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Chen B, Wang Z, Chen Z, Qu X, Fang X, Wang X, Ke G. Comparison of Two Surgical Approaches to Supination-External Rotation-Type Ankle Fractures. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7726726. [PMID: 35444779 PMCID: PMC9015882 DOI: 10.1155/2022/7726726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 11/17/2022]
Abstract
Objective To compare the clinical outcome and postoperative complications of the treatment of supination-external rotation-type ankle fractures using the posterolateral approach in the prone position and the lateral approach in the supine position. Methods A retrospective cohort study was conducted in our hospital, including a total of 66 patients ranging from January 2013 to February 2016, regardless of age or sex. All the patients were classified as Lauge-Hansen supination-external rotation (SER)-type ankle fractures and were assigned to receive an open reduction and internal fixation (ORIF) through a posterolateral approach performed in the prone position (the "posterolateral approach group," 32 patients), or a lateral approach performed in the supine position (the "Lateral Approach Group," 34 patients). In the posterolateral approach group, 5 patients had Grade II fractures, 8 had Grade III fractures, and 19 had Grade IV fractures; among whom, 12 underwent fixation of the posterior malleolus with hollow screws and 6 with plates, and none of them had fixation of the distal tibiofibular syndesmosis; in the lateral approach group, 4 patients had Grade II fractures, 12 had Grade III fractures, and 18 had Grade IV fractures; among whom, 21 received fixation of the posterior malleolus, and 5 received fixation of the distal tibiofibular syndesmosis. The postoperative complications and ankle scores were recorded. Results After 1 year of follow-up, in the posterolateral approach group, the incision healed by primary intention and sutures were removed 2 weeks after the operation in all patients; 1 patient had pain in the region posterior to the fibula, presumably peroneal tendon irritation induced by internal fixation, which disappeared after fracture union and fixation device removal; no loosening or breakage of the internal fixation device was reported; the rate of good to excellent results was 96.8% at 12 months. In the lateral approach group: 1 case of wound infection, 1 case of necrosis of lateral skin flap, and 3 cases of lateral skin irritation were reported; the rate of good to excellent results was 94.6% at 12 months. Conclusion Compared with the traditional lateral approach, the posterolateral approach for the reduction and internal fixation of supination-external rotation-type ankle fractures performed in the prone position has more satisfactory clinical outcomes, with better reduction, more secure fixation, and smaller wound.
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Affiliation(s)
- Bingqian Chen
- Department of Orthopaedics, Changshu Hospital Affiliated to Soochow University, First Peoples' Hospital of Changshu City, Changshu 215500, Jiangsu, China
| | - Zhengfei Wang
- Department of Orthopaedics, Changshu Hospital Affiliated to Soochow University, First Peoples' Hospital of Changshu City, Changshu 215500, Jiangsu, China
| | - Zhi Chen
- Department of Orthopaedics, Changshu Hospital Affiliated to Soochow University, First Peoples' Hospital of Changshu City, Changshu 215500, Jiangsu, China
| | - Xiaohong Qu
- Department of Orthopaedics, Changshu Hospital Affiliated to Soochow University, First Peoples' Hospital of Changshu City, Changshu 215500, Jiangsu, China
| | - Xiaowen Fang
- Department of Orthopaedics, Changshu Hospital Affiliated to Soochow University, First Peoples' Hospital of Changshu City, Changshu 215500, Jiangsu, China
| | - Xuesong Wang
- Department of Orthopaedics, Changshu Hospital Affiliated to Soochow University, First Peoples' Hospital of Changshu City, Changshu 215500, Jiangsu, China
| | - Guoxiu Ke
- Department of Orthopaedics, Changshu Hospital Affiliated to Soochow University, First Peoples' Hospital of Changshu City, Changshu 215500, Jiangsu, China
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Wang M, Deng Y, Xie P, Tan J, Yang Y, Ouyang H, Zhao D, Huang G, Huang W. Optimal Design and Biomechanical Analysis of a Biomimetic Lightweight Design Plate for Distal Tibial Fractures: A Finite Element Analysis. Front Bioeng Biotechnol 2022; 10:820921. [PMID: 35265599 PMCID: PMC8901108 DOI: 10.3389/fbioe.2022.820921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Mian Wang
- National Key Discipline of Human Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Guangdong Engineering Research Center for Translation of Medical 3D Printing Application, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
- Institute of Biomedical Engineering, Shenzhen Bay Laboratory, Shenzhen, China
| | - Yuping Deng
- National Key Discipline of Human Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Guangdong Engineering Research Center for Translation of Medical 3D Printing Application, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
- Institute of Biomedical Engineering, Shenzhen Bay Laboratory, Shenzhen, China
- Department of Orthopedics and Traumatology, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Pusheng Xie
- National Key Discipline of Human Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Guangdong Engineering Research Center for Translation of Medical 3D Printing Application, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
- Guangdong Medical Innovation Platform for Translation of 3D Printing Application, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Jinchuan Tan
- National Key Discipline of Human Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Guangdong Engineering Research Center for Translation of Medical 3D Printing Application, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Yang Yang
- National Key Discipline of Human Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Guangdong Engineering Research Center for Translation of Medical 3D Printing Application, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
- Department of Orthopedics and Traumatology, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Hanbin Ouyang
- National Key Discipline of Human Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Guangdong Engineering Research Center for Translation of Medical 3D Printing Application, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
- Orthopaedic Center, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, Zhanjiang, China
| | - Dongliang Zhao
- Institute of Biomedical Engineering, Shenzhen Bay Laboratory, Shenzhen, China
- Drug Discovery Center, State Key Laboratory of Chemical Oncogenomics, School of Chemical Biology and Biotechnology, Peking University Shenzhen Graduate School, Shenzhen, China
| | - Gang Huang
- Department of Orthopedics and Traumatology, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
- *Correspondence: Gang Huang, ; Wenhua Huang,
| | - Wenhua Huang
- National Key Discipline of Human Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, Guangdong Engineering Research Center for Translation of Medical 3D Printing Application, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
- Department of Orthopedics and Traumatology, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
- Guangdong Medical Innovation Platform for Translation of 3D Printing Application, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- *Correspondence: Gang Huang, ; Wenhua Huang,
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Malhotra R, Goh AQY, Gardner AW. Posterolateral Plating of Distal Tibia Fractures: Extending the Use of a Familiar Approach. Indian J Orthop 2021; 55:426-435. [PMID: 34306557 PMCID: PMC8275712 DOI: 10.1007/s43465-021-00403-8] [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: 11/18/2020] [Accepted: 04/05/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Distal tibia fractures present challenges in surgical management and when nailing is not an option, plate osteosynthesis is performed. This is usually done with a minimally invasive approach to reduce the risk of wound complications in an already fragile soft-tissue envelope. We propose that a posterolateral open approach can lead to stable fixation construct and comes with advantages of approaching fibula fractures via same approach and has a thicker soft tissue envelope over the fixation. We report a series of distal tibia fractures with posterolateral plate fixation and present the outcomes. METHODS This is a retrospective review conducted at a single institution, where 13 patients underwent posterolateral approach for distal tibia fracture fixation. Where required, medial plating and fibular fixation was additionally performed. Patients were followed-up with primary endpoint of successful clinical and radiological union or complications required re-intervention. Operative and long-term clinical outcomes were recorded. RESULTS Long term follow-up was available for 12 patients. There was 1 non-union requiring revision (8.3%). For the other patients, clinical union occurred by 14.5 weeks and radiological union by 20 weeks on average. There was no malunion and 2 patients (16.6%) underwent removal of implants for symptoms of hardware irritation. CONCLUSION We found that outcomes in our cohort demonstrate posterolateral plating is safe as a primary or adjunctive method of fixation, and does not compromise other outcomes when compared with traditional fixation methods.
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Affiliation(s)
- Rishi Malhotra
- grid.459815.40000 0004 0493 0168Department of Orthopaedic Surgery, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606 Singapore
| | - Aaron Qi Yang Goh
- grid.59025.3b0000 0001 2224 0361Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Rd, Singapore, 308232 Singapore
| | - Antony W. Gardner
- grid.459815.40000 0004 0493 0168Department of Orthopaedic Surgery, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606 Singapore
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Schloss MG, Ghulam QM, Hannan ZD, O'Hara NN, Napora JK, McAlister IP, Atchison J, Mulliken A, Zaidi SM, Nascone JW, O'Toole RV, Manson TT. Posterolateral plating is a safe alternative for the treatment of distal tibial fractures. Injury 2020; 51:1662-1668. [PMID: 32434717 DOI: 10.1016/j.injury.2020.03.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 03/07/2020] [Accepted: 03/24/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION We assessed the outcome and safety of posterior plating of distal tibial fractures. METHODS We conducted a retrospective case series at a Level I trauma center. Seventy-four consecutive patients with distal tibial fractures treated with anatomically contoured 3.5-mm T-shaped locking compression plate using a posterolateral approach from January 2008 through April 2018 were included in the study. The mean patient age was 48 years (range, 18-87 years). Fifty-nine percent of the patients were male patients, 47% of the fractures were open fractures; and 27% of the patients had multiple traumatic injuries. Eleven fractures were AO/OTA type 42, 22 were type 43A, and 41 were type 43C. Sixty-two (84%) patients were treated with initial spanning external fixation (median time, 23 days) and staged open reduction and internal fixation. The main outcome measure was unplanned reoperation to address implant failure, nonunion, deep surgical site infection, or symptomatic implant. RESULTS Overall risk of unplanned reoperation was 15% (11 of 74 patients, 95% confidence interval, 9%-25%). Four (5%) reoperations were for nonunion, three (4%) were for surgical site infection, two (3%) were for infected nonunion, and two (3%) were for implant prominence. Loss of alignment >10 degrees occurred in one patient who underwent unplanned reoperation for nonunion. No plate breakage occurred. Median time to reoperation was 221 days (range, 22-436 days). Only one other complication was noted: wound dehiscence associated with the posterolateral approach, which was treated with irrigation and débridement and a 6-week regimen of oral antibiotics. CONCLUSIONS Use of a posterolateral approach with a pre-contoured locking compression T-plate for the treatment of distal tibial fractures led to reasonable outcomes with an acceptable risk of unplanned reoperation, even with a high proportion of open fractures commonly staged with external fixation.
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Affiliation(s)
- Michael G Schloss
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Qasim M Ghulam
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Zachary D Hannan
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nathan N O'Hara
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joshua K Napora
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ian P McAlister
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jared Atchison
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Alexandra Mulliken
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Syed M Zaidi
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jason W Nascone
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Theodore T Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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Gutteck N, Schilde S, Reichel M, Holtz A, Sahmel O, Hinz P, Kielstein H, Lange J, Delank KS, Martin H. Posterolateral plate fixation with Pantalarlock® is more stable than nail fixation in tibiotalocalcaneal arthrodesis in a biomechanical cadaver study. Foot Ankle Surg 2020; 26:328-333. [PMID: 31031148 DOI: 10.1016/j.fas.2019.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/07/2019] [Accepted: 04/09/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite the promising results of ankle joint arthroplasty, the tibiotalocalcaneal (TTC) arthrodesis remains an established procedure in treatment of combined pathology of the ankle and subtalar joint. Despite the promising results in biomechanical investigations, nonunion rates of up to 24% are described in recent studies. The objective of this work was a comparative study of the biomechanical properties of the posterolateral plate fixation with retrograde intramedullary nail fixation. METHODS Twenty four fresh-frozen human lower leg specimens (12 pairs) were used for the comparative biomechanical testing. Every specimen was preconditioned with 100 N over 200 cycles. After every 250 cycles the force was increased by 50 N from 200 to 600 N. This was followed by cyclic loading in dorsi-/plantiflexion with 800 N for 3000 cycles. All specimens were subjected to bone densitometry (DXA) and computed tomography. RESULTS Significantly higher number of spacimens with nails (4) failed during the cycling testing in dorsi-/plantarflexion and futher two during the cyclic testing with 800 N. Two specimens with plates failed during the cyclic testing with 800 N. Statistical analysis showed that the specimens with the plate were significantly more stable in each test direction. The Pearson correlation demonstrated for the specimens with plate a linear relationship between the stiffness and the determined bone density. CONCLUSIONS The results demonstrate a significantly superior stiffness of the Pantalarlock®-plate in all testing directions compared with the HAN nail. Probably the position of the plate on the tension side of the joint and the combination of locking and lag screws provide the higher stiffness of the plate system. The correlation of the stiffness with bone density leads to more predictable results of the plate arthrodesis. We hope for a reduction of the pseudarthrosis rate and shorten the postoperative treatment phase. The authors expect advantages in the treatment of high risk patients with severe deformity of the ankle, bone defects, neuropathic deformity, poor bone quality and osteoporosis.
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Affiliation(s)
- N Gutteck
- Department for Orthopaedics and Traumatology, Martin-Luther-University, Halle-Wittenberg, Ernst-Grube Str. 40, 06120 Halle, Germany.
| | - S Schilde
- Department for Orthopaedics and Traumatology, Martin-Luther-University, Halle-Wittenberg, Ernst-Grube Str. 40, 06120 Halle, Germany
| | - M Reichel
- Department of the Mechanical Engineering and Marine Technology, Faculty at the University of Rostock, Albert-Einstein-Straße 2, 18059 Rostock, Germany
| | - A Holtz
- Department of the Mechanical Engineering and Marine Technology, Faculty at the University of Rostock, Albert-Einstein-Straße 2, 18059 Rostock, Germany
| | - O Sahmel
- Department of Medical Biotechnology, University of Rostock, F.-Barnewitz-Str. 4, 18119 Rostock, Germany
| | - P Hinz
- Clinic for Trauma and Recontructive Surgery, University of Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany
| | - H Kielstein
- Department for Anatomy and Cell Biology, Martin-Luther-University, Halle-Wittenberg, Große Steinstraße 52, 06108 Halle, Germany
| | - J Lange
- Clinic for Trauma and Recontructive Surgery, University of Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany
| | - K S Delank
- Department for Orthopaedics and Traumatology, Martin-Luther-University, Halle-Wittenberg, Ernst-Grube Str. 40, 06120 Halle, Germany
| | - H Martin
- Department of Medical Biotechnology, University of Rostock, F.-Barnewitz-Str. 4, 18119 Rostock, Germany
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Abstract
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.
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Risk Factors for Failure of Bone Grafting of Tibia Nonunions and Segmental Bone Defects: A New Preoperative Risk Assessment Score. J Orthop Trauma 2017; 31 Suppl 5:S55-S59. [PMID: 28938394 DOI: 10.1097/bot.0000000000000982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To develop a clinically useful prediction model of success at the time of surgery to promote bone healing for established tibial nonunion or traumatic bone defects. DESIGN Retrospective case controlled. SETTING Level 1 trauma center. PATIENTS Adult patients treated with surgery for established tibia fracture nonunion or traumatic bone defects from 2007 to 2016. Two hundred three patients met the inclusion criteria and were available for final analysis. INTERVENTION Surgery to promote bone healing of established tibia fracture nonunion or segmental defect with plate and screw construct, intramedullary nail fixation, or multiplanar external fixation. MAIN OUTCOME MEASURES Failure of the surgery to promote bone healing that was defined as unplanned revision surgery for lack of bone healing or deep infection. No patients were excluded who had a primary outcome event. RESULTS Multivariate logistic modeling identified 5 significant (P < 0.05) risk factors for failure of the surgery to promote bone healing: (1) mechanism of injury, (2) Increasing body mass index, (3) cortical defect size (mm), (4) flap size (cm), and (5) insurance status. A prediction model was created based on these factors and awarded 0 points for fall, 17 points for high energy blunt trauma (OR = 17; 95% CI, 1-286, P = 0.05), 22 points for industrial/other (OR = 22; 95% CI, 1-4, P = 0.04), and 28 points for ballistic injuries (OR = 28; 95% CI, 1-605, P = 0.04). One point is given for every 10 cm of flap size (OR = 1; 95% CI, 1-1.1, P < 0.001), 10 mm of mean cortical gap distance (OR = 1; 95% CI, 1-2, P = 0.004), and 10 units BMI, respectively (OR = 1.5; 95% CI, 1-3, P = 0.16). Two points are awarded for Medicaid or no insurance (OR = 2; 95% CI, 1-5, P = 0.035) and 3 points for Medicare (3; 95% CI, 1-9, P = 0.033). Each 1-point increase in risk score was associated with a 6% increased chance of requiring at least 1 revision surgery (P < 0.001). CONCLUSIONS This study presents a clinical score that predicts the likelihood of success after surgery for tibia fracture nonunions or traumatic bone defects and may help clinicians better determine which patients are likely to fail these procedures and require further surgery.
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Foster MJ, O'Toole RV, Manson TT. Treatment of tibial nonunion with posterolateral bone grafting. Injury 2017; 48:2242-2247. [PMID: 28736122 DOI: 10.1016/j.injury.2017.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 04/25/2017] [Accepted: 05/02/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Posterolateral bone grafting to treat nonunions of the distal two-thirds of the tibia avoids the often traumatized and more tenuous anterior soft-tissue envelope. Few modern reports of its effectiveness are available. We assessed whether posterolateral bone grafting leads to high union and low complication rates. METHODS We conducted a retrospective review at a Level I trauma center. Our study group was 59 patients with distal two-thirds tibial fractures treated with posterolateral bone grafting. Patients included those with history of deep surgical site infection (SSI) before bone grafting (n=17), established nonunions (n=42), and impending nonunions associated with open fractures and bone gaps (n=17). All patients were followed for a minimum of 12 months unless they achieved union before that time point. Our primary outcome measurement was fracture union. Secondary outcome measurements were any complication associated with the approach and infection requiring return to the operating room. RESULTS Fracture union was achieved in 44 (75%) of 59 patients without further intervention. The mean interval to union was 9.9 months (range, 3-22). Of 11 infected nonunions treated, nine progressed to union. Seventeen of 23 patients with defects >2cm, including defects up to 5.4cm without infection, were successfully treated. Two patients who underwent grafting at least 10 years after initial injury achieved union. No complications were associated with the approach (specifically, no wound breakdown, vascular injury, or tendon injury). Fourteen percent of patients experienced SSI after bone grafting. Seven of eight deep SSI occurred in patients with previous infection or positive intraoperative cultures. Only one (3%) of 36 patients without infection pre- or intraoperatively experienced SSI. CONCLUSIONS Even in this relatively difficult patient cohort that included large bone gaps and history of infection, union was achieved at a relatively high rate with posterolateral bone graft. The approach seems to be safe, considering no known complications specifically associated with the approach occurred, and seems to reduce the risk of SSI in the absence of previous infection.
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Affiliation(s)
- Michael J Foster
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Theodore T Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA.
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Yenna ZC, Bhadra AK, Ojike NI, Burden RL, Voor MJ, Roberts CS. Polyaxial Screws in Locked Plating of Tibial Pilon Fractures. Orthopedics 2015; 38:e663-7. [PMID: 26270750 DOI: 10.3928/01477447-20150804-51] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 10/13/2014] [Indexed: 02/03/2023]
Abstract
This study examined the axial and torsional stiffness of polyaxial locked plating techniques compared with fixed-angle locked plating techniques in a distal tibia pilon fracture model. The effect of using a polyaxial screw to cross the fracture site was examined to determine its ability to control relative fracture site motion. A laboratory experiment was performed to investigate the biomechanical stiffness of distal tibia fracture models repaired with 3.5-mm anterior polyaxial distal tibial plates and locking screws. Sawbones Fourth Generation Composite Tibia models (Pacific Research Laboratories, Inc, Vashon, Washington) were used to model an Orthopaedic Trauma Association 43-A1.3 distal tibia pilon fracture. The polyaxial plates were inserted with 2 central locking screws at a position perpendicular to the cortical surface of the tibia and tested for load as a function of axial displacement and torque as a function of angular displacement. The 2 screws were withdrawn and inserted at an angle 15° from perpendicular, allowing them to span the fracture and insert into the opposing fracture surface. Each tibia was tested again for axial and torsional stiffness. In medial and posterior loading, no statistically significant difference was found between tibiae plated with the polyaxial plate and the central screws placed in the neutral position compared with the central screws placed at a 15° position. In torsional loading, a statistically significant difference was noted, showing greater stiffness in tibiae plated with the polyaxial plate and the central screws placed at a 15° position compared with tibiae plated with the central screws placed at a 0° (or perpendicular) position. This study showed that variable angle constructs show similar stiffness properties between perpendicular and 15° angle insertions in axial loading. The 15° angle construct shows greater stiffness in torsional loading.
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Abstract
Surgical management of extra-articular distal tibia fractures has evolved because of the high rate of complications with conventional techniques and the technically challenging aspects of the surgery. Open reduction and internal fixation with plating or nailing remain the gold standards of treatment, and minimally invasive techniques have reduced wound complications and increased healing. Adequate reduction and stabilization as well as appropriate soft tissue management are imperative to achieving good outcomes in these fractures.
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Yaligod V, Rudrappa GH, Nagendra S, Shivanna UM. Minimizing the complications of intramedullary nailing for distal third tibial shaft and metaphyseal fractures. J Orthop 2014; 11:10-8. [PMID: 24719527 PMCID: PMC3978743 DOI: 10.1016/j.jor.2013.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 12/03/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The complications of intramedullary nailing of distal third tibial shaft and metaphyseal fractures have a direct impact on ankle and hind foot function. METHODS We retrospectively evaluated 28 patients. Unreamed nail was negotiated across the well reduced fracture till subchondral bone and fixed with 2 to 3 distal locking screws in different planes. RESULTS Fracture union rate was 85%. Three out of 28 patients had malalignment. Mean ankle, hindfoot functional score was 85. CONCLUSION Complications can be minimized by impacting the unreamed nail till the subchondral bone while maintaining the fracture well reduced and by using multiple distal locking screws in different planes.
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Affiliation(s)
| | - Girish H. Rudrappa
- Department of Orthopaedics, Sapthagiri Institute of Medical Sciences and Research Center, Bangalore 560090, India
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Gutteck N, Lebek S, Zeh A, Gradl G, Delank KS, Wohlrab D. [Ankle arthrodesis with an posterolateral approach using a polyaxial angle stable Talarlock® plate]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2013; 25:615-23. [PMID: 24306049 DOI: 10.1007/s00064-013-0253-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 03/21/2013] [Accepted: 03/30/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Safe arthrodesis of the ankle as well as load carrying capacity free of pain. INDICATION Painful arthritis of the ankle joint occurring idiopathic or posttraumatic, resulting from rheumatoid arthritis or neuromuscular diseases. Extensive bony defects in varus or valgus ankle deformities and after failed prosthesis. Complex hindfoot deformities in neurological disease, paralysis and instabilities. Joint destruction after infection. CONTRAINDICATIONS Active osteitis, extensive skin ulcers in the approach area, periphery artery occlusive disease. SURGICAL TECHNIQUE Posterolateral skin incision. Sparing cartilage resection. Penetrating sclerosis zones. Reorientating anatomic positioning of the talus thereby correcting axis deformities. Talarlock(®) plate positioning and tibiotalar arthrodesis. POSTOPERATIVE MANAGEMENT Full weight bearing in an arthodesis boot for 6 weeks. After bone grafting partial weight bearing (20 kg) in an arthrodesis boot for 8 weeks. Full weight bearing after 10weeks. RESULTS Ten patients were operated on using this procedure. The follow-up time was 1 year. There were no complications requiring further surgical procedures. Ankle fusion and a good clinical outcome could be achieved in all cases.
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Affiliation(s)
- N Gutteck
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Klinik und Poliklinik für Orthopädie und physikalische Medizin, Martin-Luther-Universität Halle-Wittenberg, Magdeburger Str. 22, 06112, Halle, Deutschland,
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Iqbal HJ, Pidikiti P. Treatment of distal tibia metaphyseal fractures; plating versus intramedullary nailing: a systematic review of recent evidence. Foot Ankle Surg 2013; 19:143-7. [PMID: 23830160 DOI: 10.1016/j.fas.2013.04.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 11/24/2012] [Accepted: 04/09/2013] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Treatment of distal tibia metaphyseal fractures is challenging. The purpose of this study was to systematically review the recent literature regarding management of extra-articular distal tibia fractures with a view to compare the outcome of intramedullary nailing with plate fixation. METHODS Advanced literature search was performed using Medline (Ovid), Embase (Ovid) and Cochrane databases. Data were extracted regarding number of participants, fracture fixation devices, percentage of open fractures, malunions, nonunions, wound infections and metal removal etc. RESULTS After inclusion, exclusion criteria, two RCTs and four retrospective comparative studies were deemed suitable for this review. The overall results showed relatively higher rate of infection in plating group as compared to intramedullary nailing. However malalignment was more common with intramedullary nailing. CONCLUSION Both techniques can provide adequate treatments in appropriately selected patients. None of the studies had sufficient power to show clinically significant difference. Further studies are required to compare new locking plates with intramedullary nails.
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Affiliation(s)
- H J Iqbal
- Trauma and Orthopaedic Department, St Helens and Knowsley Teaching Hospitals NHS Trust, Warrington Road, Prescot, Merseyside L35 5DR, UK.
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Kritsaneephaiboon A, Vaseenon T, Tangtrakulwanich B. Minimally invasive plate osteosynthesis of distal tibial fracture using a posterolateral approach: a cadaveric study and preliminary report. INTERNATIONAL ORTHOPAEDICS 2012; 37:105-11. [PMID: 23161109 DOI: 10.1007/s00264-012-1712-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 10/30/2012] [Indexed: 11/27/2022]
Abstract
PURPOSE The aims of this anatomical study were to evaluate the feasibility of minimally invasive plate osteosynthesis (MIPO) using a posterolateral approach in distal tibial fractures and to study the relationship between neurovascular structures and the plate. METHODS Two separate incisions, one proximal and one distal, were made on the posterolateral aspect of ten cadaveric legs in the prone position. A 14-hole contralateral anterolateral distal tibial locking plate was inserted into the submuscular tunnel using a posterolateral approach, and one screw was fixed on each side of the proximal and distal tibia. The MIPO tunnel was then explored to identify the relationship between neurovascular bundles and plate. RESULTS For the proximal incision, retraction of the flexor hallucis longus and the tibialis posterior muscles medially was very important because it could protect the posterior tibial artery and the tibial nerve during plating. The sural nerve and lesser saphenous vein were easily identified and retracted in the superficial layer of the distal incision. In addition, we achieved satisfactory outcomes after using this MIPO technique in one patient. CONCLUSION Based on the results of our study, it seems that using the MIPO technique through a posterolateral approach should be a reasonable and safe treatment option for distal tibial fractures, especially when the anterior soft tissue is compromised. However, studies with a higher level of evidence should be done in more patients to confirm the clinical safety of using this technique.
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Affiliation(s)
- Apipop Kritsaneephaiboon
- Department of Orthopaedic Surgery and Physical Medicine, Prince of Songkla University, Songkhla, Thailand.
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Abdelgawad AA, Kadous A, Kanlic E. Posterolateral approach for treatment of posterior malleolus fracture of the ankle. J Foot Ankle Surg 2011; 50:607-11. [PMID: 21641237 DOI: 10.1053/j.jfas.2011.04.022] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Indexed: 02/03/2023]
Abstract
Treatment of the posterior malleolus has been debated among orthopedic surgeons. Most orthopedic surgeons will fix the posterior malleolus if it is larger than 25% to 30% of the distal articular surface. The most common method of fixation of the posterior malleolus is by indirect reduction and anteroposterior screws. In the present study, we describe the technique and results of treatment of the posterior malleolus by direct reduction through the posterolateral approach to the ankle. The decision to fix the posterior malleolus was determined by its size and displacement. A total of 12 consecutive patients underwent the posterolateral approach to reduce the posterior malleolus, and these were fixed by posterior plate. Two patients were lost to follow-up in the early postoperative period (both after 2 months). No deep infection or wound dehiscence occurred. Ten patients had adequate (<2-mm displacement of the articular surface) radiologic reduction at the final follow-up visit. There were 2 cases of 2 mm or more of articular surface displacement at the final follow-up visit (1 patient had 2-mm displacement noted in the immediate postoperative period and 1 patient had adequate reduction in the beginning but was displaced with additional follow-up). The posterolateral approach to the ankle is a useful tool to treat certain cases of posterior malleolus fracture. It allows good visualization and stable fixation of the posterior malleolus.
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Affiliation(s)
- Amr A Abdelgawad
- Department of Orthopedic Surgery, Paul L. Foster School of Medicine, Texas Tech University Health Science Center, El Paso, TX, USA.
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Hong J, Zeng R, Lin D, Guo L, Kang L, Ding Z, Xiao J. Posteromedial anatomical plate for the treatment of distal tibial fractures with anterior soft tissue injury. Orthopedics 2011; 34:161. [PMID: 21667901 DOI: 10.3928/01477447-20110427-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The treatment of distal tibial fractures with anterior soft tissue injury is relatively difficult. The aim of this study was to explore the efficacy and safety of the posteromedial anatomical plate for such fractures. Between February 2006 and January 2009, twenty-six cases of distal tibial fracture with anterior soft tissue injury were treated with posteromedial anatomical plates designed by our traumatic orthopedic center. Of the 26 cases, 12 were open fractures (4 Gustilo-Anderson type I, 5 type II, 2 type IIIA, and 1 type IIIB), and 14 were closed fractures (3 Tscherne-Oestern type I, 9 type II, 2 type III). Operation time, intraoperative blood loss, fracture healing time, American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, and complications were recorded to evaluate treatment effects.Mean operation time was 72.5 ± 15.8 minutes (range, 45-105 minutes) with a mean intraoperative blood loss volume of 86.4 ± 17.3 mL (range, 50-150 mL). All 26 patients had good postoperative fracture healing. Mean union time was 19.2 ± 4.4 weeks (range, 13-30 weeks). Average AOFAS ankle score was 87.3 ± 9.2 (range, 68-99). No malunion, nonunion, limb-shortening deformity, or neurovascular injury occurred. Our results suggest that the posteromedial anatomical plate for the treatment of distal tibial fractures with anterior soft tissue injury is effective and results in no severe complications.
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Affiliation(s)
- Jiayuan Hong
- Department of Orthopedic Surgery, the Affiliated Southeast Hospital of Xiamen University, Orthopedic Trauma Center of PLA, Zhangzhou, China.
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Tarkin IS, Siska PA, Zelle BA. Soft tissue and biomechanical challenges encountered with the management of distal tibia nonunions. Orthop Clin North Am 2010; 41:119-26; table of contents. [PMID: 19931060 DOI: 10.1016/j.ocl.2009.07.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A thoughtful treatment algorithm is required to optimally treat distal tibia nonunion. A healthy respect for the tenuous soft tissue envelope, compromised vascularity, and challenging mechanical environment is advisable. Achieving osseous union and improved functionality requires an individualized plan of care based on the personality of the nonunion and host. Attention must be focused on providing mechanical stability at the site of nonunion and providing biologic supplementation.
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Affiliation(s)
- Ivan S Tarkin
- Department of Orthopedic Surgery, Division of Traumatology, University of Pittsburgh, 3471 Fifth Avenue, Suite 911, Pittsburgh, PA 15213, USA.
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Gao H, Zhang CQ, Luo CF, Zhou ZB, Zeng BF. Fractures of the distal tibia treated with polyaxial locking plating. Clin Orthop Relat Res 2009; 467:831-7. [PMID: 18719970 PMCID: PMC2635458 DOI: 10.1007/s11999-008-0459-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 08/04/2008] [Indexed: 01/31/2023]
Abstract
We evaluated the healing rate, complications, and functional outcomes in 32 adult patients with very short metaphyseal fragments in fractures of the distal tibia treated with a polyaxial locking system. The average distance from the distal extent of the fracture to the tibial plafond was 11 mm. All fractures healed and the average time to union was 14 weeks. Six patients (19%) reported occasional local disturbance over the medial malleolus. There were two cases of postoperative superficial infections and evidence of delayed wound healing. Using the American Orthopaedic Foot and Ankle Society ankle score, the average functional score was 87.3 points (of 100 total possible points). Our results show the polyaxial locking plates, which offer more fixation versatility, may be a reasonable treatment option for distal tibia fractures with very short metaphyseal segments.
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Affiliation(s)
- Hong Gao
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Jiaotong University, 600 Yishan Road, Shanghai, 200233, People's Republic of China.
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Affiliation(s)
- Peter A Cole
- Department of Orthopaedic Surgery, Regions Hospital, 640 Jackson Street, St. Paul, MN 55101, USA.
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