fractures could be associate with complications and cosmetic lesions. Many studies indicates that obesity is high risk factor for complex fractures as well as preoperative and postoperative complications. A prominant medial spike could associate with muscle entrapment, and obliquity of the fracture line. It could be also an indirect finding of instablity of the fracture. CONCLUSION We suggest that a smaller medial spike angle and a higher BMI in children with Type III supracondylar humeral fractures may require open reduction, and it is unreasonable to avoid open reduction in cases where closed reduction is not achieved. supracondylar humerus, open reduction, obesity, medial spike angle.
Laine, Jennifer C; Cherkashin, Alexander; Samchukov, Mikhail; Birch, John G; Rathjen, Karl E
Type III B and C open tibia fractures in children pose a challenge to the orthopaedic surgeon. Limb salvage is the initial goal for the majority of patients, but managing soft-tissue defects and bone loss can be a challenge. The purpose of this study was to evaluate the use of circular external fixation in the management of these injuries. In this retrospective review, we examined children with type IIIB and IIIC open tibial fractures treated with circular external fixation and soft-tissue coverage between 1990 and 2010. Chart review included: mechanism and severity of injury, degree of bone and soft-tissue loss, technique and duration of external fixation, additional procedures, clinical and radiographic outcomes, and complications. Eight patients were identified whose average age at the time of injury was 10.4 years (range, 3.8 to 15.3 y). There were 7 type IIIB and 1 type IIIC fractures. All patients received free or rotational soft-tissue flaps. Average bone loss was 5.4 cm (range, 0 to 12 cm). Three techniques of circular external fixation were used, including: (1) static stabilization to allow for soft-tissue coverage and fracture healing, (2) acute shortening with plan for later limb lengthening, and (3) stabilization of the extremity for soft-tissue coverage and intended bone transport. Seven of 8 limbs were salvaged. Of those 7, all were followed to skeletal maturity and ambulating without assistive devices at final follow-up. Three patients had a clinically relevant leg-length discrepancy (≥2 cm). Four of 8 patients required secondary or contralateral procedures. Pediatric type IIIB and IIIC tibia fractures are limb-threatening injuries that require dynamic thinking and management as the bone and soft-tissue injuries evolve. We have proposed a general algorithm to guide the treatment of these severe injuries. In our experience, circular external fixation, in conjunction with this algorithm, provides the appropriate stability and environment for managing
Jiwanlal, Aneel; Jeray, Kyle James
Isolated posterior tibial plateau fractures are rare injuries that encompass a wide variety of fracture patterns. Based on the variation in fracture pattern, the surgical approach varies, with both anterior and posterior approaches described for surgical fixation. Postoperative protocol also varies among studies. The aim of this article is to summarize the outcomes related to posterior column tibial plateau fractures. The papers reviewed, primarily small retrospective case series, showed functional knee range of motion is preserved, a low incidence of wound complications, and patient outcome scores comparable to other reported lower extremity injury outcome scores. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
VALIATI, Renato; IBRAHIM, Danilo; ABREU, Marcelo Emir Requia; HEITZ, Claiton; de OLIVEIRA, Rogério Belle; PAGNONCELLI, Rogério Miranda; SILVA, Daniela Nascimento
The treatment of condylar process fractures has generated a great deal of discussion and controversy in oral and maxillofacial trauma and there are many different methods to treat this injury. For each type of condylar fracture, the techniques must be chosen taking into consideration the presence of teeth, fracture height, patient's adaptation, patient's masticatory system, disturbance of occlusal function, deviation of the mandible, internal derangements of the temporomandibular Joint (TMJ) and ankylosis of the joint with resultant inability to move the jaw, all of which are sequelae of this injury. Many surgeons seem to favor closed treatment with maxillomandibular fixation (MMF), but in recent years, open treatment of condylar fractures with rigid internal fixation (RIF) has become more common. The objective of this review was to evaluate the main variables that determine the choice of method for treatment of condylar fractures: open or closed, pointing out their indications, contra-indications, advantages and disadvantages. PMID:18974859
FAILLACE, Vanessa; TAMBELLA, Adolfo Maria; FRATINI, Margherita; PAGGI, Emanuele; DINI, Fabrizio; LAUS, Fulvio
A 9-month-old filly donkey was referred for a comminuted diaphyseal fracture of the right tibia. Surgical osteosynthesis, with multiple lag screws and a neutralization plate, was performed for anatomical reconstruction. Despite a good gait condition, delayed bone consolidation and a bone gap were evident on follow up radiographic evaluations. Due to delayed healing, autologous platelet-rich plasma (PRP) was injected on the surface of the tibia. Increased bone consolidation was evident on radiographs one month after the PRP injection. Progressive filling of both the fracture lines and bone gap continued during the six-month follow up. Clinical outcome was excellent. Autologous PRP should be considered as a practical adjuvant therapy in bone healing process in donkeys. PMID:28190827
Ketonis, Constantinos; Dwyer, Joseph; Ilyas, Asif M
Background: Literature on open fracture infections has focused primarily on long bones, with limited guidelines available for open hand fractures. In this study, we systematically review the available hand surgery literature to determine infection rates and the effect of debridement timing and antibiotic administration. Methods: Searches of the MEDLINE, EMBASE, and Cochrane computerized literature databases and manual bibliography searches were performed. Descriptive/quantitative data were extracted, and a meta-analysis of different patient cohorts and treatment modalities was performed to compare infection rates. Results: The initial search yielded 61 references. Twelve articles (4 prospective, 8 retrospective) on open hand fractures were included (1669 open fractures). There were 77 total infections (4.6%): 61 (4.4%) of 1391 patients received preoperative antibiotics and 16 (9.4%) of 171 patients did not receive antibiotics. In 7 studies (1106 open fractures), superficial infections (requiring oral antibiotics only) accounted for 86%, whereas deep infections (requiring operative debridement) accounted for 14%. Debridement within 6 hours of injury (2 studies, 188 fractures) resulted in a 4.2% infection rate, whereas debridement within 12 hours of injury (1 study, 193 fractures) resulted in a 3.6% infection rate. Two studies found no correlation of infection and timing to debridement. Conclusions: Overall, the infection rate after open hand fracture remains relatively low. Correlation does exist between the administration of antibiotics and infection, but the majority of infections can be treated with antibiotics alone. Timing of debridement, has not been shown to alter infection rates.
Makki, Daoud; Matar, Hosam E; Webb, Mark; Wright, David M; James, Leroy A; Ricketts, David M
The aim of this study was to evaluate the rate of open reduction and complications of elastic stable intramedullary nailing (ESIN) in treating unstable diaphyseal forearm fractures in children. We performed a retrospective review of a consecutive series of 102 paediatric patients with a mean age of 9 years (range: 7-14 years) who underwent ESIN of unstable closed forearm fractures at three different centres. Closed reduction of one or both bones was achieved in 68 (67%) patients and open reduction was required in 34 (33%) patients. The rate of open reduction in single-bone fractures (52.2%) was significantly higher than that in both-bone fractures (27.8%) (P=0.04, Fisher's exact test). All the fractures united within 3 months. There were six refractures following nail removal. Five patients had superficial wound infections. Seven patients developed neuropraxia of the sensory branch of the radial nerve. All resolved spontaneously within 3 months of the surgery. ESIN is an effective technique in treating unstable diaphyseal forearm fractures. The need for open reduction should be decided promptly following failed attempts of closed reduction. Single-bone fractures are more likely to require open reduction than both-bone fractures. The radius should be reduced and stabilized first. If open reduction is required, this should be performed through a volar approach rather than a dorsal one.
Nusselt, Thomas; Hofmann, Alexander; Wachtlin, Daniel; Gorbulev, Stanislav; Rommens, Pol Maria
Bone graft substitutes are widely used for reconstruction of posttraumatic bone defects. However, their clinical significance in comparison to autologous bone grafting, the gold-standard in reconstruction of larger bone defects, still remains under debate. This prospective, randomized, controlled clinical study investigates the differences in pain, quality of life, and cost of care in the treatment of tibia plateau fractures-associated bone defects using either autologous bone grafting or bioresorbable hydroxyapatite/calcium sulphate cement (CERAMENT™|BONE VOID FILLER (CBVF)). CERTiFy (CERament™ Treatment of Fracture defects) is a prospective, multicenter, controlled, randomized trial. We plan to enroll 136 patients with fresh traumatic depression fractures of the proximal tibia (types AO 41-B2 and AO 41-B3) in 13 participating centers in Germany. Patients will be randomized to receive either autologous iliac crest bone graft or CBVF after reduction and osteosynthesis of the fracture to reconstruct the subchondral bone defect and prevent the subsidence of the articular surface. The primary outcome is the SF-12 Physical Component Summary at week 26. The co-primary endpoint is the pain level 26 weeks after surgery measured by a visual analog scale. The SF-12 Mental Component Summary after 26 weeks and costs of care will serve as key secondary endpoints. The study is designed to show non-inferiority of the CBVF treatment to the autologous iliac crest bone graft with respect to the physical component of quality of life. The pain level at 26 weeks after surgery is expected to be lower in the CERAMENT bone void filler treatment group. CERTiFy is the first randomized multicenter clinical trial designed to compare quality of life, pain, and cost of care in the use of the CBVF and the autologous iliac crest bone graft in the treatment of tibia plateau fractures. The results are expected to influence future treatment recommendations. ClinicalTrials.gov: NCT01828905.
Kovar, Florian M; Jaindl, Manuela; Schuster, Rupert; Endler, Georg; Platzer, Patrick
The purpose of this study was to determine whether different forms of stabilization for open femur fractures can be performed without influencing outcome, in particular infection and delayed unions/nonunions. Although the traditional management of these injuries is external fixation, a trend toward definitive stabilization techniques has evolved in the current literature. All open fractures of the femur shaft and the distal femur presenting to our urban Level I trauma center during a 10 year period were reviewed. A total of 40 patients (41 fractures) were initially treated at the above institution within 6 h of injury. All patients underwent emergent wound irrigation, debridement, and antibiothic theraphy. The method of fracture immobilization was left to the discretion of the attending trauma surgent. Study population consited of 12 (29 %) GI, 10 (25 %) GII, and 19 (46 %) GIII fractures. Initially, fracture management was performed with external fixation (EF) 19 (43.2 %), intramedullary nailing (IM) 18 (38.6 %), plating (PL) 3 (6.8 %), screw fixation (SF) 1 (2.3 %) and without treatment 4 (9.1 %). In all, 3 (6.8 %) fractures were complicated by infection, 7 (15.9 %) had implant failure, and 5 (11.4 %) developed delayed union. Using external fixation in acute fracture treatment for open femur fractures is a safe and effective surgical technique. Based on our results, external fixation might be superior to intramedullary nailing or plating when evaluating outcome parameters and complications.
Background Bone graft substitutes are widely used for reconstruction of posttraumatic bone defects. However, their clinical significance in comparison to autologous bone grafting, the gold-standard in reconstruction of larger bone defects, still remains under debate. This prospective, randomized, controlled clinical study investigates the differences in pain, quality of life, and cost of care in the treatment of tibia plateau fractures-associated bone defects using either autologous bone grafting or bioresorbable hydroxyapatite/calcium sulphate cement (CERAMENT™|BONE VOID FILLER (CBVF)). Methods/Design CERTiFy (CERament™ Treatment of Fracture defects) is a prospective, multicenter, controlled, randomized trial. We plan to enroll 136 patients with fresh traumatic depression fractures of the proximal tibia (types AO 41-B2 and AO 41-B3) in 13 participating centers in Germany. Patients will be randomized to receive either autologous iliac crest bone graft or CBVF after reduction and osteosynthesis of the fracture to reconstruct the subchondral bone defect and prevent the subsidence of the articular surface. The primary outcome is the SF-12 Physical Component Summary at week 26. The co-primary endpoint is the pain level 26 weeks after surgery measured by a visual analog scale. The SF-12 Mental Component Summary after 26 weeks and costs of care will serve as key secondary endpoints. The study is designed to show non-inferiority of the CBVF treatment to the autologous iliac crest bone graft with respect to the physical component of quality of life. The pain level at 26 weeks after surgery is expected to be lower in the CERAMENT bone void filler treatment group. Discussion CERTiFy is the first randomized multicenter clinical trial designed to compare quality of life, pain, and cost of care in the use of the CBVF and the autologous iliac crest bone graft in the treatment of tibia plateau fractures. The results are expected to influence future treatment
Orihuela-Fuchs, V A; Fuentes-Figueroa, S
Every year 50,000 open fractures occur in Mexico; the complication rate is 20%, and infection is the number one complication. The infection rate at the global level is 3%. The infection rate reported in Mexico is 4.4% (1999) overall for open fractures, with infection rates ranging from 0.8 to 15.6% according to the degree of exposure; however, no updated data are available. A retrospective, longitudinal, descriptive, observational study was designed, that included a total of 273 cases. The degree of exposure of the fracture was identified in patients based on the Hospital de Traumatologia Victorio de la Fuente Narváez classification of open fractures and their course within 12 months was assessed identifying the cases with infection. The infection rate was measured according to the degree of exposure of the fracture with univariate analysis, and the association of the variables of interest was established using a bivariate analysis with the chi2 statistical test. The infection rate of open fractures was 8.05%, regardless of the degree of exposure. The latter resulted in an infection rate ranging from 0 to 16.66%. According to the world literature, open fractures result in a high infection rate, with a lower infection rate for open fractures adjusted for the degree of exposure compared to reports of world series and prior national figures. The degree of exposure was statistically significant (p = 0.04) for the presence of infection, according to the Hospital de Traumatología Victorio de la Fuente Narváez classification of open 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
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.
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
Filho, Jorge Sayum; Sayum, Jorge; de Carvalho, Rogério Teixeira; Nicolini, Alexandre; Matsuda, Marcelo Mitsuro; Cheng, Wu Tu; Cohen, Moisés
The authors report the case of a patient (amateur motocross competitor) who suffered a fall during a motocross competition resulting in a supra and intracondylar open fracture in the right femur. PMID:27027061
Singh, Jasbir; Lal, Mukand; Chandel, Desh Raj
Introduction Open fractures of shaft of humerus have been treated conservatively as well as operatively. Plate osteosynthesis has been considered as the gold standard treatment. Intramedullary nailing also has same success rate in closed fractures. The results of 30 open fractures of shaft humerus fixed with locked unreamed antegrade intramedullary nailing were evaluated. Aim The purpose of the study was to evaluate the role of locked intramedullary nailing in open fractures of shaft humerus in terms of bone union, secondary procedure required, complication, shoulder dysfunction and infection. Materials and Methods Of consecutive 365 humeral shaft fractures, 63 fractures were open. Thirty-two patients were operated with plate osteosynthesis, while 31 patients who were treated with locked unreamed intramedullary nails fulfilling the inclusion criteria entered the study. Results Twenty eight of thirty patients united in mean duration of 10.5 weeks. There were two non-unions both of them united with bone grafting and plate osteosynthesis. Seven patients had superficial infection which healed with antibiotic course, while two patients had deep infection, which healed with repeat debridement. Eleven patients had preoperative radial nerve palsy, nine of which healed completely in average of six months. Twenty eight patients had excellent functional outcome at final follow-up while two patients had good outcome. Conclusion Antegrade nailing is associated with good union rates and low infection rates and is a good option in open fractures and in polytrauma patients. PMID:27790533
Bazzi, Ahmed A; Brooks, Jaysson T; Jain, Amit; Ain, Michael C; Tis, John E; Sponseller, Paul D
There is limited literature on nonoperative treatment of open type I pediatric fractures. Our purpose was to evaluate the rate of infection in pediatric patients with type I open fractures treated nonoperatively at our institution without admission from the emergency department (ED). We performed a retrospective chart review of all patients who sustained a type I open fracture of the forearm or tibia from 2000 through 2013. Forty patients fit the inclusion criteria: <18 years old with type I open fracture treated nonoperatively with irrigation and debridement, followed by closed reduction and casting of the fracture under conscious sedation in the ED. All patients were discharged home. The primary outcome was presence of infection. Secondary outcomes included occurrence of a delayed union, time to union, complications, and residual angulation. There were no reported or documented infections. There was one case of a retained foreign body (<1 cm) in a mid-diaphyseal forearm fracture, which was removed in clinic at 4 weeks after the patient developed a granuloma with no infectious sequela. There was one case of a delayed union; all patients eventually had complete bony union. There was minimal residual angulation in both upper and lower extremities at last follow-up. Nonoperative treatment of type I open fractures in pediatric patients can be performed safely with little risk of infection. This preliminary evidence may serve as a foundation for future prospective studies.
Wu, Jian; Ye, Datian; Wang, Guangzhi; Ding, Haishu
Currently, the mechanical performances of pinless external fixator are primarily evaluated for application to long bone fractures. A new method that detecting the relative displacement changes of the tibial fragments with the pinless external fixator by the three dimensional measurement system was introduced to evaluate the performance of the pinless external fixator. And such testing item was taken as the complement for the mechanical performances of the pinless external fixator. In this paper, a high precision optical 3D measurement system was used to detect the displacement change in the anterior and posterior fracture part of the tibial bones which was fixed by a clamp pattern pinless external fixator in open tibial fractures. Furthermore, the relative displacement change and relative angle rotation were analyzed after obtaining the trajectory of the markers which fixed on the tibial fragments, the results were used to evaluate the stability of the pinless external fixator, and taken as the reference for revising the design of the pinless external fixator as well.
Pitta, Guilherme Benjamin Brandão; dos Santos, Thays Fernanda Avelino; dos Santos, Fernanda Thaysa Avelino; da Costa Filho, Edelson Moreira
Fractures of the tibial plateau are relatively rare, representing around 1.2% of all fractures. The tibia, due to its subcutaneous location and poor muscle coverage, is exposed and suffers large numbers of traumas, not only fractures, but also crush injuries and severe bruising, among others, which at any given moment, could lead compartment syndrome in the patient. The case is reported of a 58-year-old patient who, following a tibial plateau fracture, presented compartment syndrome of the leg and was submitted to decompressive fasciotomy of the four right compartments. After osteosynthesis with internal fixation of the tibial plateau using an L-plate, the patient again developed compartment syndrome. PMID:26229779
Goshima, Kenichi; Sawaguchi, Takeshi; Shigemoto, Kenji; Iwai, Shintaro; Nakanishi, Akira; Ueoka, Ken
To evaluate the clinical and radiological outcomes of open-wedge high tibial osteotomy (OWHTO) with respect to the patellofemoral joint and to assess whether patellofemoral osteoarthritis (OA) progression and alignment changes after OWHTO affect clinical outcomes. Inclusion criteria were consecutive patients who underwent OWHTO from March 2005 to September 2013. Exclusion criteria were loss to follow-up within 2 years and absence of second-look arthroscopy findings at the time of plate removal. The clinical parameters, including anterior knee pain while climbing stairs, Japanese Orthopedic Association score, and Oxford Knee Score, were evaluated. Radiological outcomes, including weight-bearing line ratio, modified Blackburne-Peel ratio, posterior tibial slope, tilting angle, lateral shift ratio, and patellofemoral OA (Kellgren-Lawrence grade), were evaluated preoperatively and at the final follow-up. Cartilage status (International Cartilage Repair Society grade) was evaluated at the initial HTO and at plate removal. Fifty-three patients (60 knees) were included in this study. The mean follow-up was 58.2 ± 22.4 months. Two knees (3%) presented with mild anterior knee pain after OWHTO. The mean Japanese Orthopedic Association score (66.9 ± 11.2 to 91.2 ± 9.7) significantly improved (P < .001), and the mean Oxford Knee Score at the final follow-up was 42.0 ± 5.3. The mean modified Blackburne-Peel ratio (0.9 ± 0.1 to 0.7 ± 0.1, P < .001) and tilting angle (6.8 ± 3.7 to 5.6 ± 3.4, P = .033) significantly decreased after OWHTO, whereas no significant changes in posterior tibial slope (P = .511) and lateral shift ratio (P = .522) were observed. Radiologically, patellofemoral OA had progressed in 15 knees (27%), and arthroscopically patellofemoral cartilage degeneration had progressed in 27 knees (45%). However, there was no significant correlation between changes in patellofemoral alignment and clinical outcomes. Changes in patellofemoral alignment and
Eichhubl, Peter; Aydin, Atilla; Lore, Jason
In analogy to high-temperature sintering of ceramics and metal powder compacts, the formation of opening-mode fractures in siliceous mudstone during natural in-situ combustion of hydrocarbons is attributed to contractile surface forces between mineral grains and an interstitial melt phase. A comparison between bulk density increase during sintering and created fracture space indicates that fracturing resulted from contraction of the rock matrix due to porosity reduction, grain-scale mass transfer, and high-temperature mineral formation. It is suggested that contractile surface forces between mineral grains and between mineral grains and pore fluid contribute to subcritical fracture formation under a wide range of subsurface conditions.
Matzon, Jonas L; Reb, Christopher W; Danowski, Ryan M; Lutsky, Kevin
Trapezium fractures comprise approximately 3% to 5% of all hand fractures. Although operative management of intra-articular trapezium fractures can result in good functional outcomes, there is very little literature addressing specific operative techniques. We describe a technique for open reduction and internal fixation of severely comminuted, intra-articular trapezium fractures, utilizing autogenous cancellous bone graft from the distal radius.
Coury, John G; Lum, Zachary C; O'Neill, Nicholas P; Gerardi, Joseph A
There has been a trend towards flexible intramedullary nailing for unstable tibial shaft fractures in the pediatric population, traditionally, utilizing a 2-incision technique with passage of one nail medially and one nail laterally. Our study aims to compare a single incision approach for flexible nailing of unstable tibial shaft fractures in pediatric patients to the traditional 2-incision approach. Patients were selected for operative fixation if they had a length unstable tibial shaft fracture confirmed by fluoroscopy. Exclusion criteria included length stable tibial fractures that could undergo nonoperative treatment. Single incision technique utilized the medial incision only. Patients were monitored in the hospital for one postoperative day and followed up at 4 week, 8 week, and 12 week marks. Radiographic analysis was performed to evaluate for malunion or nonunion. Operative times, infection rates and complications were recorded and analyzed. All patients achieved complete fracture healing at the 12-week follow up. There were no delayed unions, nonunions or malunions in either treatment group. Single medial incision for tibial flexible nails had equivalent outcomes with no difference in primary healing rate, malunion or nonunion rate when compared to the dual incision technique.
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.
Clutter, Sarah Y; Morgan, Steven J; Erickson, Mark; Smith, Wade R; Stahel, Philip F
Background: Open acetabular fractures in children are rare, but potentially devastating injuries. Secondary to the low incidence, there is an apparent lack of reports on appropriate management strategies for open pediatric acetabular fractures in the literature. Methods: Description of a case study. Results: A 3 years and ten months-old girl was ejected as a passenger from an all terrain vehicle. She sustained a displaced, grade IIIA open left anterior column acetabular fracture. The injury was treated by extending the open wound to a formal first window of the ilioinguinal approach. After surgical debridement, the anterior column was reduced anatomically and fixed by two lag screws which avoided the tri-radiate cartilage. A vaginal laceration was debrided and repaired. The patient was treated in a spica cast without weight bearing on the left lower extremity for 8 weeks. No perioperative complications occurred. The acetabular fracture healed in an anatomic position within 8 weeks. To avoid premature closure of the tri-radiate cartilage, the patient underwent a physeal bar resection at one year after injury. At two-year follow up, she was walking and running without pain and had a free range of motion of her left hip. Conclusions: Operative management should represent the therapy of choice for open, displaced pediatric acetabular fractures. After fracture healing, a scheduled physeal bar resection may be required for injuries which involve the tri-radiate cartilage. PMID:19461903
anterolateral bowing of the lower leg prior to fracture in neurofibromatosis type 1. J Pediatr Orthop 2009;29:385-92. 3. Stevenson DA, Yan J, He Y, Li H...neurofibromatosis type 1 (NF1), typically identified in infancy. The majority of NF1 individuals with tibial bowing will sustain a fracture that will not...not fracture and the bowing improves over time. Clinical predictors to help drive management are lacking, and the pathophysiology of tibial bowing
Ramseier, Leonhard Erich; Bhaskar, Atul R; Cole, William G; Howard, Andrew W
Open femur fractures in children are uncommon and usually associated with other injuries. In adults, there is a current trend to treat open fractures with intramedullary (IM) devices. The goal of this study was to compare external fixator (EF) to IM devices in the treatment of open femur fractures in children. Diaphyseal femur fractures without growth plate involvement were included. Thirty-five patients (12 IM; 23 EF) were identified. Age, hospital stay, polytrauma, mechanism of injury, and Gustilo-Anderson grade were recorded. Follow-up was at least until the fracture was clinically and radiographically healed. Patients with EFs were 5.2 times more likely (95% confidence interval, 1.05-25.5) to have any complication. Excluding pin track infections, patients with EFs were 2.7 times as likely (95% confidence interval, 0.567-13.2) to have a complication. Refractures occurred only in the EF group (6/23, 26%) and not in the IM nailing group (P = 0.062, Fischer exact test). These were associated with varus malunions-all 3 of the EF group with more than 15 degrees of varus at fracture union suffered a refracture. Treatment of open femur fractures in children is a challenging problem. Treatment with IM devices had fewer complications than the EF. We think that whenever possible, the use of IM devices for the treatment of open femur fracture in children should be considered, especially grade 1 open injuries. If EFs are used, avoiding varus malunion may decrease the refracture rate, and secondary change to an IM device should be considered. Comparative cohort study. Grade 3 level of evidence.
Raschke, Michael J.; Kittl, Christoph; Domnick, Christoph
Partial tibial plateau fractures may occur as a consequence of either valgus or varus trauma combined with a rotational and axial compression component. High-energy trauma may result in a more complex and multi-fragmented fracture pattern, which occurs predominantly in young people. Conversely, a low-energy mechanism may lead to a pure depression fracture in the older population with weaker bone density. Pre-operative classification of these fractures, by Müller AO, Schatzker or novel CT-based methods, helps to understand the fracture pattern and choose the surgical approach and treatment strategy in accordance with estimated bone mineral density and the individual history of each patient. Non-operative treatment may be considered for non-displaced intra-articular fractures of the lateral tibial condyle. Intra-articular joint displacement ⩾ 2 mm, open fractures or fractures of the medial condyle should be reduced and fixed operatively. Autologous, allogenic and synthetic bone substitutes can be used to fill bone defects. A variety of minimally invasive approaches, temporary osteotomies and novel techniques (e.g. arthroscopically assisted reduction or ‘jail-type’ screw osteosynthesis) offer a range of choices for the individual and are potentially less invasive treatments. Rehabilitation protocols should be carefully planned according to the degree of stability achieved by internal fixation, bone mineral density and other patient-specific factors (age, compliance, mobility). To avoid stiffness, early functional mobilisation plays a major role in rehabilitation. In the elderly, low-energy trauma and impression fractures are indicators for the further screening and treatment of osteoporosis. Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160067. Originally published online at www.efortopenreviews.org PMID:28630761
Tilkeridis, Konstantinos; Chari, Basavraj; Cheema, Nusrat; Tryfonidis, Marios; Khaleel, Arshad
We report our experience in treating victims of the recent earthquake disaster in Pakistan. Our experience was based on two humanitarian missions to Islamabad: one in October 2005, 10 days after the earthquake, and the second in January 2006. The mission consisted of a team of orthopaedic surgeons and a second team of plastic surgeons. The orthopaedic team bought all the equipment for application of Ilizarov external fixators. We treated patients who had already received basic treatment in the region of the disaster and subsequently had been evacuated to Islamabad. During the first visit, we treated 12 injured limbs in 11 patients. Four of these patients were children. All cases consisted of complex multifragmentary fractures associated with severe crush injuries. All fractures involved the tibia, which were treated with Ilizarov external fixators. Nine fractures were type 3b open injuries. Eight were infected requiring debridement of infected bone and acute shortening. During a second visit, we reviewed all patients treated during our first mission. In addition, we treated 13 new patients with complex non-unions. Eight of these patients were deemed to be infected. All patients had previous treatment with monolateral fixators as well as soft tissue coverage procedures, except one patient who had had an IEF applied by another team. All these patients had revision surgery with circular frames. All patients from both groups were allowed to fully weight-bear post-operatively, after a short period of elevation to allow the flaps to take. Overall, all fractures united except one case who eventually had an amputation. Four patients had a corticotomy and lengthening, and three of them had a successful restoration of limb length. The fourth patient was the one with the eventual amputation.
Morris, Brandon; Mullen, Scott; Schroeppel, Paul; Vopat, Bryan
Open physeal fractures of the distal phalanx of the hallux are the lesser described counterpart to the same fracture of the finger, known by its eponym as a "Seymour fracture". Displaced Salter-Harris phalangeal fractures present with a concomitant nailbed or soft tissue injury. Often these fractures occur in the summer months when open-toe footwear can be worn, however, they may occur indoors as well. Frequently, the injury results from direct axial load of the toe, or "stubbing", which causes the fracture and associated soft tissue injury. Prompt diagnosis and appropriate treatment is necessary to prevent negative sequelae such as osteomyelitis, malunion, nonunion, or premature growth arrest. In this article, we present a 12year-old male who sustained an open physeal fracture of the distal phalanx when he "stubbed" his great toe on a bed post. His injury was initially misdiagnosed at an urgent care facility, thereby delaying appropriate intervention and necessitating an operative surgical procedure. Additionally, we review the existing literature discussing these infrequently reported injuries, as well as present key points as they pertain to the diagnosis and management of this injury in the emergency department.
Lee, Dong-Ho; Kim, Hyoungmin; Lee, Choon Sung; Hwang, Chang-Ju; Cho, Jae-Hwan; Cho, Samuel K
To investigate the clinical and radiographic fate of fractured hinges in open-door cervical laminoplasty, 135 segments of 36 patients who had undergone follow-up for more than two years after open-door cervical laminoplasty due to compressive cervical myelopathy were reviewed clinically and radiographically. Hinge fractures were identified by the intraoperative finding of obvious instability or click sounds (an obvious fracture), or by immediate postoperative computed tomography (CT) images showing a discontinuity of both the inner and outer cortex or a displacement of more than 1mm at the lamina hinge site (an occult fracture). At two years post-surgery, union and displacement of the fractured hinges were evaluated with CT and the clinical outcome was assessed by the Japanese Orthopedic Association (JOA) and Neck Disability Index (NDI) scores. Immediate postoperative CT scans revealed 28 hinge fractures in 16 patients. Only three fractures were identified during surgery, with most being identified on postoperative CT. Nineteen laminae showed non-displaced cortical discontinuity, five were anteriorly displaced by more than 1mm, and four were displaced posteriorly. Twenty-five laminae (89.3%) had achieved union according to the two-year postoperative CT scan. No de novo neurologic symptoms were found to be associated with hinge fracture. The two-year postoperative JOA and NDI scores did not differ significantly between patients with or without a hinge fracture. Most fractures at the hinge site occurred without intraoperative recognition, and usually re-unified without significant displacement or adverse clinical effects. When hinge fractures occur, careful observation without additional intervention is recommended. Copyright © 2017 Elsevier Ltd. All rights reserved.
Díaz, Verónica Jiménez; Cañizares, Alfonso Carlos Prada; Martín, Ismael Auñón; Peinado, Miguel Aroca; Doussoux, Pedro Caba
Factors that impede closed reduction in intertrochanteric fractures remain unknown. This study was designed with the aim of establishing radiological variables that can predict an open reduction when nailing those type of fractures. Observational prospective study carried out between March 2013 and March 2015. Patients of both gender who suffered an intertrochanteric fracture, and who were surgically treated by intramedullary nailing (PFN-A), were included. Patients were evaluated by means of a questionnaire designed in 12 de Octubre Trauma department. Radiological parameters assessed preoperatively, after fracture reduction in the traction table, and after fixation were: calcar, lateral wall and posterior buttress integrity or disruption; lesser trochanter location, varus or valgus deformities, and flexion or extension of the proximal fragment. Association between open reduction and the following types of fractures was statistically significant (p<0.001): subtypes A2.3, A3.2 and A3.3 of AO classification and subtypes IV and V of Evans classification. There were four radiological parameters associated with the need for open reduction: disruption of lateral wall (p<0.0000), posterior wall fracture (p<0.001), calcar (p<0.004) and malalignment in the axial view (p<0.001). Open reduction seems to be necessary for complex fracture patterns such as A2.3, A3.2 and A3.3 types of AO/OTA classification, as well as types IV and V of Evans classification. There are four major radiological parameters that can predict the need of approaching the fracture site: posterior buttress, calcar disruption, lateral wall disruption and proximal fragment flexion. The development of high quality evidence regarding this topic is necessary due to the vast impact that open reduction can have on elderly patients. © 2016 Elsevier Ltd. All rights reserved.
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.
Cotic, Matthias; Vogt, Stephan; Hinterwimmer, Stefan; Feucht, Matthias J; Slotta-Huspenina, Julia; Schuster, Tibor; Imhoff, Andreas B
The first purpose of this study was to compare the clinical and radiographic outcome of two different locking plates used for valgus-producing medial open-wedge high tibial osteotomy (HTO). The second purpose was to histologically evaluate peek-carbon wear for biocompatibility. Twenty-six consecutive patients undergoing open-wedge HTO using the first-generation PEEKPower HTO-Plate® (Group I) were matched with 26 patients after open-wedge HTO with the TomoFix™ plate (Group II). Clinical scores (visual analogue scale for pain, WOMAC, Lysholm score) were obtained pr