Isolated Fracture of the posterolateral tibial lip (Volkmann's triangle)

Purpose: to retrospectively evaluate the underlying pathomechanism of isolated fracture of the posterolateral tibial lip (Volkmann's triangle), and to demonstrate associated radiographic methods.

Material and Methods: Retrospective analysis of 2500 ankle lesions showed an isolated fracture of the dorsal tibial lip in 25 cases. Distal tibial lesions of growing individuals were not considered. All patients were examined by radiography in internal oblique and lateral views.

Results: Sixteen of 25 patients had had their accident during winter; 11 had slipped on ice or snow. All 25 patients showed a closed ankle lesion in the correct joint position with no clinical signs of instability. Evaluation of the standard images showed isolated fracture of the posterolateral tibial lip in 24 patients. the fracture was best recognized in the standard lateral view in 22 patients. in 2 patients the lateral stress projection demonstrated the fracture (20° internal rotation). in one case the fracture was only seen on axial CT images. Twenty-two patients with small wedge fragments were treated conservatively; 3 with a displaced and large fragment had surgical revision and stabilization. Sixteen cases were examined by conventional radiography at follow-up examination and 5 of these showed radiological signs of arthrosis.

Conclusion: Plain conventional radiography is still necessary in the primary diagnosis of ankle joint lesions. the isolated fracture of the dorsal tibial margin is best seen in the standard lateral view. Indication for CT in routine diagnostics is limited to cases showing clinical evidence of ankle injury without roentgenological signs of a fracture in the standard images. Differential diagnoses include the pilon lesion and the Maison-neuve-type fracture.

Same-Level Fracture of the Tibial Metal Tray and Polyethylene Insert After Total Knee Arthroplasty

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.].

Avulsion Fracture of the Tibial Tubercle Associated With Patellar Tendon Avulsion

Avulsion fractures of the tibial tubercle in adolescent athletes are uncommon injuries, believed to be a result of forceful extension of the knee against a fixed leg. Concomitant injury to the ipsilateral patella tendon is even more rare, with few cases reported in the literature. The mechanisms responsible for this association are not well understood. The significance of this double insult to the knee extensor mechanism is the potential deleterious effect of misdiagnosis and/or mismanagement. In this case report, the pathophysiology, mechanism of injury, classification, diagnosis, and management of concomitant injury are reviewed. [Orthopedics. 2016; 39(3):e561-e564.].

Differential effects of IGF-1 deficiency during the life span on structural and biomechanical properties in the tibia of aged mice

Advanced aging is associated with the loss of structural and biomechanical properties in bones, which increases the risk for bone fracture. Aging is also associated with reductions in circulating levels of the anabolic signaling hormone, insulin-like growth factor (IGF)-1. While the role of IGF-1 in bone development has been well characterized, the impact of the age-related loss of IGF-1 on bone aging remains controversial. Here, we describe the effects of reducing IGF-1 at multiple time points in the mouse life span--early in postnatal development, early adulthood, or late adulthood on tibia bone aging in both male and female igf (f/f) mice. Bone structure was analyzed at 27 months of age using microCT. We find that age-related reductions in cortical bone fraction, cortical thickness, and tissue mineral density were more pronounced when IGF-1 was reduced early in life and not in late adulthood. Three-point bone bending assays revealed that IGF-1 deficiency early in life resulted in reduced maximum force, maximum bending moment, and bone stiffness in aged males and females. The effects of IGF-1 on bone aging are microenvironment specific, as early-life loss of IGF-1 resulted in decreased cortical bone structure and strength along the diaphysis while significantly increasing trabecular bone fraction and trabecular number at the proximal metaphysis. The increases in trabecular bone were limited to males, as early-life loss of IGF-1 did not alter bone fraction or number in females. Together, our data suggest that the age-related loss of IGF-1 influences tibia bone aging in a sex-specific, microenvironment-specific, and time-dependent manner.

Tibial Tubercle Fracture After Bone-Patellar Tendon-Bone Autograft

Fractures occurring with anterior cruciate ligament (ACL) reconstruction are rare and those that do occur take place on the patellar side of a bone-patellar tendon-bone (BPTB) autograft. Here we discuss a far more infrequent occurrence, fracture of the tibial tubercle aspect of the BPTB autograft. This fracture type occurs even more infrequently than tibial plateau fractures after ACL reconstruction based on the published literature. In this article we discuss the third published episode of a tibial tubercle fracture after BPTB allograft. We also discuss the fracture types seen with this method of ACL reconstruction and provide insights into prevention of this occurrence.

Population-Based Epidemiology of Tibial Plateau Fractures

Although epidemiologic studies of tibial plateau fractures have been conducted, none have included geographically defined populations or a validated fracture classification based on computed tomography (CT). The goals of this study were to provide up-to-date information on the incidence and basic epidemiology of tibial plateau fractures in a large unselected patient population and to report the mechanisms of injury involved and the distribution of fractures according to a validated CT-based fracture classification. The authors conducted a population-based epidemiologic study of all patients treated for tibial plateau fracture over a 6-year period from 2005 to 2010. The study was based on an average background population of 576,364 citizens. A retrospective review of hospital records was performed. During this time, a total of 355 patients were treated for tibial plateau fracture. This group included 166 men and 189 women, and mean age was 52.6 years (SD, 18.3). The most common fracture type was AO type 41-B3, representing 35% of all tibial plateau fractures. The second most common fracture type was AO type 41-C3, representing 17% of all tibial plateau fractures. The incidence of tibial plateau fractures was 10.3 per 100,000 annually. Compared with women, men younger than 50 years had a higher incidence of fractures. The incidence of fractures increased markedly in women older than 50 years but decreased in men older than 50 years. In both sexes, the highest frequency was between the ages of 40 and 60 years.

Understanding the etiology of the posteromedial tibial stress fracture

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.

Distal tibial fractures are a poorly recognised complication with fibula free flaps

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.

[Lateral hinge fractures in open wedge high tibial osteotomy]

BACKGROUND

Open wedge high tibial osteotomy (HTO) is an increasingly more common surgical method. A typical problem of this procedure is fracture of the lateral hinge.

OBJECTIVES

The aims of this article are to present the special issue of fractures of the lateral hinge after HTO and to discuss surgical hints on how to prevent and treat this problem.

METHODS

The results of recently published clinical studies are summarized and tips from own clinical experiences are given.

RESULTS

Type II fractures of the lateral hinge are unstable and can create a major problem. Using short spacer plates results in a problem of stability for all types of fractures.

CONCLUSION

The classification into Takeuchi grades I-III has been proven to be suitable for fractures of the lateral hinge. The TomoFix plate is a safe implant to stabilize the osteotomy in type I and III fractures with which healing can be achieved with no problems. Type II fractures can be stabilized with the TomoFix plate; however, an autologous bone graft has to be taken into consideration. For fractures of the lateral hinge short spacer plates are not recommended due to stability issues.

QUALITY OF LIFE FOLLOWING SURGICAL TREATMENT OF LOWER LIMB METASTASES IN LONG BONE

Pathological fractures have a high incidence in musculo-skeletal oncology, and localization in long bone causes severe pain, disability and poor quality of life. The aim of this retrospective case series is to evaluate the clinical results, in particular regarding the quality of life, in patients affected by lower long bone pathological fractures surgically treated. We analyzed 93 patients with pathological fractures of tibia and femur surgically treated in our Orthopaedic Department and followed up for at least 3 years or until their death. Intramedullary nailing or endoprosthetic reconstruction for pathologic fractures located in the metadiaphyseal and diaphyseal or proximal regions in advanced-stage cancer patients are suitable methods for a stable fixation or reconstruction. These approaches guarantee a good mechanical stability, a faster mobilization, a better control of pain with an overall improvement in quality of life in all patients, confirmed also by the trend of the ECOG performance status and QOL-ACD.

Arthroscopic treatment of avulsed tibial spine fractures using a transosseous sutures technique

Severely displaced tibial spine fractures should be treated surgically to restore joint congruity and cruciate integrity with reduction and fixation through an arthrotomy or arthroscopic techniques. Arthroscopy is preferred as it allows for accurate diagnosis and treatment of associated injuries and reduction and fixation of all types of tibial spine fractures while reducing the morbidity associated with open techniques. We report the clinical and radiographical results of 11 cases treated with a technique of arthroscopic internal fixation with non-absorbable sutures, after an average follow-up of 16.3 months (range, 11 to 21 months). The clinical examination using the IKDC system revealed all patients to have a negative Lachman test and no quadriceps weakness except one patient with some laxity (hard end 1+ Lachman test). One patient had a minor extension deficit of approximately 5°. The other patients showed a full range of motion without extension loss. This technique is simple, reproducible and very useful in dealing with these fractures.

Bicondylar tibial plateau fracture after posterior cruciate ligament reconstruction

The authors present a report of a bicondylar tibial plateau fracture in an adolescent athlete after posterior cruciate ligament (PCL) reconstruction. The procedure was performed via arthroscopic transtibial PCL reconstruction with quadrupled semi-tendinosus and gracilis autograft. The patient recovered uneventfully postoperatively and was able to participate in high-level sports activity, such as baseball and track, with no limitations, no subjective complaints, and no episodes of instability. He continued to be asymptomatic up to 3.5 years postoperatively. Almost 4 years postoperatively, the patient reinjured the left knee during recreational noncontact football and was seen emergently. Plain radiographs, magnetic resonance image scan, and computed tomography scan at the time of injury showed a bicondylar tibial plateau fracture with intra-articular involvement. Operative intervention was undertaken for open reduction and internal fixation of the bicondylar tibial plateau fracture. A plate was placed along the medial aspect of the tibia with locking and nonlocking screws, and the joint line was restored appropriately. The patient recovered uneventfully and at the most recent follow-up had full active and passive range of motion, had no subjective or objective evidence of instability, and had returned to full activity with no restrictions. The patient had no history of multiple fractures or any medical or pharmacologic history that predisposed him to decreased bone density. This case shows a unique possible complication after transtibial PCL reconstruction in an adolescent patient.

Effect of transplantation of marrow mesenchymal stem cells transfected with insulin-like growth factor-1 gene on fracture healing of rats with diabetes

OBJECTIVE

To observe the effect of transplantation of marrow mesenchymal stem cells (BMSCs) transfected with insulin-like growth factor-1 (IGF-1) on fracture healing of rats with diabetes and discuss the gene therapy for diabetic fracture.

METHODS

60 8-week-old male Wistar rats weighing 180-200 g were divided into the control group and experimental group at random. All of them suffered from right tibia fracture following the model of diabetes induced by streptozotocin. BMSCs were transfected with Ad- IGF-1 and BMSCs of the appropriate group were transplanted to part of the fracture area. 6 rats were selected from each group at 1, 2, 3, 5 and 7 weeks after the surgery. Local bone callus was stained with hematoxylin-eosin (H-E) and IGF-1 in the bone callus and serum was tested.

RESULTS

Osteoid tissues formed at 3 weeks in the experimental group; mature lamellar bone formed at 7 weeks in the experimental group; fibrous bone callus was observed in the control group. IGF-1 in bone callus of the experimental group is increasing and significantly different from that of the control group (p < 0.05). Concentrations of IGF-1 in the serum of the two groups were increasing gradually from the first week. The control group reached its peak in the 5th week. The experimental group reached a high concentration in the 5th week and maintained a high concentration in the 7th week. The differences at various times between the two groups have statistical significance (p < 0.05).

CONCLUSION

Transplantation of BMSCs transfected with IGF-1 gene can promote fracture healing of rats with diabetes (Tab. 4, Fig. 1, Ref. 20).

Biomechanical evaluation of interfragmentary compression at tibia plateau fractures in vitro using different fixation techniques: a CONSORT-compliant article

Reliable osteosynthesis of intraarticular fractures depends on lasting interfragmentary compression. Its amount differs in the applied fixation method. The interfragmentary compression of cancellous and cortical lag screws and angle stable locking plates was quantified in an osteoporotic and non-osteoporotic synthetic human bone model.A split fracture of the lateral tibia plateau (AO/OTA type 41-B1.1) was mimicked by an osteotomy in right adult synthetic human tibiae with hard or soft cancellous bone. Specimens were fixed with either two 6.5 mm cancellous, four 3.5 mm cortical lag screws, or 3.5 mm LCP proximal lateral tibia plate preliminary compresed by a reduction clamp (n = 5 per group). A pressure sensor film was used to register the interfragmentary compression. One-way analysis of variance (ANOVA) with Bonferroni post hoc correction was performed for statistical analysis (p < 0.05).Interfragmentary compression under reduction clamp was 0.59 ± 0.12 MPa in the non-osteoporotic and 0.55 ± 0.14 MPa in the osteoporotic group. The locking plate itself maintained the compression in non-osteoporotic (0.53 ± 0.11 MPa) and osteoporotic bone (0.50 ± 0.14 MPa). Four 3.5 mm cortical lag screws provided a compression of 1.69 ± 0.65 MPa in non-osteoporotic bone, being not significantly different to the osteoporotic bone group (1.43 ± 0.47 MPa, P = 1.0). Two 6.5 mm cancellous lag screws showed a significantly higher compression in non-osteoporotic (2.1 ± 0.59 MPa) compared to osteoporotic (0.77 ± 0.21 MPa, P < 0.01) bone.Angle stable locking plates maintained the compression preliminarily applied by a reduction clamp. Two 6.5 mm cancellous lag screws are especially suited for non-osteoporotic bone, whereas four 3.5 mm cortical screws exhibited comparable compression in both bone qualities.

Bilateral distal tibial transitional ankle fractures

A 13-year-old boy presented to the emergency department with bilateral ankle pain and swelling following a 5-foot fall from a swing set.

Biomechanical analysis of fracture risk associated with tibia deformity in children with osteogenesis imperfecta: a finite element analysis

OBJECTIVES

Osteogenesis imperfecta (OI) frequently leads to long-bone bowing requiring a surgical intervention in severe cases to avoid subsequent fractures. However, there are no objective criteria to decide when to perform such intervention. The objective is to develop a finite element model to predict the risk of tibial fracture associated with tibia deformity in patients with OI.

METHODS

A comprehensive FE model of the tibia was adapted to match bi-planar radiographs of a 7 year-old girl with OI. Ten additional models with different deformed geometries (from 2° to 24°) were created and the elasto-plastic mechanical properties were adapted to reflect OI conditions. Loads were obtained from mechanography of two-legged hopping. Two additional impact cases (lateral and torsion) were also simulated. Principal strain levels were used to define a risk criterion.

RESULTS

Fracture risks for the two-legged hopping load case remained low and constant until tibia bowing reached 15° and 16° in sagittal and coronal planes respectively. Fracture risks for lateral and torsion impact were equivalent whatever the level of tibial bowing.

CONCLUSIONS

The finite element model of OI tibia provides an objective means of assessing the necessity of surgical intervention for a given level of tibia bowing in OI-affected children.

Surgical approach in difficult tibial pilon fractures

AIM

The aim of the present study is to emphasize the optimal moment and approach for tibial pilon complex fractures and their complications.

MATERIAL AND METHODS

We have investigated and treated 7 patients with complex fractures of the tibial pilon with tendencies to complications. According to AO classification,we have recorded 4 fractures type 43C2 AO, 2 fractures type 43C3 AO (with one open fracture type IIIA Gustilo) and 1 fracture type 43B3 AO. According to soft tissue status, surgical treatment was performed by a one-step or two-step approach.

RESULTS

All fractures healed after an interval of 13.6 weeks(range 8-28 weeks) with one delayed consolidation. The open fracture was complicated by posttraumatic arthrosis. No infections or implant failures were recorded. According toOvadia score, objective and subjective evolution showed good results in 5 cases, one excellent result and one poor result.

CONCLUSIONS

Fracture type and the soft tissue status are crucial for the results of operated fractures. These arguments determine the application of one-step or two-step surgical procedure as well as optimal implant choice.

[Surgical treatment for long bone giant cell tumor of extremity with pathologic fracture]

OBJECTIVE

To identify the clinical features of patients with giant cell tumors (GCT) of long bones in extremities presented with pathological fracture (PF), and discuss the surgical strategy with retrospective analysis and literature review.

METHODS

We searched medical electronic records from January 1999 to December 2011 in our hospital to identify patients with definite diagnosis of extremity GCT presented with PF. Clinical data including gender, tumor site, age, surgical treatment option, postoperative complication, limb function, local recurrence and pulmonary metastasis were collected and analyzed statistically. The t-test and chi-square test were used for continuous and dichotomous variables, respectively.

RESULTS

Between 1999 and 2011 we treated 201 patients with GCT in extremities (long bone only: femur, tibia, fibula, humerus, ulna, and radius), 33 of whom presented with a PF. The gender ratio was 1.06 for a male predominance. The median age was 33 (15-62), and the most common site of pathologic fractures was distal femur (n=17), followed by proximal tibia (n=5), proximal femur (n=5), proximal humerus (n=4), and distal radius (n=2). Nine fractures were intra-articular. The tumors were treated by extended curettage (n=11) or en bloc excision (n=22), and the fractures were reconstructed by endoprosthesis (n=20), autologous iliums graft combined with synthetic bone substitutes (n=7), acrylic cementing (n=3), autologous fibula graft (n=2), or allograft (n=1). Ten operations were followed by complications of any kind, where implant failure and recurrence were the commonest, and re-operation rate was 27.3%. The mean functional score according to the scoring system of the Musculoskeletal Tumor Society (MSTS) was 81% in patients who received endoprosthesis replacement and 82% in other reconstruction options.

CONCLUSION

Extended curettage and en bloc resection were all considered to be the effective treatment options for patients with extremity GCT presented with PF. However, local recurrence and implant related complication were the major concern for joint reservation and prosthetic replacement, respectively.

[Cannulated lag screw combined with lateral supporting plate for treatment of Hoffa fracture of Letenneur type I and type III]

OBJECTIVE

To investigate the effectiveness of cannulated lag screws combined with lateral supporting plates in the treatment of Hoffa fracture of Letenneur type I and type III.

METHODS

Between May 2004 and April 2011, 11 patients with Hoffa fracture of Letenneur type I and type III were treated, including 6 males and 5 females with an average age of 36 years (range, 25-47 years). Factures were caused by traffic accident in 8 cases, by falling in 2 cases, and by the other in 1 case. Fracture involved the left knee in 7 patients and the right knee in 4 patients. According Letenneur's classification criteria, there were 7 type I fractures (6 lateral condyle fractures and 1 medial condyle fracture) and 4 type III fractures (3 lateral condyle fractures and 1 medial condyle fracture). Of 11 fractures, 9 were fresh fractures and 2 were old fractures. Two 6.5 mm cannulated lag screws combined with lateral supporting plates were used to fix fractures by anterolateral or anteromedial incision.

RESULTS

All incisions achieved primary healing with no early complication. All patients were followed up 12-26 months (mean, 15 months). X-ray films showed bone healing with an average healing time of 15 weeks (range, 10-18 weeks). No loosening or breaking of internal fixator was observed; the removal time of internal fixation was 9-15 months (mean, 12 months). Accoding to Letenneur's functional assessment system, the results were excellent in 7 cases, good in 3 cases, and poor in 1 case at last follow-up.

CONCLUSION

Cannulated lag screws combined with lateral supporting plates fixation is effective in treatment of Hoffa fracture of Letenneur type I and type III with a high union rate; anterolateral or anteromedial approach is the first choice for Hoffa fracture of type I and type III, especially for complicating by tibial plateau fracture or patella fracture.

[Fractures in spinal muscular atrophy]

AIM

To determine the frequency of fractures in patients with spinal muscular atrophy, their mechanism of production, age at appearance and functional repercussions.

PATIENTS AND METHODS

Sixty-five patients with spinal muscular atrophy were studied. Cases of fractures diagnosed by means of X-rays were collected and the following parameters were analysed: type of spinal muscular atrophy, gait, age at the time the fracture occurred, mechanism of production, location, treatment applied and functional repercussion.

RESULTS

Thirteen patients (20%) presented a total of 20 fractures (four of them presented two or more fractures). The mean age was 6.35 years. The fractures were mostly located in the femur and the mechanism of production was falls in 12 cases and minor traumatic injury in eight. No vertebral fractures were detected. All of them were treated conservatively. The only patient with a fracture who was able to walk stopped walking after immobilisation.

CONCLUSIONS

The existence of fractures in these patients interferes with their quality of life and their level of functioning. It is important to prevent them from occurring during management of the patient and by ensuring a correct posture in the wheelchair with the use of restraint systems. Further studies are needed on the loss of bone mineral density in these patients and their possible relationship with fractures.

[Cause analysis of 280 case of fractures nonunion]

OBJECTIVE

To research many clinical data of nonunion cases and discover the reasons for low capacity of bone growth.

METHODS

From October 1999 to April 2009,the source material of 280 nonunion cases were conducted and followed up. The data of the study included 230 males and 50 females,with an average age of 39.4 years old ranging from 19 to 62 years. The fracture position was femur in 129 cases,tibia in 83 cases,humerus in 47 cases, feet radius bone in 21 cases, the ratio was 46:29.6:16.8:7.5. The survey included primary injury process,damage degree and the effect of first treatment,hospital level of first treatment,timing of surgery for the first time, the early callus growth conditions and whether there were obvious technical errors.

RESULTS

There were 129 femoral nonunion cases with complete data,121 cases derived from closed fractures, 8 cases from open fractures; 111 cases was aseptic nonunion. 90% of femoral aseptic nonunion had no obvious callus growth, 80% of first treatment performed intraday surgical internal fixation, 10% were undergone operation within three days and 90% was early surgery totally.

CONCLUSION

Low quality of bone callus growth is the main reason for current nonunion and the early surgical fixation has much to do with low quality of bone callus growth.