Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures

Wound infection and healing in minimally invasive plate osteosynthesis compared with intramedullary nail for distal tibial fractures: A meta-analysis

To systematically explore the effects of minimally invasive plate osteosynthesis (MIPO) versus intramedullary nail (IMN) on wound infection and wound healing in patients with distal tibia fractures. A computerised search of PubMed, Web of Science, Cochrane Library, Embase, Wanfang, China Biomedical Literature Database (CBM) and China National Knowledge Infrastructure databases was performed, from their inception to October 2023, to identify relevant studies on the application of MIPO and IMN in patients with distal tibial fractures. The quality of the included literature was evaluated by two researchers based on inclusion and exclusion criteria, and basic information of the literature was collected, with wound infection, postoperative complications and wound healing time as the main indicators for analysis. Stata 17.0 software was applied for analysis. Overall, 23 papers and 2099 patients were included, including 1026 patients in the MIPO group and 1073 patients in the IMN group. The results revealed, when compared with IMN treatment, patients with distal tibia fractures who underwent MIPO treatment had a lower incidence of postoperative complications (OR = 0.33, 95% CI: 0.25-0.42, p < 0.001) and a shorter wound healing time (SMD = -1.00, 95% CI: -1.51 to -0.49, p < 0.001), but the incidence of postoperative wound infection was higher (OR = 2.01, 95% CI: 1.35-3.01, p = 0.001). Both MIPO and IMN are excellent treatments for distal tibia fractures. MIPO is effective in reducing the incidence of complications as well as shortening the time of wound healing time but increases the risk of wound infection. In clinical practice, surgeons can make individual choices based on the patient's wishes and proficiency in both techniques.

Lower Limb Malrotation following Minimally Invasive Plating in Distal Tibia Fractures

Introduction

Minimally invasive percutaneousosteosynthesis (MIPO) plating techniques havedemonstrated good outcomes in the treatment of distal tibia fractures. Early arthritis and functional impairment mayoccur if length and rotation are not restored. This study aims to determine the incidence and severity of tibia malrotation following MIPO plating of isolated unilateral distal tibia fractures, defined as torsional difference of greater than 10° as compared to the contralateral limb and whether the degree of malrotation affects functional outcomes scores.

Materials and methods

This was a level 2 prospective cohort study. All patients with fractures of the distal tibia who underwent surgical fixation with the exclusion ofpatients with polytrauma, neurovascular injuries or pre-existing disabilities were recruited. Patients underwent MIPO plating followed by a post-operative ComputedTomography (CT) scan of bilateral lower limbs. AOFAS ankle-hindfoot score was recorded at six months and one year follow-up.

Results

A total of 24 patients (28 to 83 years old) were recruited. Nineteen patients obtained CT scans. Nine of the 19 patients (47.3%) had tibia malrotation. The mean tibia malrotation angle was 10.3° (0° - 45°). The average AOFAS scores was 82.4 and 84.3 at 6 months and 1 year follow-up. Degree of CT malrotation was not significantly associated with AOFAS scores at 6 month (spearman rho -0.386) and 1 year (spearman rho -0.343).

Conclusions

Tibia malrotation following MIPO plating of distal tibia fractures is common, with an incidence of 47.3% and an average malrotation angle of 10.3°. The degree of malrotation does not appear to have significant mid-term functional impact on the patient.

Limb Fractures Treated With the Novel Plate Osteosynthesis Application Technique: Second to Minimally Invasive Plates osteosynthesis

BACKGROUND

The main aim of this article was to propose a new concept of minimally invasive surgery for treating limb fractures, named as second to minimally invasive plates osteosynthesis (STMIPO).

METHODS

We have described the STMIPO technique in a step-wise and standardized manner based on our findings from a study involving six patients treated at our institution. All patients with fracture achieved satisfactory outcomes.

RESULTS

Ours clinical trials have shown that the STMIPO technique can be successfully applied in various limb fractures, including fibula fractures, tibial fractures, femur fractures, humerus fractures, ulna fractures, and radius fractures. All fracture patients achieved satisfactory outcomes.

CONCLUSION

As a new minimally invasive technology, the STMIPO technique can serve as an alternative solution for fractures that are difficult to reduce with minimally invasive plates osteosynthesis (MIPO).

Comparative experimental study of the biomechanical properties of retrograde tibial nailing and distal tibia plate in distal tibia fracture

Objective: A biomechanical comparative analysis was conducted to evaluate the retrograde tibial nailing (RTN) and distal tibia plate techniques for the treatment of distal tibia fractures. Methods: Fourteen fresh adult tibia specimens were selected, consisting of seven males and seven females aged 34-55 years. The specimens were randomly divided into two groups (Group A and Group B) using a numerical table method, with seven specimens in each group. Group A underwent internal fixation of distal tibial fractures using RTN, while Group B received internal fixation using a plate. The axial compression properties of the specimens were tested in the neutral positions under pressures of 100, 200, 300, 400, and 500 N. Additionally, the torsional resistance of the two groups was assessed by subjecting the specimens to torques of 1.0, 2.0, 3.0, 4.0, and 5.0 N m. Results: At pressures of 400 and 500 N, the axial compression displacement in Group A (1.11 ± 0.06, 1.24 ± 0.05) mm was significantly smaller than that in Group B (1.21 ± 0.08, 1.37 ± 0.11) mm (p = 0.023, 0.019). Moreover, at a pressure of 500 N, the axial compression stiffness in Group A (389.24 ± 17.79) N/mm was significantly higher than that of the control group (362.37 ± 14.44) N/mm (p = 0.010). When subjected to torques of 4 and 5 N m, the torsion angle in Group A (2.97° ± 0.23°, 3.41° ± 0.17°) was significantly smaller compared to Group B (3.31° ± 0.28°, 3.76° ± 0.20°) (p = 0.035, 0.004). Furthermore, at a torque of 5 N m, the torsional stiffness in Group A (1.48 ± 0.07) N m/° was significantly higher than that in Group B (1.36 ± 0.06) N·m/° (p = 0.003). Conclusion: The results obtained from the study demonstrate that the biomechanical performance of RTN outperforms that of the distal tibial plate, providing valuable biomechanical data to support the clinical implementation of RTN.

Anterior Tibial Artery Danger Zone During Anterolateral Plate Fixation of the Distal Tibia: A 3D Computed Tomography Angiogram Modeling Study

OBJECTIVES

The objective of this study was to define the danger zone at which the anterior tibial artery (ATA) is at risk during anterolateral plating of the distal tibia using a novel 3D computed tomography angiography (CTA) modeling technique.

METHODS

116 patients (232 lower extremities) who underwent lower extremity CTAs between April 2020 and April 2022 were identified. Those with lower extremity trauma, evidence of a previously healed tibial fracture, or poor visualization of the ATA were excluded. The remaining 150 lower extremities (92 patients) were modeled with an anterolateral distal tibia plate using Sectra IDS7 software. The distance of the ATA from bony landmarks was measured perpendicular to the level at which the vessel intersected the plate.

RESULTS

The ATA intersected the plate proximally at a mean distance of 10.5 cm (95% confidence intervals, 10.2-10.9) and at a mean distance of 4.6 cm (95% confidence intervals, 4.4-4.9) distally from the central tibial plafond. The ATA intersected with the plate as far distal as hole number 1 and as proximal as hole 14 of the plate. The greatest injury risk was associated with plate holes 3-8. In this region, the artery was at risk in 46-99 percent of specimens.

CONCLUSIONS

The ATA is at risk when screws are placed percutaneously in an anterolateral distal tibia plate. The artery can be as close as 4.4 cm and as far as 10.9 cm proximal to the tibial plafond when crossing the plate, correlating to a risk of injury to the ATA at plate holes 1 through 14.

Outcomes following minimally invasive plate osteosynthesis (MIPO) application in tibial pilon fractures - A systematic review

BACKGROUND

This systematic review evaluates postoperative complications and functional outcomes of minimally invasive plate osteosynthesis (MIPO) for distal tibial pilon fractures. This paper aims to fill a key literature gap, as no previous reviews have specifically addressed MIPO for tibial pilon fractures or fractures other than those involving the humeral shaft.

METHODS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic literature search was done using PubMed, Embase, Web of Science, and Scopus databases from 2000 to 2022. Inclusion criteria were MIPO treatment in skeletally mature patients, while exclusion criteria were non-English papers, conference abstracts, papers with multiple treatment modalities that didn't analyze MIPO outcomes separately, skeletally immature patients, case reports, and cohorts smaller than five patients. Unpublished papers were also searched using Clinical Trials. Data extraction included general study information, injury specification, outcome measures, and complications. Finally, a risk of bias assessment (RoB) was performed.

RESULTS

A total of 1732 studies were identified, of which 23 were included in this review, with 673 patients and 678 fractures analyzed. The mean follow-up ranged from 6 to 62.53 months, with most studies representing intermediate to long-term follow-up. Primary outcome measures showed that 87.33% achieved 'excellent to good' results, 8.67% achieved 'fair' results, and 4% achieved 'poor' results. Stratified by fracture type, 76.47%, 80.05%, and 76.92% of AO/OTA type A, B, and C fractures, respectively, achieved 'excellent to good' results. 35.06% of cases reported complications (236 in total). These included one case of deep infection (0.148%), 28 superficial wound infections (4.16%), 4 nonunion cases (0.59%), and 22 malunion instances (3.27%). RoB assessment showed that 52.17% had a moderate overall risk of bias, 39.13% had a serious overall risk of bias, and 8.7% had a critical overall risk of bias.

CONCLUSION

MIPO technique for pilon fractures showed good functional outcomes and reliability, with low complication rates and should be considered in cases where proper indirect reduction is possible. However, while the evidence is promising, further high-quality studies with larger sample sizes, longer-term follow-up, and comparison to other techniques are needed to evaluate the efficacy and safety of this technique.

LEVEL OF EVIDENCE

IV.

Treatment of Soft Tissue Defects after Minimally Invasive Plate Osteosynthesis in Fractures of the Distal Tibia: Clinical Results after Reverse Sural Artery Flap

Introduction: Distal tibial fractures make up approximately 3% to 10% of all tibial fractures or about 1% of lower extremity fractures. MIPO is an appropriate procedure and method to achieve stable metal plate fixation and osseointegration by minimizing soft tissue damage and vascular integrity at the fracture site. MIPO to the medial tibia during distal tibial fractures induces skin irritation due to the thickness of the metal plate, which causes discomfort and pain on the medial side of the distal leg, and if severe, complications such as infection and skin defect may occur. The reverse sural flap is a well-researched approach for covering defects in the lower third of the leg, ankle, and foot. Materials and Methods: Among 151 patients with distal tibia fractures who underwent minimally invasive metal plate fixation, soft tissue was injured due to postoperative complications. We treated 13 cases with necrosis and exposed metal plates by retrograde nasogastric artery flap surgery. For these patients, we collected obligatory patient records, radiological data, and wound photographs of the treatment results and complications of reconstructive surgery. Results: In all the cases, flap survival was confirmed at the final outpatient follow-up. The exposed area of the metal plate was well coated, and there was no plate failure due to complete necrosis. Three out of four women complained of aesthetic dissatisfaction because the volume of the tunnel through which the skin mirror passed and the skin plate itself were thick. In two cases, defatting was performed to reduce the thickness of the plate while removing the metal plate. Conclusions: Metal plate exposure after distal tibial fractures have been treated with minimally invasive metal plate fusion and can be successfully treated with retrograde nasogastric artery flaps, and several surgical techniques are used during flap surgery.

Distal Tibial Metaphyseal Malunion Treated with Clamshell Osteotomy: A Case Report

CASE

Here, we describe a case of a 49-year-old female patient with a history of hypertension and polysubstance use disorder presenting with a distal tibial metaphyseal malunion treated with a clamshell osteotomy. Her follow-up was 2.5 years long.

CONCLUSION

Malunions in the tibial diaphysis and distal metaphysis can cause significantly increased joint reaction forces and altered gait mechanics leading to cosmetic dissatisfaction and decreased quality of life for these patients. Correction of these deformities can improve patient satisfaction and quality of life, along with decrease the risk of early arthritis. The clamshell osteotomy, although initially described to treat diaphyseal long bone malunions, can safely be performed for treatment of complex periarticular metaphyseal malunions.

Pilon fractures: Consensus and controversy

Pilon fractures are complex injuries that require an individualized approach to treatment to avoid complications and achieve good outcomes. Staged open reduction internal fixation remains the gold standard for most cases to achieve anatomic articular reduction while minimizing soft tissue complications and infection. Careful preoperative planning based on computed tomography dictates the surgical approach for reduction. A subset of cases may be amenable to early definitive or provisional open reduction and internal fixation based on fracture pattern. In some cases of severe articular comminution where reconstruction is not possible, primary ankle arthrodesis may be a good alternative.

Suprapatellar vs infrapatellar approaches for intramedullary nailing of distal tibial fractures: a systematic review and meta-analysis

BACKGROUND

This review was conducted to compare the efficacy of suprapatellar (SP) and infrapatellar (IP) approaches for treating distal tibial fractures with intramedullary nailing.

METHOD

This systematic review included studies comparing the outcomes of patients receiving nailing for distal tibial fractures using the SP and IP approaches. We searched the Cochrane CENTRAL, MEDLINE and Embase databases for relevant studies till 18th Sep. 2022. We used the Newcastle Ottawa Scale to assess study quality and a random-effects meta-analysis to synthesize the outcomes. We used the mean difference (MD) or standardized mean difference (SMD) with the 95% confidence interval (CI) for continuous data and the odds ratio (OR) with the 95% CI for dichotomous data.

RESULTS

Four studies with 586 patients (302 in the SP group and 284 in the IP group) were included in this systematic review. The SP group may have had little or no difference in pain and slightly better knee function (MD 3.90 points, 95% CI 0.83 to 5.36) and better ankle function (MD: 8.25 points, 95% CI 3.35 to 13.15) than the IP group 12 months after surgery. Furthermore, compared to the IP group, the SP group had a lower risk of malalignment (OR: 0.22, 95% CI 0.06 to 0.75; number needed to treat (NNT): 6), a lower risk for open reduction (OR: 0.58, 95% CI 0.35 to 0.97; NNT: 16) and a shorter surgical time (MD: - 15.14 min, 95% CI - 21.28 to - 9.00).

CONCLUSIONS

With more advantages, the suprapatellar approach may be the preferred nailing technique over the infrapatellar approach when treating distal tibial fractures.

LEVEL OF EVIDENCE

Level III, systematic review of non-randomized studies.

Single-Stage Externalized Locked Plating for Treatment of Unstable Meta-Diaphyseal Tibial Fractures

(1) Background: Unstable meta-diaphyseal tibial fractures represent a heterogeneous group of injuries. Recently, good clinical results have been reported when applying a technique of externalized locked plating in appropriate cases, highlighting its advantage in terms of less additional tissue injury compared with conventional methods of fracture fixation. The aims of this prospective clinical cohort study were, firstly, to investigate the biomechanical and clinical feasibility and, secondly, to evaluate the clinical and functional outcomes of single-stage externalized locked plating for treatment of unstable, proximal (intra- and extra-articular) and distal (extra-articular), meta-diaphyseal tibial fractures. (2) Methods: Patients, who matched the inclusion criteria of sustaining a high-energy unstable meta-diaphyseal tibial fracture, were identified prospectively for single-stage externalized locked plating at a single trauma hospital in the period from April 2013 to December 2022. (3) Results: Eighteen patients were included in the study. Average follow-up was 21.4 ± 12.3 months, with 94% of the fractures healing without complications. The healing time was 21.1 ± 4.6 weeks, being significantly shorter for patients with proximal extra- versus intra-articular meta-diaphyseal tibial fractures, p = 0.04. Good and excellent functional outcomes in terms of HSS and AOFAS scores, and knee and ankle joints range of motion were observed among all patients, with no registered implant breakage, deep infection, and non-union. (4) Conclusions: Single-stage externalized locked plating of unstable meta-diaphyseal tibial fractures provides adequate stability of fixation with promising clinical results and represents an attractive alternative to the conventional methods of external fixation when inclusion criteria and rehabilitation protocol are strictly followed. Further experimental studies and randomized multicentric clinical trials with larger series of patients are necessary to pave the way of its use in clinical practice.

Intra-articular distal tibial fractures cause a major burden to individual patients and also stresses the public health care system

BACKGROUND AND PURPOSE

Intra-articular distal tibial fractures are most commonly caused by high-energy trauma. Additional difficulties are related to accompanying soft-tissue injuries. The purpose of this study was to evaluate the consequences of different types of distal tibial fractures to the individual patient and to the public health care system.

PATIENTS AND METHODS

126 patients with operatively treated intra-articular distal tibial fracture were identified between 2012 and 2016. Thirty-one (25%) were open fractures. Acute treatment, timing of definitive surgery, total number of surgical procedures, complications, need for soft-tissue reconstructions, hospital stay, and number of follow-up visits were recorded related to AO/OTA fracture types.

RESULTS

112 patients (89%) were treated with a staged treatment protocol. Of these patients, 74 first received an external fixation device. The definitive fracture fixation was performed on average 8 days after the trauma. Soft-tissue flap reconstruction was needed in 19 patients (15%). Additionally, 7 patients required split-thickness skin grafting. Total hospital stay ranged from 2 to 87 days (median 14 days). The median ward treatment period was 12 days in B2-3 group, 13 days in C1-2 group, and 18 days in C3 group. The median of 2 (range 1-13) surgical procedures were performed.

INTERPRETATION

Intra-articular distal tibial fractures cause a major burden to individual patients and stresses the public health care system due to a frequent need for several surgical procedures because of soft-tissue injuries and complications. AO/OTA type C3 fractures had the greatest burden, as patients required several consecutive operations and prolonged hospital stays.

Minimally Invasive Reduction and Fixation Techniques of Pilon Fractures Based on the Preoperative CT Findings

Tibial plafond fractures are often associated with significant articular cartilage and soft tissue damage. The presence of co-morbidities has been associated with an increased risk of surgical site complications. With improved in surgical techniques and implants, complication rates have declined; however, the overall prognosis often remains poor. The aims of this study were to evaluate the results of innovative minimally invasive reduction and fixation techniques in tibial plafond fractures based on a CT classification and to compare the difference between short and long-term outcomes. Based on preoperative CT findings, fractures were classified into varus, valgus, anterior, posterior, and neutral types. The minimally invasive reduction and fixation techniques depend on type of fracture, size and location of the intraarticular fragments, and degree of comminution of the extra-articular component. Ninety-one pilon fractures (90 patients) underwent minimally invasive reduction and fixation, of which 7 fractures (7.69%), required open reduction because of intraoperative failure to achieve anatomic reduction. Of the 84 fractures that underwent successful minimally invasive reduction and fixation reported, 35 fractures (41.7%) with excellent outcomes, 40 fractures (47.6%) with good outcomes, 6 fractures (7,1%) with fair outcomes, and 3 fractures (3.6%) had poor outcomes for the long-term American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score (follow-up ≥ 60 months). These results prove that minimally invasive treatment is an effective and durable treatment option for intra-articular pilon fractures. We encourage future clinical studies to further refine minimally invasive techniques for pilon fractures to improve outcomes.

Optimal Design and Biomechanical Analysis of a Biomimetic Lightweight Design Plate for Distal Tibial Fractures: A Finite Element Analysis

The treatment of fractures of the distal tibia can be problematic due to the insubstantial soft-tissue covering this part of the anatomy. This study investigates a novel strategy for minimally invasive plate osteosynthesis of distal tibia fractures called bionic lightweight design plating. Following the structure of the animal trabecular bone, we utilized topological mathematical methods to redesign the material layout of the internal fixation device to fulfill the desired lightweight design within given boundary conditions. The results showed that this method can maintain the same stability of the construct as the original plate after a reduction in the original volume by 30%, and the differences in strain energy of plates and maximum node displacement of constructs between the constructs [RP construct vs. LP construct] were not statistically significant (p > 0.05). In the safety assessment of the constructs, the peak stress of plates between constructs was found to not be statistically significantly different under a doubled physiological load (p > 0.05). The average stress of the plates’ elements exceeding the allowable stress was analyzed, and no statistically significant differences were found between the two constructs under axial compression stress conditions (p > 0.05). The average stress of the plates’ elements in the redesigned plating construct under torsional stress conditions was 3.08% less than that of the locked plating construct (p < 0.05). Under the double physiological load condition, 89% of the elements of the plate in the redesigned plating construct and 85% of the elements of the plate in the locked plating construct were lower than the maximum safe stress of the plate, which was 410 MPa (secondary allowable stresses). That reminds us the topology optimization offer a possible way to improve the capacity of soft tissue protection while ensuring the safety of the RP construct by reducing the volume of the implants.

MIPO vs. intra-medullary nailing for extra-articular distal tibia fractures and the efficacy of intra-operative alignment control: a retrospective cohort of 135 patients

INTRODUCTION

Definitive treatment of distal extra-articular fractures of the tibia is challenging and both minimal invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are considered to be feasible surgical modalities with their own implant-specific merits and demerits. This retrospective study was designed to compare MIPO versus IMN in terms of fracture healing, complications, functional and radiological outcomes and to assess the efficacy of intra-operative alignment control to reduce the rate of malalignment after definitive fixation of distal extra-articular fractures of the tibia.

MATERIALS AND METHODS

All consecutive adult patients with extra-articular distal meta- or diaphyseal tibia fractures that were treated between January 2012 and September 2019 either with MIPO or IMN were included. Outcome measures included fracture healing, complications (infection, malalignment, subsequent surgeries), functional and radiological outcomes. Intra-operative alignment control encompassed bilateral draping of the lower extremities.

RESULTS

A total of 135 patients were included out of which 72 patients (53%) were treated with MIPO and 63 patients (47%) underwent IMN. There was a significantly higher incidence of non-union for fractures treated with IMN (13 (22%) vs. 4 (6%), p = 0.04). There was no significant difference between both groups in terms of rotational malalignment (3% vs. 10%) and angular malalignment (4% vs. 5%). A significantly higher rate of infection was found after MIPO after correction of significant differences in baseline characteristics. No differences were found in subsequent surgeries or functional outcomes.

CONCLUSION

Both MIPO and IMN are reliable surgical techniques. IMN is associated with higher rates of non-union, whereas MIPO results in a higher risk for infection. The incidence of malalignment was surprisingly low endorsing the utility of the intra-operative alignment control.

Comparison of complications of early and delayed open reduction and internal fixation for treating pilon fracture: A protocol of systematic review and meta-analysis

BACKGROUND

Tibial Pilon fractures are severe fractures accompanied by soft tissue injury. Although open reduction and internal fixation (ORIF) are effective in treating Pilon fractures, there is a controversy over time to surgery due to reported postoperative complications. However, there is no systematic review evaluating the difference of postoperative complications between early and delayed ORIF for treating pilon fractures.

METHODS

Relevant literature written in English will be searched through PubMed, Cochrane Library, Embase, MEDLINE, and Web of Science. The study aims to compare the effects and complications of early and delayed ORIF for treating fresh pilon fractures in adult patients. The primary outcome will be infection rate, fracture union time, nonunion and malunion rate. And the secondary outcome will be metalwork removal, amputation, and ankle function grade. Two reviewers will independently assess the eligibility of the studies according to the pre-defined inclusion and exclusion criteria. A meta-analysis for the available data will be conducted using Revman 5.3. To measure effect size, odds ratios (ORs) and mean difference will be used for dichotomous and continuous data, respectively. Statistical heterogeneity will be explored. And a random-effects model or a fixed-effects will be used in pooled data on the basis of the existence or absence of heterogeneity. Subgroup analysis will be conducted to identify sources of heterogeneity and sensitivity analysis to test the results' robustness. We will assess the risk of bias by four different quality assessment tools according to the study design. Publication bias will be evaluated by funnel plot. The study data will be stored in the Open Science Framework website.

PROSPERO REGISTRATION NUMBER

CRD42020207465.

Results and complications of minimally invasive medial plate osteosynthesis for distal metaphyseal tibial fractures: A prospective case series from Vietnam

Introduction and importance

The treatment of a fractures in tibial distal metaphyseal remained controversial. The purpose of this study was to assess the results and complications of minimally invasive medial plate osteosynthesis for distal metaphyseal tibial fractures.

Material and method

From April 2014 to December 2019, 70 patients were enrolled in the study who were underwent MIPPO for metaphyseal tibial fractures using a medial distal tibial locking plate in our hospital. Wound healing, alignment, full weight bearing time, function, and complications were recorded.

Results

All wounds primarily healed, just one fibular plating wound was deeply infected. All tibial fractures were solid union without secondary displacement. The average time back to walk without a crutch was 12,5 weeks. The mean AOFAS score was 89 at a mean of 15 months follow-up. There were seven cases of late infection, 14 patients of skin impingement by implants and nine cases of broken screws, who were older than 65 years old. No case was varus, valgus or rotation >5°.

Conclusion

Minimally invasive medial plate osteosynthesis for the distal metaphyseal tibial fracture is safe and effective. This technique decreases the incidence of complications and can help patients to resume their function early. The implant impingement, late wound infections and screw breakage were the quite common complications in old patients but these complications could be simply resolved and did not affect the overall rehabilitation and functions of the patient.

A comparative biomechanical study of the Distal Tibia Nail against compression plating for the osteosynthesis of supramalleolar corrective osteotomies

The Distal Tibia Nail (DTN; Mizuho, Japan) has demonstrated higher biomechanical stiffness to locking plates in previous research for A3 distal tibia fractures. It is here investigated as a fixation option for supramalleolar corrective osteotomies (SMOT). Sixteen Sawbones tibiae were implanted with either a DTN (n = 8) or Medial Distal Tibia Plate (MDTP; n = 8) and a SMOT simulated. Two surgical outcome scenarios were envisaged: "best-case" representing an intact lateral cortex, and "worst-case" representing a fractured lateral cortex. All samples were subjected to compressive (350 N, 700 N) and torsional (± 4 Nm, ± 8 Nm) testing. Samples were evaluated using calculated construct stiffness from force-displacement data, interfragmentary movement and Von Mises' strain distribution. The DTN demonstrated a greater compressive stiffness for the best-case surgical scenario, whereas the MDTP showed higher stiffness (p < 0.05) for the worst-case surgical scenario. In torsional testing, the DTN proved more resistant to torsion in the worst-case surgical setup (p < 0.05) for both ± 4 Nm and ± 8 Nm. The equivalent stiffness of the DTN against the MDTP supports the use of this implant for SMOT fixation and should be considered as a treatment option particularly in patients presenting vascularisation problems where the MDTP is an inappropriate choice.

Risk factors for infection in fixation of distal tibia fractures

BACKGROUND

The aim of this study is to evaluate risk factors for infection as well as infection rates after open reduction and internal fixation for distal tibia fractures with a distal tibia locking plate and/or isolated screws.

METHODS

This is a retrospective and descriptive study based on 55 patients treated in our Major Trauma Centre from January 2009 to December 2016. All patients were classified by age, sex, open or closed fracture, injury mechanism, comorbidities, fixation and time from injury to surgery. 22 extraarticular fractures AO/OTA 43-A and 33 intraarticular (14 cases 43-B and 19 43-C) were recorded. High energy trauma was related in 27 patients, while open fractures were observed in 10 patients. Splint until surgery was applied routinely while temporary external fixation (EF) was performed in 21 patients (7 extraarticular and 14 intraarticular). Patients were treated by 5 different consultant surgeons performing isolated screws (SC) in 20% of the surgeries, antero-medial locking distal tibia plate (AM) and anterolateral (AL) were used in 47% and 33% of the patients respectively. After assessing normality and homogeneity of the subgroups, statistical contrast tests were performed.

RESULTS

Infection rate was 31.5%, mainly caused by S. aureus. We obtained a statistically significant correlation between greater age and infection rate. In the same way, a positive statistical trend between infection and AL plating was found. The use of EF followed by ORIF was not observed as a risk factor for infection compared with splint followed by internal fixation, however, the group of patients in which a splint was used, a positive relationship was found between the infection rate and shorter time until the definitive fixation. No statistically significant associations were found between extra/intraarticular fracture pattern, use of corticosteroids or open fractures and infection rate.

CONCLUSION

Greater age was a predisposing factor for infection. The use of external fixation before definitive ORIF seems to be a safe procedure regarding risk infection, and if an external fixation is not used, we recommend longer waiting time until definitive ORIF. Screw fixation or antero-medial plates, if allowed by fracture pattern, can be an option to avoid infection.

Effect of Nitrided and Nitrocarburised Austenite on Pitting and Crevice Corrosion Resistance of 316LVM Steel Implants

Harmful lesions occur in the body around multielement stabilisers made of AISI 316 LVM (Low Vacuum Melted) steel, caused by products of pitting, fretting or crevice corrosion. Preventing the effect is possible by modifying the surface of the steel implants. Therefore, the goal of the paper is the comparison of the mechanical and physiochemical properties of plates for treating deformations of the anterior chest wall made of AISI 316 LVM steel, subjected to diffusion and sterilisation processes and exposed to Ringer's solution. The surface of the implants was subjected to electrochemical polishing, chemical passivation and, in order to modify their properties, nitrocarburised and nitrided diffusion layers were created on selected stabilisers under glow discharge conditions with the use of an active screen at a temperature of 420 °C, over 60 min. The conducted studies involved the examination of the microstructure of the formed layers, surface roughness testing, analysis of contact angles and surface free energy, examination of resistance to pitting and crevice corrosion and examination of nanohardness. On the basis of the results of the conducted studies, it was established that the most advantageous set of properties after sterilisation and exposure to Ringer's solution was displayed by implants with a formed diffusion nitrocarburised layer.

Minimally invasive plate osteosynthesis (MIPO) versus open reduction and internal fixation (ORIF) in the treatment of distal fibula Danis-Weber types B and C fractures

Background

Minimally invasive plate osteosynthesis (MIPO) has been reported to be superior to open reduction and internal fixation (ORIF) in the treatment of different long bone fractures. Nevertheless, in distal fibula fractures, the evidence of MIPO remains scarce. The aim of this retrospective study was to compare the clinical and radiological outcomes of the minimally invasive techniques applied to the distal fibula with open reduction and internal fixation within a 12 months follow-up.

Methods

A consecutive series of patients who underwent surgery using either ORIF or MIPO for the treatment of distal fibula fractures between 2010 and 2014 were retrospectively analyzed. All distal fibular fractures requiring an operative treatment (Danis-Weber type B ≙ AO type 44 B1, 2, 3 and Danis-Weber type C ≙ AO type 44 C1, 2) were included (ORIF n = 35, MIPO n = 35). Patients were assessed for postoperative pain using a visual analog scale (VAS) for pain (ranging from 0 to 10) and classified into 4 groups: “no pain” for VAS = 0, “low” for VAS = 1–3, “moderate” for VAS = 3–5, and “severe” for VAS = 5–10. In addition, complications of postoperative fracture-related infection, wound healing disorders, vascular and nerve injury and development of nonunion were evaluated and analyzed. Radiologic outcome measures assessing the talocrural angle, lateral and medial clear space, tibiofibular overlap, and talar tilt angle were evaluated postoperatively.

Results

The overall complication rate showed to be lower in the MIPO group compared to the ORIF group (14% vs. 37%, p = 0.029). Even though not statistically significant, specific surgery-related complications such as skin necrosis (3% vs. 9%, p = 0.275), nonunion (0% vs. 6%, p = 0.139), infections and wound healing disorders (9% vs. 20%, p = 0.141), as well as postoperative pain (17% vs. 26%, p = 0.5) were found more frequently in the ORIF group. The tibiofibular overlap demonstrated to be significantly lower in the ORIF group (3.3 mm vs. 2.7 mm, p = 0.033). The talocrural angle, talar tilt angle, and lateral and medial clear space showed to be equivalent in both groups.

Conclusion

In this retrospective single-center consecutive series, MIPO was superior to ORIF in the surgical treatment of distal fibula fractures with respect to the overall complication rate.

Trial registration

EKNZ Project-ID: 2019-02310, registered on the 20th of December 2019 with swissethics

Supplemental cerclage wiring in angle stable plate fixation of distal tibial spiral fractures enables immediate post-operative full weight-bearing: a biomechanical analysis

Purpose

Distal tibial fractures generally require post-operative weight-bearing restrictions. Especially geriatric patients are unable to follow these recommendations. To increase post-operative implant stability and enable early weight-bearing, augmentation of the primary osteosynthesis by cerclage is desirable. The purpose of this study was to identify the stabilizing effects of a supplemental cable cerclage following plate fixation of distal tibial spiral fractures compared to solitary plate osteosynthesis.

Methods

In eight synthetic tibiae, a reproducible spiral fracture (AO/OTA 42-A1.1c) was stabilized by angle stable plate fixation. Each specimen was statically loaded under combined axial and torsional loads to simulate partial (200 N, 2 Nm) and full (750 N, 7 Nm) weight-bearing. Tests were repeated with supplemental cable cerclage looped around the fracture zone. In a subsequent stepwise increased dynamic load scenario, construct stiffness and interfragmentary movements were analyzed.

Results

With supplemental cable cerclage, construct stiffness almost tripled compared to solitary plate osteosynthesis (2882 ± 739 N/mm vs. 983 ± 355 N/mm; p < 0.001). Under full weight-bearing static loads, a supplemental cerclage revealed reduced axial (− 55%; p = 0.001) and shear movement (− 83%; p < 0.001), and also lowered shear movement (− 42%; p = 0.001) compared to a solitary plate under partial weight-bearing. Under dynamic loads supplemental cerclage significantly reduced axial (p = 0.005) as well as shear movements (p < 0.001).

Conclusion

Supplemental cable cerclage significantly increases fixation stiffness and reduces shear movement in distal tibial spiral fractures. This stabilizing effect enables from a biomechanical point of view immediate mobilization without any weight-bearing restrictions, which may improve the quality of care of orthopedic patients and may trigger a change towards early weight-bearing regimes, especially geriatric patients would benefit from.

The Impact of EBM-Manufactured Ti6Al4V ELI Alloy Surface Modifications on Cytotoxicity toward Eukaryotic Cells and Microbial Biofilm Formation

Electron beam melting (EBM) is an additive manufacturing technique, which allows forming customized implants that perfectly fit the loss of the anatomical structure of bone. Implantation efficiency depends not only on the implant's functional or mechanical properties but also on its surface properties, which are of great importance with regard to such biological processes as bone regeneration or microbial contamination. This work presents the impact of surface modifications (mechanical polishing, sandblasting, and acid-polishing) of EBM-produced Ti6Al4V ELI implants on essential biological parameters. These include wettability, cytotoxicity toward fibroblast and osteoblast cell line, and ability to form biofilm by Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans. Obtained results indicated that all prepared surfaces exhibited hydrophilic character and the highest changes of wettability were obtained by chemical modification. All implants displayed no cytotoxicity against osteoblast and fibroblast cell lines regardless of the modification type. In turn, the quantitative microbiological tests and visualization of microbial biofilm by means of electron microscopy showed that type of implant's modification correlated with the species-specific ability of microbes to form biofilm on it. Thus, the results of the presented study confirm the relationship between such technological aspects as surface modification and biological properties. The provided data are useful with regard to applications of the EBM technology and present a significant step towards personalized, customized implantology practice.

Intramedullary Nailing Versus Minimally Invasive Plate Osteosynthesis for Distal Tibial Fractures: A Systematic Review and Meta-Analysis

To evaluate the application, safety and efficacy of the patients treated with intramedullary nailing (IMN) and minimally invasive plate osteosynthesis (MIPO) in distal tibia fractures. Following the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) guidelines, we searched databases PubMed, Cochrane library, EMBASE and Web of Science from inception of the database up to 10 October 2018, using the keywords "distal tibia fractures", "plate", "intramedullary nailing" and "RCT" to identify randomized clinical trials about distal tibia fractures. The included studies were assessed by two researchers according to the Cochrane risk-of-bias criteria. The primary outcome of measurement included operation time, malunion rate, nonunion/delayed union rate, and wound complication. Data analysis was conducted with Review Manager 5.3 software. A total of 10 RCTs involving 911 patients fulfilled the inclusion criteria with 455 patients in the IMN group and 456 patients in the MIPO group. There were no significant differences in radiation time, nonunion or delayed union rate, union time and operation time between the two groups. Patients treated with MIPO had lower incidence of malunion compared with IMN (RR = 1.85, 95%CI: 1.21 to 2.83, P = 1.00), while IMN seemed to have lower surgical incision complications whether in closed or opening fractures (RR = 0.49, 95%CI 0.33 to 0.73, P = 0.43). But in patients classified as 43A, the result of subgroup analysis suggested that there was no significant inwound complication between the two groups. MIPO was superior in preventing malunion compared with IMN, and intramedullary nailing appeared to have lower wound complications. However, in patients with 43A distal tibial fractures, MIPO was more recommended for its prevention of malunion. No matter which method we choose, we should notice and prevent the associated complications.

Does surgical approach affect sagittal plane alignment and pilon fracture outcomes?

PURPOSE

Sagittal plane alignment beyond articular reduction and its effect on clinical outcomes has not been emphasized. Surgical approach may influence a surgeon's ability to correct the sagittal plane alignment. The purpose of our study was to evaluate how surgical approach impacts anterior distal tibial angle (ADTA) and lateral talar station (LTS). Our hypothesis was that the anterolateral (AL) approach would improve the sagittal plane parameters due to the primary plate placement.

PATIENTS AND METHODS

A retrospective review was performed on patients who underwent operative management for pilon fractures at 2 ACS Level 1 Academic Trauma Centers. Clinical data points including demographics, comorbidities, AO/OTA classification, surgical approach, and complications were recorded. Quality of reduction was measured using the ADTA, lateral distal tibia angle (LDTA), and lateral talar station (LTS) from radiographs.

RESULTS

580 pilon fractures met inclusion criteria. When compared to the AL approach, the modified anteromedial (AM) approach had decreased rates of local wound care, and unplanned reoperations. The AM approach had increased rates of superficial infection, deep infection, non-union, and amputations. There was no difference in ADTA, LDTA, or LTS between the AM and AL approach (P = 0.49, P = 0.41, P = 0.85). There was a difference in LTS with tobacco users (P = 0.02).

CONCLUSIONS

The sagittal plane alignment does not appear to be affected by the surgical approach. Therefore, the surgical approach to pilon fractures should be based on the fracture pattern and the patient's soft tissue envelope. This study shows that the AM is a relatively safe and effective approach to complex fractures and the surgeon should consider the specific fracture pattern and patient soft tissue envelope when choosing the specific approach.

Minimally invasive medial plate osteosynthesis in tibial pilon fractures: Longterm functional and radiological outcomes

OBJECTIVE

The aim of this study was to evaluate the long-term follow-up and functional and radiological outcomes of minimally invasive medial plate osteosynthesis in distal tibia fractures.

METHODS

From January 2011 to November 2015, we reviewed the medical records of 60 patients with 62 tibia fractures (41 men and 19 women; mean age: 45.3±14.9 years) who were treated with open reduction and internal fixation for distal tibia pilon fractures. The mean follow-up time after surgery was 42.7±4.6 months. Union time, coronal plan deformity, complication rates and AOFAS and Olerud-Molander functional outcome scores were evaluated.

RESULTS

According to the AO/OTA classification, there were thirty four (54.8%) type 43-A fracture, eight (12.9%) type 43-B fractures, twenty (32.3%) type 43-C fractures. The average time for fracture union was 16.1 weeks. The mean AOFAS score was 86.6±9.1. The mean Olerud-Molander score was 85.6±9.8. There were four patients (6.5%) with a varus of less than 5°, two patients (3.2%) with a valgus of less than 5°, 39 patients (62.9%) with recurvatum (34 of them less than 5°; five of them less than 10°), and 14 patients (22.6%) with procurvatum (12 of them less than 5°; two of them less than 10°). The AOFAS and Olerud-Molander scores in the smoker and diabetic patients were significantly lower than the non-smoker (p=0.002; p=0.005) and non-diabetic patients (p=0.022, p=0.002). The duration of union was significantly higher in both diabetic (p=0.025) and smoker patients (p=0.041). There was no association between the fracture type and the presence of varus, valgus, recurvatum and rotation deformity. The AOFAS score, Olerud-Molander score and plantar-flexion were significantly higher in type A fractures than in type C fractures (p=0.021; p=0.030, and p=0.033, respectively). AOFAS score, Olerud-Molander score, plantar-flexion value did not differ between type B and type C fractures. There was no significant difference among the dorsi-flexion (p=0.211), the follow-up time (p=0.531) and duration of union (p=0.908) of type A, type B and type C fractures. Three patients with open fracture had delayed wound healing. One patient developed skin necrosis. They were treated by local wound care.

CONCLUSION

Minimally invasive medial plate osteosynthesis is a reliable method of treatment for tibial pilon fractures. This technique provides a high fracture healing rate and satisfying functional outcome with minimal wound healing complications. Sagittal plan deformity remains a common complication with minimally invasive medial plate osteosynthesis.

LEVEL OF EVIDENCE

Level IV, Therapeutic Study.

Minimally invasive percutaneous plate osteosynthesis versus intramedullary nail fixation for distal tibial fractures: a systematic review and meta-analysis

Background

The treatment for distal tibial fractures remains controversial to date. Minimally invasive percutaneous plate osteosynthesis (MIPPO) and intramedullary nailing (IMN) are well-accepted and effective methods for distal tibial fractures, but these methods were associated with complications. This study aimed to assess and compare the clinical and functional outcomes in patients with distal tibial fractures treated with MIPPO or IMN.

Methods

We systematically reviewed randomized controlled trials (RCTs) that compared MIPPO with IMN in patients with distal tibial fractures from inception till 15 August 2019. Also, quantitative summaries of time to reunion, rate of complications, and functional outcomes were evaluated.

Results

The pooled results suggested that patients in the MIPPO group had a longer time to reunion with a mean difference of 1.21 weeks [P = 0.02; 95% confidence interval (CI) 0.16–2.26)] than those in the IMN group. The overall union complications and deep infection between IMN and MIPPO were similar (P > 0.05). IMN had a significantly low risk of wound complications [risk ratio (RR) = 0.51, P = 0.00, 95% CI 0.34–0.77)]. The pooled functional outcomes of the two groups remained controversial by different evaluating scores.

Conclusions

Compared to MIPPO, IMN had a significantly low risk of wound complications and associated with limited time for reunion. Although the pooled functional outcomes of the two groups were controversial due to different evaluating scores, IMN was the preferred surgical technique than MIPPO for treating distal tibial fractures.

Early clinical and radiographic outcomes of a mini-fragment, low profile plating system in tibial plafond fractures

OBJECTIVE

The Smith and Nephew mini-EVOS plating system is a mini-fragment, low profile, variable-angled plating system designed to obtain anatomic reduction while also minimizing soft tissue handling. However, literature has been limited in reporting the clinical and surgical outcomes of these specific plates. The goal of our study is to evaluate the safety and efficacy of the Smith and Nephew mini-EVOS plate in pilon fracture management, where significant high energy forces can result in severe fracture patterns and soft tissue injury.

METHODS

Patients 18-65 years of age who underwent plate fixation of their tibial plafond fractures (OTA/AO) using the Smith and Nephew mini-EVOS plating system at our urban university-based level-1 trauma center were included in this retrospective investigation. A total of 37 patients (37 fractures) from January 2015 to March 2018 were included in this study. Primary outcome measure was mechanical hardware failure. Secondary outcome measures included nonunion, malunion, medical and surgical complications.

RESULTS

The fractures were classified according to the OTA/AO classification as 43C1 (n = 15), 42C2 (n = 6), and 43C3 (n = 16). A mechanical failure was observed in three patients (8.1%). Six additional patients needed a re-operation of the surgical site including two nonunion repairs, one malunion repair, one symptomatic hardware removal, and two soft tissue debridements. The mean follow-up was 298.9 days (range: 96-936).

CONCLUSIONS

Early results of operative fixation of tibial plafond fractures using the Smith-Nephew mini-EVOS demonstrated low hardware failure and complication rates. This plating system is a safe and effective implant.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Preliminary exploration of a quantitative assessment index for the matching performance of anatomical bone plates using computer

BACKGROUND

To explore a new quantitative index to assess the matching performance of anatomical bone plates using digital technology.

METHODS

CT data of normal tibias of 40 adults were collected. Two brands of medial distal tibia plates were digitized. Two trained orthopedists simulated the surgical operation in Rhino 5.1 software by placing the plate curve on the medial distal tibia surface. The volume of the interstice between the plate curve and the bone surface was measured. The inverse value of this average interstice distance was used as the matching performance index (MPI). A wall thickness analysis tool was used to mark various interstice distances with varied colors.

RESULTS

The Kangli medial distal tibia plate had a MPI of 0.55 ± 0.08 by operator A and 0.55 ± 0.06 by operator B. The general care medial distal tibia plate had a MPI of 0.32 ± 0.06 by operator A and 0.31 ± 0.05 by operator B. There were significant variations in the MPI between the two types of plates by both operators (p < 0.001). And significant variations were observed in the MPI of general care medial distal tibia plates among various operator groups (p = 0.028).

CONCLUSION

This quantitative index of matching performance is straightforward and intuitive. However, we still need a method to improve the experimental repeatability, especially when it comes to a plate with poor matching performance.

Can Preoperative 3D Printing Change Surgeon's Operative Plan for Distal Tibia Fracture?

This study aimed to determine if 3D printing can affect surgeon's selection of plate for distal tibia fracture surgery and to find out whether orthopedic surgeons consider this technology necessary and would use it in their practice. A total of 102 orthopedic surgeons were asked to choose anatomically contoured locking plates among 5 most commonly used types for one simple and one complex distal tibia fracture based on X-ray and CT images. Next, they were provided real-size 3D printed models of the same fractures, allowed to apply each of the 5 plates to these models, and asked if they would change their choice of plate. A 10-point numeric rating scale was provided to measure the extent of the help that 3D printing provided on preoperative planning. Finally, we asked the surgeons if they would use 3D printing in their practice. Seventy-four percent of inexperienced surgeons changed their selection of plate after using 3D printed models for the complex fracture. In contrast, only 9% of experienced surgeons changed their selection of plate for the simple fracture. Surgeons rated the extent of usefulness of the 3D models in preoperative planning as a mean of 4.84 ± 2.54 points for the simple fracture and 6.63 ± 2.54 points for the complex fracture. The difference was significant (p < 0.001). Eighty-six percent of inexperienced surgeons wanted to use 3D models for complex fractures. However, only 18% of experienced surgeons wanted to use 3D printed models for simple fractures. The use of a real-size 3D-printed model often changed surgeon's preoperative selection of locking plates, especially when inexperienced surgeons evaluated a complex fracture. However, experienced surgeons did not find 3D models very useful when assessing simple fractures. Future applications of 3D models should focus on training beginners in fracture surgery, especially when complex fractures are concerned.

Minimally Invasive Osteosynthesis of Distal Tibia Fractures using Anterolateral Locking Plate

Introduction: Plating in distal tibia fractures are associated with higher rate of soft tissue complications. As adequate soft tissue cover is available over anterolateral surface of the tibia, use of anterolateral plate fixation in distal tibia fractures has increased. The purpose of our research is to evaluate the outcomes of anterolateral locking plate fixation in distal tibia fractures using ORIF.

Materials and Methods: A retrospective analysis of 25 patients, who had distal tibia fractures and underwent open reduction and anterolateral plating. Bone and soft tissue healing and complications encountered were analysed.

Result: Full weight bearing was allowed at an average of 5.4 months (range: 3-12 months) after seeing radiological union. We have observed superficial wound infection in four cases. Two cases had marginal necrosis, two cases had sensory disturbance over dorsolateral aspect of foot and two cases had delayed non-union. Mean length of surgical incision was 9cm (range: 5-12 cm).

Conclusion: Open reduction internal fixation of distal tibia fractures with anterolateral plating is a reliable way of fracture fixation and stabilisation with proper surgical technique and aseptic precautions.

Pilon Fracture: Preventing Complications

Fractures of the distal tibial plafond (ie, pilon) comprise a broad range of injury mechanisms, patient demographics, and soft-tissue and osseous lesions. Patients often present with considerably comminuted fracture patterns and notable soft-tissue compromise. Surgical intervention must be performed with respect for the exceedingly vulnerable soft-tissue envelope and with a properly executed technique. Even with proper timing, favorable host factors, and expert surgical technique, restoration of function and avoidance of complications are not always achievable. Recently validated techniques further diminish the risk of soft-tissue and osseous sepsis. These techniques include early (ie, "immediate") fixation, upgrading, primary arthrodesis, staged sequential posterior and anterior fixation, acute shortening, and transsyndesmotic fibular plating. Proper application of these recently adopted techniques may be instrumental in achieving aseptic union of pilon fractures.

The Outcomes of Pilon Fracture Treatment: Primary Open Reduction and Internal Fixation Versus Two-stage Approach

BACKGROUND

Pilon fracture is one of the challenging injuries in orthopedic surgery. Associated soft tissue injury is an important factor in choosing treatment options. Two major methods of treatment are considered as one-stage open reduction internal fixation (ORIF) and two-stage treatment (primary external fixation and secondary ORIF). The latter is most accepted in literature. In the current study, we compared the results of these two methods.

METHODS

In a retrospective study, 41 patients were assigned to two groups containing one-stage primary ORIF (21 patients) group, and two-stage group included external fixation and secondary ORIF (20 patients). The rate of infection (superficial or deep infection, osteomyelitis), malunion, nonunion, duration of hospital stay, neurovascular injury, pain intensity, and patients' satisfaction with AOFAS score, were compared between the two groups.

RESULTS

There was no significant difference between the two groups in measured variables except hospital stay which was significantly longer for the two-stage group.

CONCLUSION

Based on our findings, we recommend using one stage ORIF for a patient with Pilon fractures type C and Tscherne 1, 2 if the patient is planned to be operated on during the first 24 hours after the injury.

Distal Tibia Metaphyseal Fractures: Which is Better, Intra-medullary Nailing or Minimally Invasive Plate Osteosynthesis?

Introduction

Tibia fractures are the most common long bone fractures encountered by the orthopedic surgeons and distal tibia fractures have the second highest incidence of all tibia fractures after the middle third of tibia the distal tibial fractures are unique and are considered as most challenging fractures to treat due to its proximity to the ankle joint and its superficial nature. The objective of this study is to compare two osteosynthesis systems developed for surgical treatment of distal tibia fractures: the intramedullary nailing and the MIPPO technique.

Methods

The study was conducted between Jan 2011 to Dec 2012. 63 patients with extra-articular distal tibia fracture treated with intramedullary nailing and MIPPO technique were reviewed retrospectively and clinical outcome was evaluated according to American Orthopaedic Foot and Ankle Score.

Results

31 patients were treated with intramedullary nail & 32 with MIPPO technique. Fibular fixation was done in cases where fibular fracture was at or below the level of tibial fractures. We found no difference in terms of time for fracture union, mal-union, non-union, duration of surgery and amount of blood loss. But there was significant difference in terms of infection and duration of hospital stay. Also weight bearing was possible much earlier in intramedullary group as compared to the MIPPO group.

Conclusion

Thus we conclude that intramedullary nailing is better choice of implant in patients with extra- articular distal tibia fractures & helps in early weight bearing and ambulation of patient with fewer complications.

Minimally Invasive Plate Osteosynthesis for Distal Tibia Fractures

Surgical treatment of distal tibia fractures can present as a difficult task. Intramedullary nailing (IMN), external fixation, and open reduction internal fixation (ORIF) have displayed various complications ranging from a high rate of knee morbidity with IMN to wound complications and infection with ORIF. Minimally invasive plate osteosynthesis (MIPO) has been used to decrease development of these complications. MIPO respects the soft tissue envelope along with maintaining the biological environment needed for proper osseous healing. Favorable results have been shown with MIPO in regard to function, healing time, and decreased complications.

Comparing intramedullary nailing and plate fixation for treating distal tibail fractures: A meta-analysis of randomized controlled trials

BACKGROUND

Intramedullary nailing (IMN) and plate have been reported as two effective devices for treating distal extra-articular fractures. However, reports of complications after fractures with use of different tibial fixation techniques in literature are controversial. Thus, we performed a meta-analysis of randomized controlled trials (RCTs) to compare IMN with plate for evaluating the safety and efficacy.

METHODS

The studies were searched from PubMed, Embase, Web of science and the Cochrane Central Register of Controlled Trials by two reviewers up to August 2017. The quality of RCTs was assessed by Cochrane Handbook. Data were extracted from studies and analyzed by Review Manager 5.3. 95% confidence interval (CI) and risk ratio (RR) were calculated for dichotomous data.

RESULTS

Eight RCTs with 482 patients were included in the meta-analysis. We found no statistically significant differences between IMN and plate on union time (SMD = -0.20, 95%CI -0.58 to 0.18, P = 0.3), delayed or nonunion (RR = 1.19, 95%CI 0.66 to 2.14, P = 0.56) and malunion (RR = 1.63, 95%CI 1.01 to 2.65, P = 0.05). IMN group had shorter operative time (P < 0.0001) and radiation time (P < 0.0001), lower incidence of wound complications (P = 0.0003) and higher rate of knee pain (P < 0.0001) than the plate group.

CONCLUSION

The meta-analysis showed that intramedullary nailing reduced the time of surgery and radiation and the risk of wound complications compared with plate fixation. Furthermore, union time and union complications were common following both treatments. Overall, intramedullary nailing is found to be taken priority for distal tibial metaphyseal fractures. More RCTs are required to support current evidence.

Medium-Long-Term Radiographic and Clinical Outcomes after Surgical Treatment of Intra-Articular Tibial Pilon Fractures by Three Different Techniques

Introduction

The goal of this retrospective, observational, case series study was to evaluate the medium-long-term clinical and radiographic results of the three most common surgical osteosynthesis techniques used for the treatment of articular tibial pilon fractures: ORIF, MIPO, and EF.

Materials and Methods

A consecutive series of patients with articular pilon fractures who underwent surgery at our institution were enrolled in this study. Fractures were classified according to the Müller AO classification system. Overall outcomes took the following into account: radiographic quality of reduction, evaluated using Ovadia and Beals' criteria; clinical assessment, evaluated using the AOFAS questionnaire; and general health, evaluated with the SF36-v2 Health Survey.

Results

A total of 94 articular pilon fractures (34 type 43-B and 60 43-C) were evaluated with a mean follow-up of 56.34 months (range 33–101). The techniques used were ORIF, MIPO, and EF in 63 (67%), 17 (18.9%), and 14 cases (14.1%), respectively. According to Ovadia and Beals' criteria, good, fair, and poor results were reported in 61 (64.89%), 26 (27.66%), and 7 (7.45%) cases, respectively. The mean AOFAS score was 82.41 for MIPO, 79.83 for ORIF, and 50.57 for EF, respectively. Thirty-nine patients (41.49%) presented early and/or late complications.

Conclusion

Satisfactory outcomes using the three different techniques were reported. In particular, the radiographic outcomes were inversely proportional to the fracture comminutions and statistically different between internal and external osteosynthesis, but comparable between ORIF and MIPO techniques. On the other hand, the clinical outcomes were closely related to the soft tissue conditions and the anatomical reconstruction of the joint.

A Prospective Randomized Study on Operative Treatment for Simple Distal Tibial Fractures-Minimally Invasive Plate Osteosynthesis Versus Minimal Open Reduction and Internal Fixation

OBJECTIVES

To compare the radiologic and clinical results of minimally invasive plate osteosynthesis (MIPO) and minimal open reduction and internal fixation (ORIF) for simple distal tibial fractures.

DESIGN

Randomized prospective study.

SETTING

Three level 1 trauma centers.

PATIENTS

Fifty-eight patients with simple and distal tibial fractures were randomized into a MIPO group (treatment with MIPO; n = 29) or a minimal group (treatment with minimal ORIF; n = 29). These numbers were designed to define the rate of soft tissue complication; therefore, validation of superiority in union time or determination of differences in rates of delayed union was limited in this study.

INTERVENTION

Simple distal tibial fractures treated with MIPO or minimal ORIF.

MAIN OUTCOME MEASUREMENTS

The clinical outcome measurements included operative time, radiation exposure time, and soft tissue complications. To evaluate a patient's function, the American Orthopedic Foot and Ankle Society ankle score (AOFAS) was used. Radiologic measurements included fracture alignment, delayed union, and union time.

RESULTS

All patients acquired bone union without any secondary intervention. The mean union time was 17.4 weeks and 16.3 weeks in the MIPO and minimal groups, respectively. There was 1 case of delayed union and 1 case of superficial infection in each group. The radiation exposure time was shorter in the minimal group than in the MIPO group. Coronal angulation showed a difference between both groups. The American Orthopedic Foot and Ankle Society ankle scores were 86.0 and 86.7 in the MIPO and minimal groups, respectively. Minimal ORIF resulted in similar outcomes, with no increased rate of soft tissue problems compared to MIPO.

CONCLUSIONS

Both MIPO and minimal ORIF have high union rates and good functional outcomes for simple distal tibial fractures. Minimal ORIF did not result in increased rates of infection and wound dehiscence.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for the Surgical Field Infections After the Osteosynthes of Tibia Diaphysis

Introduction:

Infections occurring in the wound as a consequence of the surgery represent the surgical field infections (SFI). Tibia diaphysis fractures are common due to its exposure to the external force. Clinical signs include: pain, swelling, lower leg deformity and skin changes. Tibia in the lower extremities has an eccentric position - from the front inner side it is covered only with the skin and from the back and the outer by muscle mass. The most common pathogens are: Staphylococcus aureus, Coagulase negative Staphylococcoc aureus or S. Epidermitis, Escherichia coli, and other. For the fracture fusion process, it is important that the skin and subcutaneous tissue above the fracture are well supplied with the blood. The American Association of Anesthesiologists defined the so-called ASA score, based on which all patients are divided into five categories according to health status before surgery.

Goal:

The goal of the study is to demonstrate the influence of risk factors on the occurrence of infection following osteosynthesis of tibial diaphysis, comparing emergency surgical interventions with elective.

Material and methods:

The study was conducted at the Clinic for Orthopedics and Traumatology of the Clinical Center of Sarajevo University during 2015 and 2016, with a total of 68 patients.

Results:

The age of the patient as risk factor is evident in our study, because deeper infections have had patients at the age over 60 with accompanying diseases such as Diabetes mellitus. Most of the hospitalized patients had a good health status prior to surgery, or they had ASA 1 or ASA 2 score. Surgical field infections were more common in men than in women, but the difference was not statistically significant (p>0.05). Patients who are operated as an elective surgery have longer hospitalization and more frequent surgical field infection. Also, infections are more common among smokers.

Locked plating as an external fixator in treating tibial fractures: A PRISMA-compliant systematic review

OBJECTIVES

This article is a systematic review of the published literature about the biomechanics, functional outcomes, and complications of a locked plate as an external fixator in treating tibial fractures.

METHODS

We searched the PubMed, Ovid Medline, Embase, ScienceDirect, and Cochrane Library databases to retrieve the relevant studies. Studies published in English and Chinese which assessed adult patients and more than 4 cases who had sustained any type of fresh tibial fracture treated with the external locking plate, provided that they reported functional outcomes, range of motion (ROM), union or complication rates, and the biomechanical studies of external locked plating are also included.

RESULTS

The electronic search strategy revealed 248 studies, and 2 studies were identified as relevant through manual search of references. Finally, 12 studies were included in this systematic review. These consist of 3 pure biomechanical studies, 8 case series, and 1 study including both of biomechanics and case series. Due to the heterogeneity of biomechanical studies, we can only conclude that external locked plate shows inferior structural stiffness than internal locked plate. The clinical studies reported that external locked plating gave a satisfactory ROM of the knee and ankle, functional outcomes, union rate, and low complication rate.

CONCLUSIONS

We can only conclude that external locked plate shows inferior structural stiffness than internal locked plate because of the heterogeneity of biomechanical studies. The clinical studies showed locked plating as an external fixator in treating tibial fractures can be considered as a safe and successful procedure. However, as yet, there is unconvincing evidence that it is superior to standard techniques with regards to clinical and functional outcomes. More and well-designed studies about this technique should be carried out.

Successful treatment of infected wound dehiscence after minimally invasive locking-plate osteosynthesis of tibial pilon and calcaneal fractures by plate preservation, surgical debridement and antibiotics

OBJECTIVE

The aim is to present a case series that illustrates possible benefits from combining minimally invasive plate osteosynthesis (MIPO), plastic surgery and antibiotic therapy, in order to treat and eradicate infection in patients with tibial pilon or calcaneal fractures.

METHODS

Eleven consecutive patients with dehiscence of the surgical wound in outcomes MIPO using a Locking Compression Plate (LCP) for tibial pilon, or calcaneus fractures. The patients had developed a documented infection of the surgical wound. All patients were treated and followed-up by the multidisciplinary team with the orthopedic surgeon, the plastic surgeon and the infectious disease physician. All patients were followed by the plastic surgeon to treat the wound dehiscence, as well as by the orthopedic surgeon until fracture consolidation. The duration of the antibiotic therapy was from 4 to 6 months. After 6 weeks, the intravenous treatment was replaced by oral administration. The follow-up intervals were 15 days, 40 days, and 3 months.

RESULTS

The average time of wound closure was 109±60 days. The antibiotics used were chosen according to the antibiogram. The antibiotic therapy had a duration of 4-6 months, and after 6 weeks, the therapy switched to oral administration. At the 3-month follow-up, all patients had excellent outcomes and had returned to their normal activity of daily living.

CONCLUSION

The patients in this study responded positively to a combination of MIPO, plastic surgery and antibiotic therapy, confirming that multidisplinary treatment in association with titanium devices are able to eradicate infection in short time.

Soft tissue complications in distal tibial fractures managed with medial locking plates: A myth or reality?

BACKGROUND

Distal tibial fractures are common injuries that are prone to complications and require careful management. The use of medial periarticular locking plates is an established modality in the treatment if these fractures. These plates are inserted using the minimally invasive plate osteosynthesis (MIPO) or open technique. Our study looks at the soft tissue complications associated with the use of medial locking plates in the management of these fractures.

METHODS

This was a retrospective study carried out at a tertiary care university hospital in an urban setting. Forty four patients with distal tibia fractures treated with periarticular locking plates during a three year period were included in the study. Both closed and open fractures were included while those with an established non-union were excluded. Patient data related to inpatient stay, outpatient visits as well as readmissions was extracted from hospital records and analysed. Spanning external fixation was done if necessary and definitive fixation was done using medial locking plates with either MIPO technique or open reduction and internal fixation (ORIF) with biological technique. The sub cohort of patients with soft tissue complications was compared to the parent group.

RESULTS

The study group included 44 patients (28M:16F) with 45 fractures with a median age of 42.6 years (range 18-65 years) followed up for a mean of 9.2 months (range 5-20 months). Domestic falls were the cause of injury in 61.4% (n = 27) of the fractures. The average time to union was 26.2 weeks (range 12-66 weeks). Out of these 45 fractures, soft tissue complications were seen in 22.2% of cases (n = 10) with road side accidents seen in 60% (n = 6) of cases. In four patients, there was difficulty in achieving primary wound closure and in five other cases wound dehiscence with exposure of implant was seen within 12 to 30 days of surgery. One patient required secondary suturing after readjustment for malreduction. No statistically significant difference was found in the parent cohort and the sub cohort with soft tissue complications with respect to the use of spanning external fixator, MIPO/ORIF technique or fibular fixation.

CONCLUSION

The incidence of soft tissue complications with the use of medial locking plates in distal tibial fractures may be more than what is currently reported in literature and further studies are required to shed more light on this subject.

Evaluation of Fibular Fracture Type vs Location of Tibial Fixation of Pilon Fractures

BACKGROUND

Comminuted fibular fractures can occur with pilon fractures as a result of valgus stress. Transverse fibular fractures can occur with varus deformation. No definitive guide for determining the proper location of tibial fixation exists. The purpose of this study was to identify optimal plate location for fixation of pilon fractures based on the orientation of the fibular fracture.

METHODS

One hundred two patients with 103 pilon fractures were identified who were definitively treated at our institution from 2004 to 2013. Pilon fractures were classified using the AO/OTA classification and included 43-A through 43-C fractures. Inclusion criteria were age of at least 18 years, associated fibular fracture, and definitive tibial plating. Patients were grouped based on the fibular component fracture type (comminuted vs transverse), and the location of plate fixation (medial vs lateral) was noted. Radiographic outcomes were assessed for mechanical failures.

RESULTS

Forty fractures were a result of varus force as evidenced by transverse fracture of the fibula and 63 were due to valgus force with a comminuted fibula. For the transverse fibula group, 14.3% mechanical complications were noted for medially placed plate vs 80% for lateral plating ( P = .006). For the comminuted fibular group, 36.4% of medially placed plates demonstrated mechanical complications vs 16.7% for laterally based plates ( P = .156). Time to weight bearing as tolerated was also noted to be significant between groups plated medially and laterally for the comminuted group ( P = .013).

CONCLUSIONS

Correctly assessing the fibular component for pilon fractures provides valuable information regarding deforming forces. To limit mechanical complications, tibial plates should be applied in such a way as to resist the original deforming forces. Level of Evidence Level III, comparative study.

Outcome and complications in dogs with appendicular primary bone tumors treated with stereotactic radiotherapy and concurrent surgical stabilization

OBJECTIVE

To document the outcome of dogs with appendicular primary bone tumors treated with stereotactic radiotherapy (SRT) and concurrent stabilization.

STUDY DESIGN

Multi-institutional retrospective case series.

ANIMALS

Eighteen dogs with presumptive or definitive diagnosis of appendicular osteosarcoma.

METHODS

Medical records of dogs with appendicular primary bone tumors treated with SRT and stabilization were reviewed for signalment, preoperative staging and diagnostics, radiation dose, stabilization method, and outcome.

RESULTS

The distal radius was affected in 13/18 cases. Osteosarcoma or sarcoma was confirmed cytologically or histologically in 15/18 cases. Seven dogs were diagnosed with a pathological fracture at the time of treatment, and 11 were considered at high risk for pathological fracture. Dogs received a single dose (n = 5) or 3 doses (n = 13) of SRT. Surgical stabilization was performed under the same anesthetic event as the final dose of SRT in 10 dogs. Stabilization was achieved with a bone plate (n = 15) or interlocking nail (n = 3). Seventeen dogs received adjuvant chemotherapy. Complications occurred in 16/17 dogs, 15/17 of those being considered major complications. Four dogs experienced more than one complication. Infection was the most common complication, diagnosed in 15/17 cases, and considered as a major complication in 13/15 cases. Postoperative fracture was recorded as a major complication in 3 cases. Nine dogs were amputated at a median of 152 days. The median survival time was 344 days.

CONCLUSION

Treatment of bone tumors with SRT and concurrent stabilization was associated with a prohibitively high complication rate in dogs. Alternative methods for limb salvage should be considered for dogs at risk for pathologic fracture.

Plating of pilon fractures based on the orientation of the fibular shaft component: A biomechanical study evaluating plate stiffness in a cadaveric fracture model

OBJECTIVES

To evaluate mechanically superior method of pilon fracture fixation by comparing axial stiffness between anterolateral and medial tibial locking plates in a cadaveric fracture model.

METHODS

Eight matched pairs of fresh frozen cadaver specimens (lower limb after through-knee disarticulation) were used to eliminate confounder of bone quality. Simulated pilon fractures were created so that each pair represented either varus or valgus fracture pattern (AO 43-A2) with associated fibular fractures (transverse or comminuted). Specimens were plated with DePuy anterolateral or medial locking plate and axial load applied, measuring displacement at the fracture site. Each lower extremity was tested with a fracture wedge in place and removed to mimic comminution. Average force at which failure occurred was compared between the two fixation methods, for varus and valgus fracture pattern respectively, with the use of a Mann-Whitney U test.

RESULTS

On average, medial plate fixation of varus fractures resulted in 2.27 times (range of 1.6-3.9) greater load prior to failure as compared to anterolateral plate. Similarly, valgus simulated fractures tolerated 1.6 times (range 1.12-2.34) higher force prior to failure if anterolateral plate was applied versus medial plate. Analysis utilizing the Mann-Whitney U test for fracture patterns vs plate configuration approached statistical significance (p = 0.081 varus failure and p = 0.386 valgus failure).

CONCLUSIONS

Lateral plate fixation is biomechanically superior for pilon fractures resulting from valgus force as evident by comminuted fibular fracture. Similarly, medial plate location resulted in improved stiffness in compression for varus type fractures, evident by transverse fibular fracture. We approached statistical significance, however our lack of power regarding adequate sample size is an issue that is consistent with other biomechanical studies in this area.

Complications of Minimally Invasive Percutaneous Plating for Distal Tibial Fractures

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.