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Hierholzer C, Neuhaus V, Pape HC. Frame concept using combined locked nail and plate osteosynthesis for treatment of osteoporotic distal tibial fractures (DiTiFra) how augmented fixationrigidity may help early weightbearing. Injury 2024; 55:111713. [PMID: 39018641 DOI: 10.1016/j.injury.2024.111713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Affiliation(s)
| | - Valentin Neuhaus
- Department of Traumatology, University Hospital Zurich, Switzerland
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Liu B, Wang L, Li X, Chen Z, Hou G, Zhou F, Wang C, Tian Y. Applying 3D-printed prostheses to reconstruct critical-sized bone defects of tibial diaphysis (> 10 cm) caused by osteomyelitis and aseptic non-union. J Orthop Surg Res 2024; 19:418. [PMID: 39033286 PMCID: PMC11264997 DOI: 10.1186/s13018-024-04926-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 07/16/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND Clinical repair of critical-sized bone defects (CBDs) in the tibial diaphysis presents numerous challenges, including inadequate soft tissue coverage, limited blood supply, high load-bearing demands, and potential deformities. This study aimed to investigate the clinical feasibility and efficacy of employing 3D-printed prostheses for repairing CBDs exceeding 10 cm in the tibial diaphysis. METHODS This retrospective study included 14 patients (11 males and 3 females) with an average age of 46.0 years. The etiologies of CBDs comprised chronic osteomyelitis (10 cases) and aseptic non-union (4 cases), with an average defect length of 16.9 cm. All patients underwent a two-stage surgical approach: (1) debridement, osteotomy, and cement spacer implantation; and (2) insertion of 3D-printed prostheses. The interval between the two stages ranged from 8 to 12 weeks, during which the 3D-printed prostheses and induced membranes were meticulously prepared. Subsequent to surgery, patients engaged in weight-bearing and functional exercises under specialized supervision. Follow-up assessments, including gross observation, imaging examinations, and administration of the Lower Extremity Functional Scale (LEFS), were conducted at 3, 6, and 12 months postoperatively, followed by annual evaluations thereafter. RESULTS The mean postoperative follow-up duration was 28.4 months, with an average waiting period between prosthesis implantation and weight-bearing of 10.4 days. At the latest follow-up, all patients demonstrated autonomous ambulation without assistance, and their LEFS scores exhibited a significant improvement compared to preoperative values (30.7 vs. 53.1, P < 0.001). Imaging assessments revealed progressive bone regeneration at the defect site, with new bone formation extending along the prosthesis. Complications included interlocking screw breakage in two patients, interlocking screw loosening in one patient, and nail breakage in another. CONCLUSIONS Utilization of 3D-printed prostheses facilitates prompt restoration of CBDs in the tibial diaphysis, enabling early initiation of weight-bearing activities and recovery of ambulatory function. This efficacious surgical approach holds promise for practical application.
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Affiliation(s)
- Bingchuan Liu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Liwei Wang
- Department of Anesthesiology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, China
| | - Xingcai Li
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Zhuo Chen
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Guojin Hou
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Fang Zhou
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Caimei Wang
- Beijing AKEC Medical Co., Ltd, Beijing, China
| | - Yun Tian
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China.
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China.
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Li X, Chen K, Xue H, Cheng J, Yu X. Efficacy comparison between intramedullary nail fixation and plate fixation in distal tibia fractures: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2024; 19:403. [PMID: 38997735 PMCID: PMC11241967 DOI: 10.1186/s13018-024-04900-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 07/03/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Intramedullary nail (IMN) and plate fixation are the most commonly used surgical modalities for distal tibia fractures. However, the superiority of their efficacy regarding functional outcomes and complications remains controversial. Here, we performed a systematic review and meta-analysis to compare the efficacy of these two modalities. METHODS Randomized controlled trials (RCTs) comparing the efficacy of IMN and plate fixation in distal tibia fractures were searched in PubMed, Web of Science, EMBASE, ClinicalTrials.gov, and Cochrane Library up to January 31, 2024. Weighted mean difference (WMD) and odds ratio (OR) with corresponding 95% confidence interval (CI) were estimated using a random-effect model for continuous and categorical outcomes, respectively. RESULTS A total of 20 RCTs comprising 1528 patients were included. Compared with plate fixation, IMN significantly shortened surgery time (WMD=-10.73 min, 95%CI: -15.93 to -5.52), union time (WMD=-1.56 weeks, 95%CI: -2.82 to -0.30), and partial (WMD=-1.71 weeks, 95%CI: -1.91 to -0.43) and full (WMD=-2.61 weeks, 95%CI: -3.53 to -1.70) weight-bearing time. IMN was associated with markedly reduced risk of wound infection (OR = 0.44, 95%CI: 0.31-0.63) and secondary procedures (OR = 0.72, 95%CI: 0.55-0.95), but increased the risk of malunion (OR = 1.53, 95%CI: 1.02-2.30) and anterior knee pain (OR = 3.94, 95%CI: 1.68-9.28). The rates of nonunion, delayed union, and functional assessment scores did not significantly differ between the two groups. The percentages of patients obtaining an excellent functional outcome or an excellent and good functional outcome post-operation were comparable. CONCLUSIONS Both IMN and plate fixation are effective modalities for the surgical treatment of distal tibia fractures. IMN seems to be preferred since it confers more advantages, but the elevated rates of malunion and knee pain require attention. The decision on fixation modality should be tailored to the specific fracture, considering these pros and cons.
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Affiliation(s)
- Xiaobin Li
- Department of Traumatic Orthopedics, Yuncheng Central Hospital affiliated to Shanxi Medical University, Yuncheng, Shanxi Province, 044000, China
| | - Kaipeng Chen
- Department of Traumatic Orthopedics, Yuncheng Central Hospital affiliated to Shanxi Medical University, Yuncheng, Shanxi Province, 044000, China
| | - Haipeng Xue
- Department of Traumatic Orthopedics, Yuncheng Central Hospital affiliated to Shanxi Medical University, Yuncheng, Shanxi Province, 044000, China
| | - Junwen Cheng
- Department of Traumatic Orthopedics, Yuncheng Central Hospital affiliated to Shanxi Medical University, Yuncheng, Shanxi Province, 044000, China
| | - Xiaoping Yu
- Department of Clinical Laboratory, Yuncheng Central Hospital affiliated to Shanxi Medical University, No. 3690, Hedong East Street, Yanhu District, Yuncheng, Shanxi Province, 044000, China.
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4
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Guran O, Ozmanevra R, Husemoglu RB, Havitcioglu H, Altinoz O. Intramedullary nailing at different distal tibial fracture levels: A biomechanical study. Medicine (Baltimore) 2024; 103:e38353. [PMID: 39259099 PMCID: PMC11142844 DOI: 10.1097/md.0000000000038353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Distal tibial fractures remains a significant challenge in orthopedic trauma surgery. As the fracture level approaches the joint, alternative fixation options instead of intramedullary nailing (IMN) come to the fore. The present study aimed to assess the biomechanical stability of IMN at different distal tibial fracture levels and the number of locking screws required. METHODS Using a total of 21 sawbone models, 3 different tibial fracture levels (3, 4.5, and 6 cm proximally to the talocrural joint) were created and the fractures were fixed using 2, 3, or 4 distal locking screws. A single compression force at a speed of 30 mm/min with a maximum force of 800 Newton and a cyclic compression force of 60 cycles at a speed of 60 mm/min was applied to all tibia models. The applied weight and displacements from the fracture lines were recorded and evaluated. RESULTS There was no statistically significant difference in fixation with 2 distal locking screws in groups 1, 2, and 3 (single test P =.9689) (cyclic test P =.8050). Therefore, if 2 distal screws are used, the fracture level does not affect the strength of fixation. In fractures located 6 cm proximal to the talocrural joint, all 4 holes of the nail can be used to insert screws, which provides a stronger fixation. When 2 screws are used, a statistically weaker fixation is obtained than with 3 or 4 screws. However, there is no significant difference between using 3 or 4 screws. CONCLUSION Our findings support the use of IMN with 2 distal locking screws as a viable option for the management of distal tibial fractures. We found that it provides sufficient fixation regardless of the fracture level, suggesting that there is no need to choose an alternative fixation technique due to concerns of inadequate fixation as the fracture line moves distally. In cases where more stable fixation is desired, an additional locking screw can be used, but the potential increase in procedure and fluoroscopy time should be considered.
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Affiliation(s)
- Ortac Guran
- Sancaktepe Şehit Prof. Dr. Ilhan Varank Training and Research Hospital, Istanbul, Turkey
| | | | - Resit Bugra Husemoglu
- Department of Biomechanics, Institute of Health Sciences, Dokuz Eylul University, Izmir, Turkey
| | - Hasan Havitcioglu
- Department of Orthopedics and Traumatology, Dokuz Eylul University, Izmir, Turkey
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He M, Zhang X, Cheng T, Hu J, Li J. Imaging risk factors for predicting postoperative complications of intramedullary nailing for tibial fracture. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02480-4. [PMID: 38421390 DOI: 10.1007/s00068-024-02480-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/19/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE The objective of this study was to analyze the ratio of fracture site diameter to tibial isthmus diameter (TFI ratio) as a predictor of postoperative complications, including malunion and delayed union, after tibial intramedullary nailing for middle and lower tibial fractures. METHODS Data were collected from all adult patients older than 20 years of age who underwent tibial intramedullary nailing for middle and lower tibial fractures between January 2015 and January 2023 and were followed up for at least 1 year. Diabetes history, smoking history, fracture type, injury mechanism, surgical method, surgical approach, diameter of the medullary cavity at the fracture site, and diameter of the tibial isthmus were recorded. Logistic regression analysis was used to determine the variables affecting the occurrence of complications. The TFI ratio was used to calculate the sensitivity and specificity of the parameters, and ROC curves were generated to establish TFI ratio thresholds for predicting complications. RESULTS A total of 123 patients with middle and lower tibial fractures were treated with intramedullary nails. The mean age of the patients was 43.72 years (range, 21-81 years); 89 were males, and 34 were females. Univariate logistic regression analysis showed that fracture type, open reduction surgery, superior patellar approach, and TFI ratio were significantly correlated with postoperative complications after intramedullary nailing of a tibial fracture. Multivariate logistic regression analysis showed that the TFI ratio was an independent risk factor for complications (P = 0.001*). By using the TFI ratio as a predictor of complications, an ROC curve was generated to establish a threshold. The ROC curve showed that a TFI ratio ≥ 1.31 had a sensitivity of 0.89, a specificity of 0.71, and an area under the ROC curve of 0.82 for predicting complications. CONCLUSIONS The results of this study suggest that a wider intramedullary diameter and a shorter fixed length at the fracture site are associated with a higher incidence of complications after tibial intramedullary nailing. The TFI ratio may be used as a reliable parameter for predicting complications after such surgery. In patients with a high TFI ratio (≥ 1.31), additional reduction and fixation techniques may be needed to obtain and maintain fracture reduction.
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Affiliation(s)
- Miao He
- Department of Orthopedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), Jiankang Road 1, Chongqing, 400010, China
| | - Xiaoxing Zhang
- Department of Orthopedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), Jiankang Road 1, Chongqing, 400010, China
| | - Tianjun Cheng
- Department of Orthopedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), Jiankang Road 1, Chongqing, 400010, China
| | - Jianhua Hu
- Department of Orthopedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), Jiankang Road 1, Chongqing, 400010, China
| | - Jie Li
- Department of Orthopedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), Jiankang Road 1, Chongqing, 400010, China.
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Kougioumtzis IE, Chloros GD, Bakhshayesh P. Plate-Assisted Intramedullary Nailing of Distal Tibia Fractures. Sultan Qaboos Univ Med J 2024; 24:115-118. [PMID: 38434460 PMCID: PMC10906772 DOI: 10.18295/squmj.9.2023.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/29/2023] [Accepted: 07/19/2023] [Indexed: 03/05/2024] Open
Abstract
The combination of plate and intramedullary nailing has been established as the treatment of proximal tibial fractures. Nevertheless, at the distal end of the tibia, the application of the plate-assisted intramedullary nailing is rarely applied as a therapeutic technique. This technical note demonstrates the use of the reduction plating technique for nail insertion as the management of distal tibia fractures.
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Affiliation(s)
| | - George D. Chloros
- Department of Trauma & Orthopaedics, “Hygeia” Hospital, Athens, Greece
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7
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Jang Y, Wilson N, Jones J, Alcaide D, Szatkowski J, Sorkin A, Slaven JE, Natoli R. Plating Versus Intramedullary Nailing of OTA/AO 43C1 and C2 Intra-articular Distal Tibia Fractures: A Propensity Score and Multivariate Analysis. J Orthop Trauma 2024; 38:e9-e14. [PMID: 37735766 DOI: 10.1097/bot.0000000000002697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To compare rates of reduction loss, nonunion, and infection in intra-articular distal tibia fractures (IADTF) treated with limited open reduction internal fixation and intramedullary nailing (IMN) as compared to open reduction internal fixation with plate and screws (plate fixation [PF]). METHODS DESIGN Retrospective review. SETTING Level-I academic trauma center. PATIENT SELECTION CRITERIA Patients age ≥ 18 with OTA/AO 43C1 and C2 IADTF treated with IMN or PF between 2013-2021. OUTCOME MEASURES AND COMPARISONS Loss of reduction, surgical site infection (SSI), nonunion, and patient-reported outcomes (PROs) were compared for IMN versus PF treatments. RESULTS One hundred ten patients met the inclusion criteria (IMN 33 and PF 77). There was no loss of reduction found. Seventeen nonunions (15% overall; IMN 4/33 and PF 13/77) and 13 SSIs (12% overall; IMN 2/33 and PF11/77) were identified. Despite several risk factors being identified for nonunion and SSI in bivariate analysis, only open fracture remained significant as a risk factor for both nonunion (odds ratio 0.09 for closed fracture, 95% confidence interval, 0.02-0.56, P = 0.009) and SSI (odds ratio 0.07 for closed fracture, 95% confidence interval, 0.06-0.26, P = 0.012) in the multivariate model. Propensity scoring based on presurgical variables was significantly different between patients who received IMN versus PF ( P = 0.03); however, logistic regression incorporating the propensity score revealed no significant association with nonunion and SSI. Adjusting for the propensity score, there remained no association comparing IMN versus PF with nonunion and SSI ( P = 0.54 and P = 0.17, respectively). There was also no difference in PROs between IMN and PF (physical function: P = 0.25 and pain interference: P = 0.21). CONCLUSIONS Overall nonunion and SSI prevalence was 15% and 12%, respectively, in operatively treated OTA/AO 43C1 and C2 IADTF. An open fracture was a significant risk factor for nonunion and SSI. Metaphyseal fixation through IMN or PF did not affect loss of reduction, nonunion, SSI, or PROs. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Yohan Jang
- Division of Orthopedic, Trauma, Indiana University, Methodist Hospital, Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN; and
| | | | - Jenna Jones
- Indiana University School of Medicine, Indianapolis, IN; and
| | - Doriann Alcaide
- Indiana University School of Medicine, Indianapolis, IN; and
| | - Jan Szatkowski
- Division of Orthopedic, Trauma, Indiana University, Methodist Hospital, Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN; and
| | - Anthony Sorkin
- Division of Orthopedic, Trauma, Indiana University, Methodist Hospital, Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN; and
| | - James E Slaven
- Indiana University School of Medicine, Indianapolis, IN; and
| | - Roman Natoli
- Division of Orthopedic, Trauma, Indiana University, Methodist Hospital, Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN; and
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Xiong Y, Zhang J, Liu H, Cai T, Xu W, Wu J. Intramedullary nail fixation of fibular fractures in combination with extra-articular distal tibial fractures (AO/OTA 43A): a single-center retrospective study. Acta Orthop Belg 2023; 89:719-726. [PMID: 38205766 DOI: 10.52628/89.4.12153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Treatment of fibular fractures associated with extra-articular distal tibia fractures is technically challenging and the purpose of this study was to evaluate the use of intramedullary nail fixation of fibular fractures when associated with this fracture. Between January 2018 and December 2021, 33 patients presenting extra-articular distal tibia fractures and fibular fractures (AO/OTA 43A) were treated. Clinical and radiological data were collected during routine postoperative follow-ups. Thirty-one patients were monitored for a period of time ranging from 12 to 23 months, with an average follow-up of 17.5 ± 3.3 months. Fibular bone union took an average of 3.6 ± 0.9 months. At the last follow-up, the average fibular alignment and postoperative ankle talocrural angles were 1.8° and 9.1°, respectively. No detectable radiographic rotational malalignment and serious complications related to the fibular incision was observed. The average AOFAS and OMAS scores at the most recent follow-up were 88.3 ± 6.2 and 87.4 ± 6.0, respectively. Intramedullary nail fixation worked well to keep the fibula in place in fibular fractures connected to extra-articular distal tibia fractures.
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Elnewishy A, Elkholy M, Hamada A, Salem M. Comparing Minimally Invasive Percutaneous Plate Osteosynthesis With Interlocking Intramedullary Nail Fixation for the Management of Adult Extra-Articular Distal Tibial Fractures: A Comprehensive Systematic Review and Meta-Analysis. Cureus 2023; 15:e49214. [PMID: 38024044 PMCID: PMC10665766 DOI: 10.7759/cureus.49214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 12/01/2023] Open
Abstract
Intramedullary nailing (IMN) and minimally invasive percutaneous plate osteosynthesis (MIPPO) fixation are both viable approaches for managing distal tibia fractures. IM nailing offers advantages in terms of shorter operation time, faster union, and reduced infection rates, yet it may lead to alignment issues and residual knee pain. Conversely, MIPPO fixation provides better alignment and minimizes knee discomfort but comes with a higher risk of soft-tissue complications and hardware irritation. Notably, this review reveals that MIPPO is associated with a greater risk of both superficial (15% vs. 7% for IMN) and deep infections (14% vs. 6.3% for IMN). This study aims to comprehensively assess the optimal surgical approaches for distal tibia fractures by comparing clinical and functional outcomes between MIPPO and interlocking IMN techniques in treating extra-articular distal tibial fractures. Key outcome parameters include operation duration, union time, non-union occurrence, malunion cases, infection rates, secondary surgical interventions, and functional results, as indicated by quality of life and ankle scores. Regarding union complications, it is notable that IMN demonstrates a higher incidence of malunion, affecting 14.7% of patients compared to 8.8% in the MIPPO fixation group. Interestingly, both treatment methods exhibit a similar incidence of non-union, occurring in 3.5% of patients in both groups. Furthermore, when assessing the union time, IMN fixation notably achieves significantly shorter union times, especially evident in AO 43A fracture types and closed fractures. The mean time for union is 18 weeks with IMN compared to 20 weeks with MIPPO fixation. In our analysis of nine studies involving 813 patients, the reported operation times revealed an overall weighted mean operation time of 74.1 minutes (ranging from 56.4 to 124 minutes) for IMN and 85.4 minutes (ranging from 51.4 to 124 minutes) for MIPPO fixation. Notably, the operation time for IMN was significantly shorter compared to MIPPO, showing a weighted mean difference (WMD) of -11.24 minutes, with a 95% confidence interval (CI) ranging from -15.44 to -7.05 (P<0.05). This difference exhibited significant moderate heterogeneity (I2 = 68%). In light of this comprehensive study, both MIPPO and IMN emerge as equally effective therapeutic options for addressing functional outcomes in distal tibial extra-articular fractures. While IMN offers several advantages, including lower infection rates, reduced implant irritation, shorter operation time, and earlier weight-bearing and union, it is associated with a heightened risk of malunion and anterior knee pain. Consequently, the choice of implant should be tailored on a case-by-case basis. Patients at elevated infection risk, stemming from factors, such as advanced age, comorbidities, smoking, or severe soft tissue injuries, are better suited for nail treatment. Conversely, MIPPO fixation may present a more advantageous choice for young, active, and healthy patients, given its ability to mitigate the risk of knee pain and malunion.
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Affiliation(s)
- Ahmed Elnewishy
- Trauma and Orthopedics, Kasr Al-Ainy Medical School, Cairo, EGY
| | | | - Ahmed Hamada
- Trauma and Orthopedics, King's College Hospital, London, GBR
| | - Mohamed Salem
- General Surgery, King's Mill Hospital, Nottingham, GBR
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Sidiropoulos K, Panagopoulos A, Tsikopoulos K, Saridis A, Assimakopoulos SF, Kouzelis A, Vrachnis IN, Givissis P. Septic Tibial Nonunions on Proximal and Distal Metaphysis-A Systematic Narrative Review. Biomedicines 2023; 11:1665. [PMID: 37371760 DOI: 10.3390/biomedicines11061665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/05/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Infected nonunion of the tibia represents a challenging complication for orthopedic surgeons and poses a major financial burden to healthcare systems. The situation is even more compounded when the nonunion involves the metaphyseal region of long bones, a rare yet demanding complication due to the poor healing potential of infected cancellous bone; this is in addition to the increased likelihood of contamination of adjacent joints. The purpose of this study was to determine the extent and level of evidence in relation to (1) available treatment options for the management of septic tibial metaphyseal nonunions; (2) success rates and bone healing following treatment application; and (3) functional results after intervention. METHODS We searched the MEDLINE, Embase, and CENTRAL databases for prospective and retrospective studies through to 25 January 2021. Human-only studies exploring the efficacy of various treatment options and their results in the setting of septic, quiescent, and metaphyseal (distal or proximal) tibia nonunions in the adult population were included. For infection diagnosis, we accepted definitions provided by the authors of source studies. Of note, clinical heterogeneity rendered data pooling inappropriate. RESULTS In terms of the species implicated in septic tibial nonunions, staphylococcus aureus was found to be the most commonly isolated microorganism. Many authors implemented the Ilizarov external fixation device with a mean duration of treatment greater than one year. Exceptional or good bone and functional results were recorded in over 80% of patients, although the literature is scarce and possible losses of the follow-up were not recorded. CONCLUSION A demanding orthopedic condition that is scarcely studied is infected metaphyseal tibial nonunion. External fixation seems promising, but further research is needed. SYSTEMATIC REVIEW REGISTRATION PROSPERO No. CRD42020205781.
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Affiliation(s)
| | | | | | - Alkis Saridis
- General Hospital of Drama, Orthopaedic Department, 66100 Drama, Greece
| | - Stelios F Assimakopoulos
- School of Health Sciences, Faculty of Medicine Department of Internal Medicine-Division of Infectious Diseases, University of Patras, 26504 Patras, Greece
| | - Antonis Kouzelis
- Patras University Hospital, Orthopaedic Department, 26504 Patras, Greece
| | - Ioannis N Vrachnis
- Patras University Hospital, Orthopaedic Department, 26504 Patras, Greece
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11
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Verweij LPE, Doornberg JN, van den Bekerom MPJ. Early Treatment of Shoulder Pathology May Be Necessary, but Let Us First Improve Patient Risk Stratification to Prevent Overtreatment. Arthroscopy 2023; 39:1123-1125. [PMID: 37019526 DOI: 10.1016/j.arthro.2023.01.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/28/2023] [Indexed: 04/07/2023]
Affiliation(s)
- Lukas P E Verweij
- Academic Medical Center, University of Amsterdam, Department of Orthopedic Surgery and Sports Medicine, Amsterdam, The Netherlands; Amsterdam Movement Sciences, Musculoskeletal Health Program, Amsterdam, The Netherlands; Amsterdam Shoulder and Elbow Centre of Expertise, Amsterdam, The Netherlands
| | - Job N Doornberg
- University Medical Center, Groningen, Department of Orthopaedic & Trauma Surgery, the Netherlands; Flinders University, Department of Orthopaedic Trauma, Adelaide, Australia
| | - Michel P J van den Bekerom
- Amsterdam Shoulder and Elbow Centre of Expertise, Amsterdam, The Netherlands; Department of Orthopedic Surgery, Shoulder and Elbow Unit, Amsterdam, The Netherlands; Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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12
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Yang CY, Tay ST, Kuo LT. Suprapatellar vs infrapatellar approaches for intramedullary nailing of distal tibial fractures: a systematic review and meta-analysis. J Orthop Traumatol 2023; 24:14. [PMID: 37041367 PMCID: PMC10090252 DOI: 10.1186/s10195-023-00694-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/19/2023] [Indexed: 04/13/2023] Open
Abstract
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.
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Affiliation(s)
- Chen-Yuan Yang
- Department of Orthopedics, Kuang Tien General Hospital, Taichung, 433, Taiwan
- Department of Nursing, Hungkuang University, Taichung, 433, Taiwan
| | - Soon-Tzeh Tay
- School of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Liang-Tseng Kuo
- School of Medicine, Chang Gung University, Taoyuan, 333, Taiwan.
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, No. 6 Western Sec., Chia-Pu Road, Putzi City, Chiayi, 613, Taiwan.
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Cerclage Wiring Improves Biomechanical Stability in Distal Tibia Spiral Fractures Treated by Intramedullary Nailing. J Clin Med 2023; 12:jcm12051770. [PMID: 36902557 PMCID: PMC10002559 DOI: 10.3390/jcm12051770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Partial weight-bearing after operatively treated fractures has been the standard of care over the past decades. Recent studies report on better rehabilitation and faster return to daily life in case of immediate weight-bearing as tolerated. To allow early weight-bearing, osteosynthesis needs to provide sufficient mechanical stability. The purpose of this study was to investigate the stabilizing benefits of additive cerclage wiring in combination with intramedullary nailing of distal tibia fractures. METHODS In 14 synthetic tibiae, a reproducible distal spiral fracture was treated by intramedullary nailing. In half of the samples, the fracture was further stabilized by additional cerclage wiring. Under clinically relevant partial and full weight-bearing loads the samples were biomechanically tested and axial construct stiffness as well as interfragmentary movements were assessed. Subsequently, a 5 mm fracture gap was created to simulate insufficient reduction, and tests were repeated. RESULTS Intramedullary nails offer already high axial stability. Thus, axial construct stiffness cannot be significantly enhanced by an additive cerclage (2858 ± 958 N/mm NailOnly vs. 3727 ± 793 N/mm Nail + Cable; p = 0.089). Under full weight-bearing loads, additive cerclage wiring in well-reduced fractures significantly reduced shear (p = 0.002) and torsional movements (p = 0.013) and showed similar low movements as under partial weight-bearing (shear 0.3 mm, p = 0.073; torsion 1.1°, p = 0.085). In contrast, additional cerclage had no stabilizing effect in large fracture gaps. CONCLUSIONS In well-reduced spiral fractures of the distal tibia, the construct stability of intramedullary nailing can be further increased by additional cerclage wiring. From a biomechanical point of view, augmentation of the primary implant reduced shear movement sufficiently to allow immediate weight-bearing as tolerated. Especially, elderly patients would benefit from early post-operative mobilization, which allows for accelerated rehabilitation and a faster return to daily activities.
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14
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Mavragani A, Panagopoulos A, Assimakopoulos SF, Givissis P, Kouzelis A, Vrachnis I, Lakoumentas J, Saridis A. Treatment of Infected Tibial Metaphyseal Nonunions Using the Ilizarov Method: Protocol for a Prospective Nonrandomized Study. JMIR Res Protoc 2022; 11:e39319. [PMID: 36580353 PMCID: PMC9837705 DOI: 10.2196/39319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 12/02/2022] [Accepted: 12/12/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The management of infected metaphyseal nonunion of the tibia is devastating, especially when associated with significant bone loss, poor soft tissues, draining sinuses, axial deformity, knee or ankle joint stiffness, limb discrepancy, and multiresisted pathogens. A systematic review, performed recently by the primary investigators but not yet published, yielded the lack of studies in the field and the huge heterogeneity of the presented results. We found several bias and controversies such as no clear definition of the exact part of the tibia where the nonunion was located, the pathogen causing the fracture-related infection, the number of previous interventions and time to presentation, and the exact type of treatment methods including the use of muscle flaps or bone grafting. Time to final union as a functional score is another important but missing data. OBJECTIVE The proposed study is designed to evaluate a sufficient number of patients with infected metaphyseal tibial nonunions using various general health, functional, and bone scores. METHODS This prospective clinical trial study, with a minimum follow-up period of 36 months, focuses on the effectiveness of the Ilizarov method after radical nonunion debridement and targeted antibiotic therapy in patients with infected metaphyseal tibial nonunions. The primary outcomes would be the definite healing of nonunion and infection-free results. Secondary outcomes would be limb alignment and discrepancy, alteration in the patient's quality of life, and functional results. A power analysis calculated a minimum of 11 patients to obtain statistical power, but we aim to include at least 25 patients. Limb discrepancy, clinical validation of infection eradication and fracture healing, radiographic validation, and patient-reported outcome measures will be highlighted and correlated. Statistical analysis of the results will offer data missing from the literature so far. Measurements are scheduled at specific times for each patient: preoperatively, 3 and 6 months postoperatively, 1 month after Ilizarov frame removal, and once per semester afterward until the end of the follow-up period (minimum 36 months). Laboratory evaluation will be assessed once per month. Any complication will be reported and treated when it occurs. RESULTS The trial has already started. It was funded in June 2020. As of May 2022, 19 participants have been recruited and no major complications have been noticed yet. Data analysis will be performed after data collection ends, and results will be published afterward. CONCLUSIONS An infected metaphyseal tibial nonunion is a rare condition with limited treatment options and many controversies. There is no consensus in the literature about the best treatment strategy, and this lack of evidence should be fulfilled. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number (ISRCTN) 30905788; https://www.isrctn.com/ISRCTN30905788. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/39319.
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Affiliation(s)
| | | | - Stelios F Assimakopoulos
- Department of Internal Medicine & Infectious Diseases, Patras University Hospital, Patras, Greece.,Faculty of Medicine, School of Health Sciences, University of Patras, Patras, Greece
| | - Panagiotis Givissis
- Orthopaedic Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Ioannis Vrachnis
- Orthopaedic Department, Patras University Hospital, Patras, Greece
| | - John Lakoumentas
- Department of Physics, Patras University Hospital, Patras, Greece
| | - Alkis Saridis
- Orthopaedic Department, General Hospital of Drama, Drama, Greece.,Orthopaedic Department, General Hospital of Serres, Serres, Greece
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15
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Kim RG, An VVG, Petchell JF. Fibular fixation in mid and distal extra-articular tibia fractures - A systematic review and meta-analysis. Foot Ankle Surg 2022; 28:809-816. [PMID: 34836719 DOI: 10.1016/j.fas.2021.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/06/2021] [Accepted: 11/11/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The surgical management of extra-articular mid and distal tibia fractures has primarily focused on reducing rates of non-union and malunion, preserving hip-knee-ankle alignment and improving functional outcomes. Fibular fractures commonly accompany these injuries and the contributory role of fixation of these fractures has been increasingly studied. A systematic review and meta-analysis were performed to determine whether concurrent fibular fixation (FF) during extra-articular mid and distal tibia fracture fixation (AO/OTA 42 and 43-A) altered the risk of malunion, non-union and post-operative complications when compared to no fibular fixation (NF). METHODS A systematic search of literature in the databases of MEDLINE (via OvidSP), PubMed, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) from the dates of inception was performed for randomised and non-randomised controlled trials. All studies published in English were included. Risk of Bias in Non-randomised Studies (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05. RESULTS A total of ten studies with 1174 patients were included for analysis. There was a statistically significant reduced risk of overall malunion in the FF group compared to the NF group (11.8% vs 21.9%, RR 0.63, 95% CI: 0.41-0.98, p = 0.04) and this was supported through a sensitivity analysis of only randomised controlled trials (21.8% vs 40.3%, RR 0.37, 95% CI: 0.18-0.76, p = 0.006). There was no statistically significant difference in rates of non-union between groups (p > 0.05). Overall, there were similar incidences of diabetes, open fractures and smoking history between groups (p > 0.05). Detailed information regarding methods of tibial fixation were not available for subgroup analysis. CONCLUSION In conclusion, in extra-articular mid and distal tibia (AO/OTA 42 and 43-A) fracture fixation, additional fibular fixation (FF) appears to significantly reduce the risk of overall malunion (RR, 0.37, 95% CI: 0.18-0.76, p = 0.006) without increasing the risk of non-union. These results should be interpreted with caution given the lack of subgroup analysis for methods of tibial fixation. Future high-quality randomised controlled trials should therefore delineate between types of tibial fixation.
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Affiliation(s)
- Raymond G Kim
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW, Australia.
| | - Vincent V G An
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW, Australia
| | - Jeffrey F Petchell
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW, Australia
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16
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Mecharla S, Thadiparthi V, Kunche A, Paka V, Shaik J, Eleshwaram N. Comparison of clinical and functional outcomes between intramedullary nailing and minimally invasive locking plates for closed extra-articular distal tibial fractures. JOURNAL OF ORTHOPAEDIC DISEASES AND TRAUMATOLOGY 2021. [DOI: 10.4103/jodp.jodp_18_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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