Segmental tibial fractures: an assessment of procedures in 27 cases

The Clinical Application of Double Taylor Spatial Frame in Segmental Tibial Fracture

OBJECTIVES

Multi-planar external fixation has been used for the management of segmental tibial fractures with severe soft tissue injuries. However, fewer specialized studies have been reported. The primary aim of this study was to describe our experience of treating fractures of this type using the Taylor Spatial Frame and Ilizarov external fixation methods.

METHODS

We retrospectively analyzed 33 patients with segmental tibial fracture treated at our institution between January 2016 and December 2020. The patients were divided into double Taylor Spatial Frame (D-TSF) and Ilizarov groups based on the external fixation structure. Baseline demographic data included sex, age, injury side and cause, open or closed fracture, time from injury to surgery, complications, and external frame removal and fracture healing time. The hip-knee-ankle angle (HKA) was measured from preoperative, immediate postoperative, and final follow-up full-length X-rays of bilateral lower limbs. We determined the degree of deviation in the HKA by calculating the difference between the measured angle and the ideal value of 180°; the absolute value was used to assess recovery of the lower limb force line. At the final follow-up, Johner-Wruhs tibial fracture outcome criteria (J-W TFOC) were used to classify the postoperative function of the affected limb as excellent, good, moderate, or poor. Count data were analyzed with the chi-square test or Fisher's exact test; the Mann-Whitney U test was used for rank data.

RESULTS

No statistically significant differences were observed between the two groups in terms of sex, age, side of injury, cause of injury, closed or open fracture, or time between injury and surgery, which indicates that the groups were comparable (p > 0.05). A statistically significant difference was observed in external frame removal and fracture healing time between the D-TSF and Ilizarov groups (36.24 ± 8.34 vs 45.42 ± 10.21 weeks, p = 0.009; 33.33 ± 8.21 vs 42.00 ± 9.78 weeks, p = 0.011). The Johner-Wruhs criteria were used to assess the function of the affected limb, the D-TSF group performed better in correcting the lower limb force line than the Ilizarov group. A statistically significant difference in terms of excellent ratings was observed between the two groups (18/2/1/0 vs 5/5/1/1, p = 0.010). Postoperative follow-up X-rays demonstrated a significant improvement in the HKA in both groups immediately after surgery and at the final follow-up compared to the angle before surgery. At the final follow-up, a statistically significant difference was observed in the degree of deviation in the HKA between the two groups (1.58° ± 0.84° vs 2.37° ± 1.00°, p = 0.023).

CONCLUSION

The D-TSF treatment is associated with minimal secondary damage to soft tissue, a straightforward and minimally invasive procedure, multiplanar stable fracture fixation, and optimization of fracture alignment and lower limb force lines, therefore, it is highly effective therapeutic option for segmental tibial fracture.

Suprapatellar nailing in complex Tibial Fractures

PURPOSE

This study evaluates the functional and radiological outcomes of segmental and comminuted tibial fractures using a suprapatellar approach in semi extended position.

METHODS

A total of 62 patients, with a mean age of 40.8 (range: 21-78 yrs) and 43 males and 19 females, were retrospectively evaluated between January 2017 and December 2022. Patients with comminated tibial fracture AO Type 42 C3 (32) and segmental AO Type 42 C2 (21) AO Type 42 C1 (9) were treated with a IMN using the suprapatellar technique. There were 51 closed fractures and 11 grade-one open fractures. All patients were subjected to the suprapatellar nailing technique in the semi-extended position.

RESULTS

Fracture healing 20.4 weeks on average was needed for the fracture to heal in segmental and 21.2 weeks in comminuted fracture. There were two instances of the delayed union in comminuted fractures. In two cases of segmental fracture dynamization is required. One case of non-union required bone grafting in a segmental fracture and in two instances in comminuted fractures to improve union after four months of monitoring. Primary union occurred in 56 patients. After minimum of 10.2 months of follow-up. According to Johner and Wruh's criteria with modifications, out of 62 patients, 47 had excellent results, 10 had good results, and 5 had fair results.

CONCLUSIONS

In segmental and comminuted fracture tibia, the suprapatellar IMN technique in a semi-extended position results in a significantly lower rate of malalignment, and good union because of soft tissue friendly bypass surgery.

A comparative evaluation of the time to frame removal for tibia fractures treated with hexapod and Ilizarov circular frames

INTRODUCTION

Traditional Ilizarov and hexapod frames have different biomechanical properties and there is limited literature regarding their effect on time to fracture union or time to frame removal.

METHODS

Tibial fractures managed with a circular frame at a tertiary limb reconstruction referral centre between 2011 and 2018 were retrospectively identified from a prospectively maintained database. They were classified into three treatment groups; Ilizarov style, Taylor Spatial Frame (TSF) and TrueLok Hex (TL-Hex). Data were extracted from electronic patient records and digital radiographs. The primary outcome was time to frame removal, which was seen as an indicator of clinical and radiological fracture union. Odds ratios were calculated with the clinical significance set at 30 days.

RESULTS

274 patients (median age 49 years, 36% female) were included in the analysis. 8.4% Ilizarov, 10.5% TSF and 13.5% TL-Hex frames required further surgery to aid fracture healing (p = 0.38). 30% of patients had open fractures. Median time to removal for Ilizarov, TSF & TL Hex frames was 167, 198 and 185 days respectively. There was a significant difference between Ilizarov and hexapod frames. Both TSF (OR 2.2, p<0.003) and TL-Hex (OR 1.8, p<0.04) had a significantly increased time to removal of 30 days or more compared with Ilizarov frames.The time to frame removal in metaphyseal fractures was significantly shorter for Ilizarov frame fixation than hexapod frames (p = 0.04). Open fractures were significantly more likely to require at least 30 days extra time to removal than closed fractures (OR 3.3, p<0.001). There was no significant difference in the time to frame removal between fracture location, age or sex.

CONCLUSION

Ilizarov frames have demonstrated a reduced time to frame removal in the management of tibial fractures than hexapod frames. Differences in the time to frame removal, an indicator of time to fracture union, may be due to the different mechanical properties of the frame, or early disruption of the fracture haematoma through secondary frame manipulation and fracture reduction, increased proportion of metaphyseal fractures treated with Ilizarov, or patient selection. The healing time was comparable across the tibia. Pooled meta-analyses may be able to further quantify these associations.

Treatment of Posttraumatic Tibial Diaphyseal Bone Defects: A Systematic Review and Meta-Analysis

OBJECTIVE

To describe evidenced-based treatment options for patients who sustained trauma and/or posttraumatic osteomyelitis of the tibia resulting in diaphyseal bone defects and to compare outcomes between patients treated with nonvascularized bone grafts (NBGs), bone transport (BT), or vascularized bone grafts (VBGs).

DATA SOURCE

The Preferred Reporting Items for Systematic Review and Meta-Analyses of individual participant data and Cochrane guidelines were followed. PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, and CINAHL were searched from inception to June 2020.

STUDY SELECTION

Patients who were ≥18 years, had sustained trauma to the tibia resulting in fracture and/or osteomyelitis with measurable diaphyseal bone defects, and were treated by interventions such as NBGs, BT, or VBGs were eligible. Excluded studies were non-English, reviews, nonreviewed literature, cadavers, animals, unavailable full texts, nondiaphyseal defects, atrophic nonunions, malignancy, and replantations.

DATA EXTRACTION

A total of 108 studies were included with 826 patients. Two reviewers systematically/independently screened titles/abstracts, followed by full texts to ensure quality, accuracy, and consensus among authors for inclusion/exclusion of studies. A third reviewer addressed disagreements if investigators were unable to reach a consensus. Studies were quality assessed using "Methodological Quality and Synthesis of Case Series and Case Reports".

DATA SYNTHESIS

Analyses were performed with IBM SPSS version 25.0 (IBM Corporation, Armonk, NY) and G*Power3.1.9.2.

CONCLUSIONS

NBGs may be considered first line for trauma defect sizes ≤ 10 cm or posttraumatic osteomyelitis defect sizes <5 cm. BT may be considered first line for posttraumatic osteomyelitis defect sizes <5 cm. VBGs may be considered first line for trauma and posttraumatic osteomyelitis defect sizes ≥5 cm.

LEVEL OF EVIDENCE

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

Surgical technique for biological fixation of closed segmental tibial fractures by the Less Invasive Stabilization System (LISS)

INTRODUCTION

This prospective case series study aimed to assess the value of the Less Invasive Stabilization System (LISS) to treat closed Segmental Tibial Fractures (STFs) using a proposed surgical technique.

MATERIALS AND METHODS

Between August 2010 and January 2014, 21 consecutive recently (within 1 week) closed STFs that matched the inclusion criteria were enrolled. Patients were treated with the 13-hole LISS plate. All patients were followed up every 2 weeks for the first 2 months, then every month for the rest of the first 6 months and then every 6 months thereafter. Patients were assessed radiologically during the follow-up appointments and clinically at the final visit by the Lower Extremity Functional Scale (LEFS) to evaluate the result.

RESULTS

The mean time to union of the proximal fracture was 15.72 ± 2.78 (range: 12-20) weeks and for the distal fracture was 20 ± 2.22 (range: 16-24) weeks, excluding delayed union in three patients. All patients except the three showed radiological observable callus in a mean duration of 4.95 (range: 3-7) weeks. The mean final follow-up LEFS was 72.4 (range: 60-80).

CONCLUSION

The mean time to union of the proximal fracture was shorter than the distal fracture. The use of LISS to treat closed STFs using the proposed surgical technique has proved to give favorable results. Further studies using the described technique are needed to justify the achieved results.

LEVEL OF EVIDENCE

IV (Prospective case series).

Segmental Tibia Fractures: An Analysis of Complication and Healing Rates

OBJECTIVES

To determine the most commonly associated injuries, complications, and healing rates of patients sustaining segmental tibial shaft fractures.

DESIGN

Retrospective review.

SETTING

Two Level I trauma centers.

PATIENTS

A total of 108 patients with segmental tibial shaft fractures were identified between 2005 and 2013.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Demographics, injury characteristics, treatments, and complications. Categories were evaluated and analyzed based on frequency of occurrence. Time to union was assessed based on serial radiographs.

RESULTS

A total of 108 patients met the inclusion criteria. All fractures were OTA/AO type 42C2. Seventy-three patients (68%) sustained open fractures. There were 34 patients (31%) who had compartment syndrome. The median Injury Severity Score was 27 (range 4-75). Ninety-five patients underwent reamed intramedullary nailing of the tibia, 4 underwent open reduction internal fixation, and 2 patients were definitively treated with external fixation. The median length of hospital stay was 11 days (range 3-48). Outcome data (time to union/delayed union/malunion) was available for 101 patients. The median time to union was 26 weeks (range 14-48). The delayed union rate was 40% (40/101) and the nonunion rate was 10% (10/101).

CONCLUSION

Segmental tibial shaft fractures are often associated with severe polytrauma and are most often open fractures. Reamed intramedullary nailing after appropriate resuscitative and stabilization methods can result in excellent alignment and union in these fractures, with low nonunion and infection rates at 1 year.

LEVEL OF EVIDENCE

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

Comparison of closed reduction and expert tibial nailing with open reduction and plate and screw fixation in the treatment of two segmental tibial fractures

PURPOSE

To compare the outcomes of closed reduction and expert tibial nailing (ETN) versus open reduction and plate and screw fixation in treating two segmental tibial fractures.

METHODS

This study included 53 cases of two segmental fractures of the tibial shaft. They were admitted to our department between March 2010 and June 2013 and treated respectively by closed reduction and ETN (ETN group, n=31) or open reduction fixation with plate and screws (PS group, n=22). The general data of two groups including gender, age, injury cause, fracture type, etc showed no significant difference (p>0.05). To compare the therapeutic effects between two groups, the intraoperative condition, post- operative function and related complications were investigated.

RESULTS

All the patients were successfully followed up. The period was 19.2 months for ETN group and 20.5 months for PS group. All the fractures in ETN group had union without complications such as malunion, infection, or osteofascial compartment syndrome; whereas there were 3 cases of superficial infection cured by repeated dressing change and 2 cases of delayed union in PS group. The total incidence of complication in PS group was 22.7% (5/22), much higher than that in ETN group (p<0.05). Moreover, ETN group showed a better result in terms of intraoperative blood loss, operation time, postoperative weight bearing time and fracture union time. In ETN group, at one-year follow-up, Johner-Wruhs' criteria was adopted to assess the postoperative function, which was reported as excellent in 18 cases, good in 10 cases and fair in 3 cases in ETN group (100% excellent-good rate). While in PS group, the result was excellent in 10 cases, good in 7 cases, fair in 3 cases and poor in 2 cases (77.3% excellent-good rate). The comparison was insignificant (p>0.05).

CONCLUSION

Compared with plate and screw fixation, ETN fixation has the advantages of fewer complications, shorter operation time, being less invasive, earlier postoperative rehabilitation and weight bearing, quicker fracture union and better functional recovery, thus being an effective way to treat two segmental tibial fractures.

Prevalence and risk factors for re-interventions following reamed intramedullary tibia nailing

INTRODUCTION

This study aimed to identify the prevalence and the risk factors for re-interventions following reamed intramedullary nailing (IMN) of tibial shaft fractures.

PATIENTS AND METHODS

We retrospectively analysed a prospectively populated data of adult patients that underwent reamed intramedullary nailing for stabilization of tibial shaft fractures over a period of three years. Exclusion criteria were immature patients, pathological and periarticular fractures. Data collected included patient demographics, mechanism of injury, open or closed injury pattern, ISS, perioperative complications, reintervention characteristics (time, cause, number), smoking habits, medical co-morbidities and progress to radiological fracture union. Fractures were classified according to AO/OTA system. The cohort of these patients was divided in two groups: Group 1 included the patients who healed uneventfully and Group 2 included the patients who underwent a re-intervention for the healing of the fracture. A logistic regression analysis model was used to assess the odds ratio (OR) of identified risk factors predicting the necessity of re-interventions.

RESULTS

181 (129 male) patients with a mean age of 37 (range 16-87) met the inclusion criteria. 30 patients were excluded due to inadequate follow up, leaving 151 patients for the study group. 119 patients were included in Group 1. 32 (21.2%) patients who had at least one re-intervention (range 1-3) were included in Group 2. The most common causes for re-intervention were aseptic non-union (31.3%) and removal of implants due to soft tissue irritation/anterior knee pain (31.3%), followed by early metalwork failure (12.5%), infected non-union (9.4%), correction of rotational deformities (9.4%) and canal intramedullary sepsis with evident fracture healing (6.3%). 29 (25.8%) from the study cohort patients sustained an open fracture and 8 of them underwent a re-intervention (20.5% of interventions). Incidence of fracture pattern 42-B, C was statistically significant greater in the reintervention (40.6%) compared to the non-re-intervention group (23.53%) (p = 0.026). Risk factors predicting the need for re-interventions included the type of fracture B, C (p = 0.026 OR: 2.528, range: 1.117-5.721) and increased alcohol consumption (p = 0.027/OR: 2.618, range: 1.116-6.141).

CONCLUSION

Fracture pattern and alcohol abuse were highly predictive for re-interventions following reamed IM nailing for stabilization of acute tibial shaft fractures.

Radiographic Predictors of Compartment Syndrome Occurring After Tibial Fracture

OBJECTIVES

Compartment syndrome (CS) is a potentially devastating injury associated with tibial fractures. Few data exist regarding radiographic indicators of CS. We hypothesized that radiographic signs are associated with development of CS.

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENTS

Consecutive series of adult patients with tibial fractures with (n = 56) and without (n = 922) CS.

INTERVENTION

None.

OUTCOMES

AO/OTA fracture classification, Schatzker type, fracture length, fibular fracture, CS diagnosis.

RESULTS

The odds of CS increased by 1.67 per 10% increase in the ratio of fracture length to tibial length when considering all fractures. CS was most likely to occur with plateau fractures at 12% (shaft fractures, 3%; pilon fractures, 2%). Schatzker VI fractures were more likely to develop CS than any other Schatzker type. Fibular fracture was predictive of CS with plateau fractures only. Segmental fractures (AO/OTA type 42-C2) were not more likely to develop CS than other shaft fractures.

CONCLUSIONS

Several objective and easily reproducible radiographic indicators should raise suspicion for CS. CS was more likely in plateau fractures, especially when fracture length was >20% of the tibial length, in the presence of fibular fracture, and classified as Schatzker VI. Conversely, segmental tibial shaft fractures were not more likely than other shaft fractures to develop CS.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The management of segmental tibial shaft fractures: A systematic review

INTRODUCTION

Segmental tibial fractures are complex injuries associated with significant soft tissue damage that are difficult to treat. This study aimed to identify the most effective method of treating segmental tibial fractures.

METHOD

A PRISMA compliant systematic review was conducted. Studies investigating the management of segmental tibial fractures with intramedullary nail fixation (IMN), open reduction and internal fixation (ORIF) or circular external fixation (CEF) were included for review. The primary outcome measure was time to fracture union. Secondary outcomes were complications and functional outcome. A narrative analysis was undertaken as meta-analysis was inappropriate due to heterogeneity of the data.

RESULTS

Thirteen studies were eligible and included. No randomised controlled trials were identified. Fixation with an intramedullary nail provided the fastest time to union, followed by open reduction and internal fixation and then CEF. The rate of deep infection was highest after IMN (5/162 [3%]), followed by open reduction and internal fixation (2/78 [2.5%]) and CEF (1/54 [2%]). However, some studies reported particularly high rates of infection following IMN for open segmental tibial fractures. There was limited reporting of postoperative deformities. From the studies that did include such data, there was a higher rate of deformity following ORIF (8/53 [15%]), compared to IMN (13/138 [9%]), and CEF (4/44 [9%]). Three studies, not including IMN, described patient reported outcome measures with results ranging from 'excellent' to 'fair'.

DISCUSSION

The available evidence was of poor quality, dominated by retrospective case series. This prevented statistical analysis, and precludes firm conclusions being drawn from the results available.

CONCLUSION

IMN has the fastest time to fracture union, however there are concerns regarding an increased deep infection rate in open segmental tibial fractures. In this subgroup, the data suggests CEF provides the most satisfactory results. However, the available literature does not provide sufficient detail to make this statement with certainty. We recommend a randomised controlled study to further investigate this challenging problem.

Minimally invasive surgical technique: Percutaneous external fixation combined with titanium elastic nails for selective treatment of tibial fractures

INTRODUCTION

Several techniques have been described to treat tibial fractures, which respectively remains defects. This article presents a novel intra- and extramedullary fixation technique: percutaneous external fixator combined with titanium elastic nails (EF-TENs system). The purpose of this study is to introduce this new minimally invasive surgical technique and selective treatment of tibial fractures, particularly in segmental fractures, diaphysis fractures accompanied with distal or proximal bone subfissure, or fractures with poor soft-tissue problems.

METHODS

Following ethical approval, thirty-two patients with tibial fractures were treated by the EF-TENs system between January 2010 and December 2012. The follow-up studies included clinical and radiographic examinations. All relevant outcomes were recorded during follow-up.

RESULTS

All thirty-two patients were achieved follow-ups. According to the AO classification, 3 Type A, 9 Type B and 20 Type C fractures were included respectively. According to the Anderson-Gustilo classification, there were 5 Type Grade II, 3 Type Grade IIIA and 2 Type Grade IIIB. Among 32 patients, 8 of them were segmental fractures. 12 fractures accompanied with bone subfissure. Results showed no nonunion case, with an average time of 23.7 weeks (range, 14-32 weeks). Among them, there were 3/32 delayed union patients and 0/32 malunion case. 4/32 patients developed a pin track infection and no patient suffered deep infection. The external fixator was removed with a mean time of 16.7 weeks (range, 10-26 weeks). Moreover, only 1/32 patient suffered with the restricted ROM of ankle, none with the restricted ROM of knee.

CONCLUSION

This preliminary study indicated that the EF-TENs system, as a novel intra- and extramedullary fixation technique, had substantial effects on selective treatment of tibial fractures.

Does it really spin? Intra-medullary nailing of segmental tibial fractures--a cadaveric study

This study aims to quantify the effect of intra-medullary reaming on rotational displacement of both long diaphyseal segmental tibial fractures (Melis Type III) and short (Melis Type IV) in a cadaveric model with differing degrees of soft tissue stripping. Eighteen fresh-frozen cadaveric specimens (9 matched pairs), median age at death was 85 years (68-92) were used to perform a standardized reaming procedure for an intra-medullary tibial nail and the rotational displacement of the segmental fracture fragment (long and short diaphyseal fractures) was recorded. Rotational displacement was recorded using a goniometer and K-wires positioned in the proximal, segmental and distal fracture fragments. Type III fractures rotate more than Type IV fractures (p<0.0001). In Type III fractures reaming to fit with 0%, 50% and 100% soft tissue stripping resulted in rotational displacement of 11.7 SD 12), 13 (SD 16.5) and 307.3 (SD 118.1) degrees respectively. In Type IV fractures reaming to fit with 0%, 50% and 100% soft tissue stripping resulted in rotational displacement of 8.5 (SD 5.5), 12.7 (SD 9.9) and 135.3 (SD 147.1) degrees respectively. The use of a pointed reduction clamp or unicortical plate eliminated rotational displacement. Reaming is a major risk factor for rotational displacement of segmental tibial fractures irrespective of the degree of soft tissue stripping. Long diaphyseal segmental fractures rotate more than shorter segmental fractures. We recommend always clamping the fracture during reaming to avoid rotational displacement.

Locking plate as a definitive external fixator for treating tibial fractures with compromised soft tissue envelop

INTRODUCTION

Tibial fractures with compromised soft tissue envelop may lead to significant complications. The optimal management of these injuries remains controversial. Recently, locking plate used as a definitive external fixator is attractive because it not only minimizes trauma to the soft tissues, but also overcomes the shortcomings of standard external fixators. The objective of this study was to evaluate the outcome of using locking plate as a definitive external fixator for treating tibial fractures with compromised soft tissue envelop.

PATIENTS AND METHODS

A prospective series of 12 consecutive tibial fractures with compromised soft tissue envelop were treated using locking plate as a definitive external fixator. Of these patients, six were Gustilo and Anderson type IIIA, three were type II and three were closed fractures (AO/ASIF soft tissue injury classification IC4: 2, IC5: 1). Time to union, nonunion, malunion, leg shortening, range of motion and function for the knee and ankle, deep infection, pin tract infections were evaluated.

RESULTS

The mean bone healing time was 37.8 weeks (range 20-56 weeks). Eventually, all of the fractures united. Most of the fractures healed in acceptable positions. There were no cases of deep infection. Pin tract infection was seen in 1 (8.3 %) patient, no loosening or failure of the external fixator was seen. At the most recent follow-up, the mean range of motion at the knee was extension 0° to flexion 135°, and the mean ankle range of motion was dorsi flexion 12° to plantar flexion 32°. All patients had excellent or good functional results and were fully weight bearing with a well-healed tibia at the final follow-up.

CONCLUSION

The locking plate used as a definitive external fixator provided a high rate of union. The patients experienced a comfortable clinical course, excellent knee and ankle joint motion, satisfactory functional results and an acceptable complication rate. However, the stiffness of external locked plating is not clear, therefore, clinical recommendation on its practical use to reduce the risk of implant failure still need to be determined.

Segmental tibial fractures: an infrequent but demanding injury

BACKGROUND

Segmental tibial fractures are considered to be a special injury type associated with high complication rates. However, it is unclear whether healing of these fractures truly differs from that of nonsegmental fractures.

QUESTIONS/PURPOSES

We therefore asked (1) does the time to union in segmental tibial fractures differ from that of nonsegmental fractures; and (2) does the complication rate of segmental fractures differ from that of nonsegmental fractures?

METHODS

We retrospectively studied 30 patients with segmental tibial fractures treated at a Level I trauma center from January 2000 to December 2008 and compared healing and complications with a matched control group of 30 nonsegmental tibial fractures. In followup we determined time to union, delayed and nonunion, and overall complication rates. Patients were followed at least until union was attained. The minimum followup was 5 months (median, 15 months; range, 5-54 months).

RESULTS

Median time to union was 34 weeks (range, 12-122 weeks). Segmental fractures took longer to heal than nonsegmental fractures (median, 34 weeks; range, 12-122 weeks and median, 24 weeks; range, 11-39 weeks, respectively). The overall rate of complications was higher in segmental fractures as was the necessity for reoperation to attain healing.

CONCLUSIONS

Healing of segmental tibial fractures is characterized by substantially more complications and longer healing times than nonsegmental fractures and should be considered as a special type of injury. We believe these should be treated in specialized trauma centers.

The treatment of complex tibial shaft fractures by the Ilizarov method

We report on the use of the Ilizarov method to treat 40 consecutive fractures of the tibial shaft (35 AO 42C fractures and five AO 42B3 fractures) in adults. There were 28 men and 12 women with a mean age of 43 years (19 to 81). The series included 19 open fractures (six Gustilo grade 3A and 13 grade 3B) and 21 closed injuries. The mean time from injury to application of definitive Ilizarov frame was eight days (0 to 35) with 36 fractures successfully uniting without the need for any bone-stimulating procedure. The four remaining patients with nonunion healed with a second frame. There were no amputations and no deep infections. None required intervention for malunion. The total time to healing was calculated from date of injury to removal of the frame, with a median of 166 days (mean 187, (87 to 370)). Minor complications included snapped wires in two patients and minor pin-site infections treated with oral antibiotics in nine patients (23%). Clinical scores were available for 32 of the 40 patients at a median of 55 months (mean 62, (26 to 99)) post-injury, with ‘good’ Olerud and Molander ankle scores (median 80, mean 75, (10 to 100)), ‘excellent’ Lysholm knee scores (median 97, mean 88, (29 to 100)), a median Tegner activity score of 4 (mean 4, (0 to 9)) (comparable to ‘moderately heavy labour / cycling and jogging’) and Short Form-12 scores that exceeded the mean of the population as a whole (median physical component score 55 (mean 51, (20 to 64)), median mental component score 57 (mean 53, (21 to 62)). In conclusion, the Ilizarov method is a safe and reliable way of treating complex tibial shaft fractures with a high rate of primary union.

Fixation and reconstruction of severe tibial shaft fractures with vascularized fibular grafting

INTRODUCTION

Based on the considerable experience for management of combined bone and composite soft-tissue defects in the limbs by free vascularized fibula or osteocutaneous fibular flap grafting, the authors present the effective alternative for management of the severe comminuted tibial shaft fractures in one-stage reconstructive technique.

METHOD

Twenty-six patients were male and 12 were female, and their mean age was 32 years (range 15-57 years). Ten tibial shaft fractures were closed and 28 were open. Based on the AO classification, there were 12 group C1 fractures and 24 group C3 fractures according to the fracture pattern and degree of comminution.

RESULTS

With the exception of eight cases that were delayed for 3-5 days for primary treatment in another hospital, 30 cases were treated on an emergency basis within an average of 12 h since the initial injury (range 6-22). Normal healing occurred in 31 fractures with a mean healing time of 21 weeks (range 18-24 weeks). Delayed union in 7 with a mean of 32 weeks (range 28-41 weeks), and there were no nonunion and infections. The vascularized fibula allows for fast bone fusion. In this context, the grafted fibula segment appeared to be a valuable reconstructive tool that offered good fracture stabilization and vascularised bone graft.

CONCLUSION

The attached fibular flap can also provide a large piece of mobile skin to cover the soft-tissue defect in grade III open-tibial fractures. It demonstrates that this early free vascularized fibula graft is a useful and effective option for treating the severe comminuted tibial shaft fractures.

Treatment of 103 displaced tibial diaphyseal fractures with a radiolucent unilateral external fixator

OBJECTIVE

The authors report their experience in the treatment of the diaphyseal tibial fractures, using the unilateral radiolucent External Fixator (EF) XCaliber.

DESIGN

A total of 100 patients (average age 35 years, range 16-76) with 103 displaced diaphyseal tibial fractures were treated with the XCaliber. There were 59 type A fractures, 35 type B, and 9 type C (according to the AO classification) and 35 were open fractures.

MAIN OUTCOME MEASUREMENTS

During the last assessment, patients were evaluated for level of pain, ability to perform weight-bearing activities, and number of residual deformities.

RESULTS

The average follow-up time was 24 months, 3 patients (4 fractures) were excluded for final assessment and 1 patient moved abroad. Of the remaining 98 fractures, 83 (84.7%) healed with a single operation in a mean 21 weeks (SD 3.97; 12-38 weeks), 10 fractures had a delayed union and 5 fractures proceeded to a non-union. There were 13 complications. Among them, a loss of reduction was observed in 3 cases due to overload of the EF, in 3 cases, deep pin track infections were observed and 2 fractures healed with more than 1 cm of shortening.

CONCLUSIONS

The results are encouraging, since both complex and open fractures were included in this study. The XCaliber was shown to be a valid unilateral external fixator, combining the advantage of radiolucency during application and radioscopic follow-up with a stable and flexible fracture fixation. This represents the first report in the literature specifically examining treatment of tibial diaphyseal fractures with a radiolucent external fixator.

Segmental fractures of the tibia treated by circular external fixation

We have carried out a retrospective review of 20 patients with segmental fractures of the tibia who had been treated by circular external fixation. We describe the heterogeneity of these fractures, their association with multiple injuries and the need for multilevel stability with the least compromise of the biology of the fracture segments. The assessment of outcome included union, complications, the measurement of the functional IOWA knee and ankle scores and the general health status (Short-form 36).

The mean time to union was 21.7 weeks (12.8 to 31), with no difference being observed between proximal and distal levels of fracture. Complications were encountered in four patients. Two had nonunion at the distal level, one a wire-related infection which required further surgery and another shortening of 15 mm with 8° of valgus which was clinically insignificant. The functional scores for the knee and ankle were good to excellent, but the physical component score of the short-form 36 was lower than the population norm. This may be explained by the presence of multiple injuries affecting the overall score.

Open acute segmental tibial fracture fixation using the Less Invasive Stabilisation System (LISS): study of 23 consecutive cases

AIM

To evaluate the Less Invasive Stabilisation System (LISS) in the treatment of segmental tibial fractures.

METHODS

A prospective series of 23 consecutive open acute segmental tibial fractures were treated with a long LISS plate, in a university hospital. All but three fractures were temporarily fixed with a unilateral external frame. The minimal follow-up was 2 years.

RESULTS

Mean age of the casualties was 34 (17-72) years, all but two were male and all were involved in high-energy accidents, had multiple injuries and open fractures. Of the fractures, 4 were grade IIIA, 16 grade IIIB and 3 grade IIIC. It was possible to span the distal fracture with the LISS plate in 20 cases; of these, 3 developed compartment syndrome. Two people with trifocal fractures required additional distal plates, one of which became loose and infected, resulting in a malunion of 8 degrees. Dermatofasciotomy was performed in 13 cases, in 10 of these as a preventive measure and in 3 because of impending compartment syndrome. In five cases a post-fixation neural palsy of the extensor hallucis longus was observed. All except three fractures healed; mean time for union for the proximal fractures was 16 (10-24) weeks and for the distal fractures was 22 (16-44) weeks.

CONCLUSION

Use of the LISS plate in fixing these difficult fractures is commended, but immediate fixation should be avoided. A staged sequential procedure with a temporary spanning external fixation and definitive treatment after soft-tissue healing is preferred.

Acute treatment of segmental tibial fractures with the Ilizarov method

OBJECTIVES

We evaluated the results of acute application of the Ilizarov external fixator for segmental tibial fractures and also examined the experience with these special type fractures.

METHODS

Twenty-four patients (19 males, 5 females) with a mean age of 37.8 years (range 22-66) with segmental tibial fractures were treated with the use of an Ilizarov type circular fixator. According to the categorisation of Melis et al., the fractures were types I, II, III and IV in seven, nine, five and three patients, respectively. Seven fractures were closed and 17 were open (9 grade IIIa, 5 grade IIIb, 2 grade II, 1 grade I according to the Gustilo classification). The mean time from the injury to surgery was 14 h (range 4-36). Eight patients with partial-thickness soft-tissue defects with no bone exposure were managed by split thickness skin grafting. Flap procedures were performed in four patients. All patients had good lower leg viability with a MESS score 6 and below. No patients had bone defects of 3 cm or more at the fracture level. Functional and bone results were made using the criteria proposed by ASAMI. The mean follow-up 28 months (range 12-70).

RESULTS

We obtained excellent results in 20 and good results in 4 patients in terms of bone assessment. Functional results were excellent in 19 and good in 5 patients. All radiological evaluations showed normal alignment except in two patients. Both united with a residual procurvatum deformity. No rotational deformity was seen. Bone grafting was performed in one patient with a distal fracture. Complete union was achieved in all patients. None of the patients required amputation. There were no refractures after frame removal. Pin-tract infection occurred in 13 of the 24 patients. There were no incidents of chronic osteomyelitis secondary to pin-tract infection. The mean time for proximal fracture union was 36.4 weeks (range 10-78) and 39.8 weeks (range 12-80) for the distal fractures (p>0.05). Callus and consolidation occurred earlier posterolaterally. There were no implant failures.

CONCLUSION

Ilizarov external fixator is a successful method in the acute management of segmental tibial fractures. This method is particularly effective in the treatment of distal segmental fractures of the tibia when the distal segment is short. This method allows for control of complications by decreasing the need for new operations even in the presence of infection.

Operative treatment of tibial shaft fractures: a comparison of different methods of primary stabilisation

INTRODUCTION

Segmental fractures of the tibial shaft (AO type 42-C2) often occur after a high energy direct trauma with consecutive severe soft tissue injury and a high rate of open fractures. The blood supply of the intermediate bone fragment can be severely disturbed and therefore operative treatment is demanding. In this retrospective study, we compared three different methods of stabilisation.

MATERIALS AND METHODS

We reviewed the clinical charts and postoperative problems of 26 patients in a ten year period. Sixteen (62%) fractures were stabilised with an intramedullary nail, five (19%) fractures by plate osteosynthesis and five (19%) fractures with an external fixator.

RESULTS

Bony consolidation was obtained in all patients after an average time of 11.4 months. In 17 patients (65.4%) a second operative procedure had to be performed. Pseudarthrosis was seen in 11 fractures (40%), three times in the proximal and eight times in the distal fracture. In the intramedullary nailing group, pseudarthrosis occurred in nine patients. In the group treated with an external fixator, pseudarthrosis was seen three times. After changing to a different implant bony consolidation was achieved in every patient.

CONCLUSION

Conventional intramedullary nailing is not suitable for stabilisation of segmental fracture types with a short metaphyseal fracture fragment. New nails with proximal and distal interlocking in three different planes offer better stability. Bone vascularisation should not be endangered by the stabilisation procedure and optimal reduction of the fracture is an important prerequisite for uneventful fracture healing, especially in this difficult fracture configuration.

Percutaneous reduction during intramedullary nailing in comminuted tibial shaft fractures

Percutaneous reduction with a reduction clamp during intramedullary nailing without reaming is a simple, easily reproducible, and minimally invasive method.

Reconstruction of large defects of the long bones with free vascularized bone grafts: functional results after minimum 5-year follow-up

This study evaluated the clinical and radiographic results of 44 patients (26 men and 18 women) who underwent reconstruction of large defects of the long bones with free vascularized bone grafts. Mean patient age was 29+/-15 years and mean follow-up was 8.6+/-2.1 years. Mean Enneking index was 78.6% (95% confidence interval, 73.8-83.4). No differences were noted for different types of graft, etiologies, or anatomic locations. Regression analysis revealed no association between defect size and functional results. Sixteen patients developed 29 complications. All but 1 patient showed full incorporation of the graft. These results confirm the value of vascularized grafts for bridging large bone defects.

Fractures of the distal tibia treated with closed reduction and minimally invasive plating

INTRODUCTION

The treatment of fractures of the distal tibia can be problematical because of the thin soft-tissue covering. Bridging slide-insertion plate osteosynthesis is performed by indirect, axially correct reduction of the fracture and stabilization without opening the soft tissue at the fracture site. Stripping of the periosteum is thus avoided, the fragments remain integrated into the soft tissue, and healing occurs spontaneously by way of callus formation.

MATERIALS AND METHODS

Seventy-one patients treated by slide-insertion plate osteosynthesis were followed up over at least 2 years. As would be expected in this anatomical region, the proportion of C fractures and fractures with concomitant soft-tissue damage was high. The majority of patients were treated by application of an external fixator on the day of the accident; the definitive osteosynthesis with the slide-insertion plate was performed at a later date after healing of the soft tissues.

RESULTS

In 68 patients, fracture healing was achieved within 2 years. In 80% of the cases, the final X-ray follow-up showed no or tolerable axis deviations (<5 degrees) in the varus/valgus plane or in the recurvation/antecurvation plane. A deviation >10 degrees requiring a correcting osteotomy was found in only 1 patient. Postoperative complications were rare occurrences. Five patients required an additional cancellous bone graft to deal with inadequate bone healing. System-related complications (instability, malalignment) due to intraoperative technical errors only had to be corrected in revision operations in 2 patients.

CONCLUSION

Closed reduction and minimally invasive plating offers the combined advantages of minimal soft-tissue damage with stable fracture fixation.

Tryptophan availability modulates serotonin release from rat hypothalamic slices

Application of a novel in vitro experimental system has allowed us to describe the relationship between tryptophan availability and serotonin release from rat hypothalamic slices. Superfusing hypothalamic slices with a physiologic medium containing l-tryptophan (1, 2, 5, or 10 microM) caused dose-dependent elevations in tissue tryptophan levels; the magnitude of the elevations produced by supplementing the medium with less than 5 microM tryptophan was within the physiologic range for rat brain tryptophan levels. Slice serotonin levels rose biphasically as the tryptophan concentration in the medium was increased. Superfusing the slices with medium supplemented with a low tryptophan concentration (1 or 2 microM) caused proportionally greater incremental changes in serotonin levels than the increases caused by further elevating the tryptophan concentration (5 or 10 microM). The spontaneous release of serotonin from the slices exhibited a dose-dependent relationship with the tryptophan concentration of the superfusion medium. Electrically evoked serotonin release, which was calcium-dependent and tetrodotoxin-sensitive, also increased in proportion to the medium tryptophan concentration. These data suggest that the rate at which serotonin is released from hypothalamic nerve terminals is coupled to brain tryptophan levels. Accelerations in hypothalamic serotonin synthesis, caused by elevating brain tryptophan levels, result in proportionate increases in the rates of serotonin release during rest and with membrane depolarization.