Long-term follow-up of tibial shaft fractures treated with intramedullary nailing

Knee Injury and Osteoarthritis Outcome Score for Tibial Shaft Fractures: Validity, Reliability, Responsiveness, and Minimal Clinically Important Difference

BACKGROUND

This study evaluated the relevance, construct validity, test-retest reliability, and responsiveness and estimate the minimal clinically important difference in the Knee Injury Osteoarthritis outcome score (KOOS) for patients with tibial shaft fractures.

MATERIALS AND METHODS

This prospective cohort study included adult patients who were surgically treated after tibial shaft fracture (AO 42-). The primary outcome measure was the score on the KOOS subscales of pain, symptoms, activities of daily living, sport and recreational activities, and knee-related quality of life. Scores were obtained at 14 days, 15 days, 6 weeks, and 3, 6, and 12 months postoperatively. Relevance was evaluated by patients' ranking all KOOS items; construct validity was evaluated by comparing KOOS scores with the Health-Related Quality of Life questionnaire; test-retest reliability was evaluated by comparing KOOS scores over a 24-hour period; and responsiveness was evaluated based on predefined hypotheses and effect size.

RESULTS

Sixty patients (mean age, 47.1 years; range, 18-84 years) were included. Results showed acceptable relevance and construct validity for all KOOS subscales. Test-retest reliability was high for all 5 subscales, with an intraclass correlation coefficient of 0.9. Responsiveness was observed with moderate to high correlations (r≥0.3) for the predefined hypotheses and moderate to large effect sizes, ranging from 0.5 to 1.3, for the subscales of pain, activities of daily living, symptoms, and sport and recreational activities.

CONCLUSION

The KOOS showed acceptable relevance, construct validity, and responsiveness and moderate to high test-retest reliability for patients with tibial shaft fractures. Further validation of the psychometric properties of the KOOS for tibial shaft fractures may expand its usefulness for this patient group. [Orthopedics. 2025;48(3):146-152.].

Comparison of lateral parapatellar vs. infrapatellar approaches for intramedullary nailing for tibial shaft fractures

Background

This study aimed to evaluate the clinical and functional outcomes of tibial shaft fractures treated with intramedullary nailing (IMN) using the lateral parapatellar entry (LPE) and infrapatellar (IP) surgical approaches.

Methods

A total of 85 patients with tibial shaft fractures treated with IMN between January 2019 and December 2022 were retrospectively analyzed. A total of 40 and 45 patients underwent IMN using the LPE and IP surgical approaches, respectively. The operation time, intraoperative fluoroscopy times, blood loss, closed reduction rate, fracture healing time and complications were reviewed in this study. The American Orthopaedic Foot and Ankle Society (AOFAS) scale and Lysholm Knee Scoring Scale were used as functional measurements.

Results

The study included 85 patients (40 in the LPE group and 45 in the IP group), with a minimum follow-up of 12 months. No significant differences were found in fracture healing time, closed reduction rate, infection, deformity healing rate, Lysholm scores, and AOFAS scores between the groups. The LPE group displayed an significantly shorter operation duration, less blood loss, fewer fluoroscopy times, and a lower average VAS score compared to the IP group (P < 0.05).

Conclusions

The LPE approach for IMN in tibial shaft fractures may offer advantages in terms of fewer fluoroscopy times, and lower complication rates, suggesting it could be a preferable surgical approach.

Comparison of transverse and longitudinal incisions in tibia intramedullary nailing: Implications for pain, numbness, and functional recovery

BACKGROUND

The current standard of care for surgically managed tibia shaft fractures is intramedullary nailing. Chronic postoperative knee pain is the most common complication of the infrapatellar technique in intramedullary nailing. Literature suggests it may be related to infrapatellar nerve injury.

OBJECTIVE

This study compares the incidence of anterior knee pain after tibia nail insertion between conventional longitudinal and transverse incisions.

METHODS

This clinical trial study was conducted in our Level I trauma center from February 2022 to August 2024. Patients with closed diaphyseal tibia fractures were included in this study. All the cases were treated with reamed statically locked intramedullary nailing. The patients were randomly allocated to the longitudinal infrapatellar approach group (LIPAG) and transverse infrapatellar approach group (TIPAG). The primary outcomes measured at every follow-up included anterior knee pain by visual analog scale (VAS), numbness by monofilament test, range of motion, quality of life, and union success. Postoperative follow-up was performed at 2, 6, and 12 weeks and 6, and 12 months.

RESULTS

In our study, significant improvements in pain, quality of life, and functionality were observed in both groups; however, only the changes in numbness sensation and numbness pattern were significantly different between the two groups. TIPAG demonstrated earlier resolution of numbness compared to the LIPAG, and the numbness region significantly differed between the two groups, with LIPAG demonstrating more lateral numbness and TIPAG demonstrating more inferolateral numbness. However, no significant difference was observed between the two groups regarding operation time, length of stay, union outcome, pain, range of motion, or quality of life.

CONCLUSION

Transverse and longitudinal incisions for tibia IMN give comparable long-term results in pain relief, functional recovery, and quality of life.

Long-term effect of lower limb fractures A national register-based cohort study with a mean of 16.7 years follow-up

AIM

Information on patient-reported recovery from lower limb fractures includes limited information with >10 years follow-up. The aim was to investigate the long-term effect of lower limb fractures on the Hip Disability and Osteoarthritis Outcome Score (HOOS), the Knee Injury Osteoarthritis Outcome Score (KOOS) and the Foot and Ankle Outcome Score (FAOS) five subscales.

METHODS

Study design was a national register-based cohort study. A representative national sample of 26,877 citizens were invited to participate by completing the HOOS, KOOS or FAOS. Individual information on fractures to the foot/ankle, knee and hip as well as date/year of diagnoses was derived from the Danish National Patient Register.

RESULTS

HOOS, KOOS or FAOS were completed by 7,850 citizens. 489 (2 %) patients were registered with a lower limb fracture. The mean follow-up time from fracture to survey was 16.7 years, ranging from 0 to 45 years. The mean age of participants with a lower extremity fracture was 62.9 years and 61 % were women, compared to patients without a lower extremity fracture with a mean age of 60.2 years and 54 % were women. The HOOS/KOOS/FAOS mean differences between patients with and without a lower limb fracture were pain:4.4 (95 % CI -6.1- -2.7); symptoms:4.2 (95 % CI -5.9- -2.6); ADL:3.8 (95 % CI -5.4- -2.1); sport/rec:8.2 (95 % CI -10.9- -5.5); and QOL:6.5 (95 % CI -8.7- -4.2). Further subgroups analysis comparing hip-related fractures to the HOOS, knee-related fractures to the KOOS and foot/ankle-related fractures to the FAOS showed comparable results.

CONCLUSION

We showed that long-term patient-perceived complaints following lower limb fractures are common even decades after treatment. Most complaints were observed in high performance activities such as running, jumping and kneeling as well as QOL. More research is needed to address questions regarding causality.

Targeting the Infrapatellar Branch of the Saphenous Nerve for Pain Relief in Patients With Acute or Chronic Knee Pain: A Systematic Review of Randomized Controlled Trials and Cohort Studies

Blocking the infrapatellar branch of the saphenous nerve (IPBSN) can provide analgesic benefits for patients with postoperative acute pain or chronic pain, with minimal adverse effects. To evaluate the analgesic efficacy and potential adverse events associated with IPBSN block in patients suffering from acute or chronic knee pain. We conducted a systematic review across PubMed, Cochrane, Web of Science, and Embase to identify all relevant randomized controlled trials (RCTs) and cohort studies according to predefined selection criteria. The study quality of the RCTs was evaluated using the Cochrane risk of bias assessment tool, while cohort studies were assessed using the ROBINS-I risk of bias tool. The primary outcomes measured were pain intensity and opioid consumption following the nerve block. A total of eight studies were included in this systematic review, encompassing 613 subjects with 276 participants in the control group and 337 participants in the IPBSN block group. The level of evidence was rated high for the RCTs and moderate for the cohort studies. The nerve block was administrated either through the injection of local anesthetic or percutaneous cryoneurolysis targeting the IPBSN. The results indicated that the IPBSN block significantly improved pain relief and reduced opioid consumption in patients with acute postoperative or chronic pain, with no significant difference in the rate of adverse events relating to the procedures or device. The IPBSN block holds promise for improving pain relief and reducing opioid consumption. However, further well-designed randomized controlled trials are needed to confirm these results.

Tibial Malalignment Is an Independent Predictor of Nonunion After Intramedullary Nailing of Tibial Shaft Fractures

OBJECTIVES

This study aimed to assess the relationship between postoperative alignment and nonunion in patients with tibial shaft fractures treated with intramedullary nailing.

METHODS

DESIGN

Retrospective case-control study.

SETTING

Single academic trauma center.

PATIENTS SELECTION CRITERIA

Adult patients with closed or open tibial shaft fractures (42A-C) treated with intramedullary nailing from 2007 to 2018.

OUTCOMES MEASURES AND COMPARISONS

Case patients with nonunion were compared with control patients with radiographic evidence of healing in terms of the postoperative tibial alignment measured in the coronal and sagittal planes.

RESULTS

Of the 192 included patients (median age, 38 years; 76% male), 51 patients had a nonunion, and 141 patients had united fractures and served as the control group. A strong association between postoperative tibial malalignment in 1 plane and nonunion (odds ratio, 3.0; 95% confidence interval, 1.1-8.3; P = 0.03) was demonstrated. This association was even greater for malalignment in both coronal and sagittal planes (odds ratio, 5.7; 95% confidence interval, 2.1-16.1; P < 0.001) after controlling for confounders.

CONCLUSIONS

After controlling for confounding factors, postoperative malalignment in the coronal or sagittal plane was associated with significantly increased odds of tibial shaft nonunion after intramedullary nailing.

LEVEL OF EVIDENCE

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

A Prospective Study on the Suprapatellar Approach for Tibial Shaft Fractures: Insights Into Functional and Radiological Outcomes

BACKGROUND

Tibial shaft fractures are among the most common long bone injuries and often can be challenging to manage surgically. While infrapatellar (IP) intramedullary nailing (IMN) has been a widely accepted treatment, its limitations have led to the emergence of alternative approaches, such as suprapatellar nailing (SPN) in a semi-extended knee position.

AIM

To evaluate the clinical, radiological, and functional outcomes of tibial shaft fractures treated with an SPN approach in a semi-extended knee position.

METHODS

A prospective study was conducted at Saveetha Medical College, including 20 patients diagnosed with tibial shaft fractures between August 2021 and December 2022. All patients underwent IMN using a suprapatellar approach after being assessed for surgical fitness and providing informed consent. Clinical and radiological follow-ups were performed over a 12-month period to evaluate knee range of motion, fracture healing, implant positioning, and knee pain, using the Lower Extremity Functional Scale (LEFS) and Visual Analog Scale (VAS).

RESULTS

The study cohort consisted of 20 patients, with a male-to-female ratio of 3:1. The majority (70%) were aged between 20 and 40 years. Fractures affected the left tibia in 11 cases and the right in nine cases. Among the fractures, 12 were closed and eight were open, classified according to the Gustilo-Anderson classification as ranging from Grade 1 to Grade 3. The mean surgery duration was 83.5 minutes, with an average blood loss of less than 100 mL. The mean time to fracture union was 12 weeks, and the mean LEFS score recorded was 75.75. Three patients experienced complications, which were managed successfully. Overall, patients demonstrated favorable clinical, radiological, and functional outcomes with minimal knee pain post-surgery.

CONCLUSION

Suprapatellar IMN in the semi-extended position is a viable and effective surgical approach for managing tibial shaft fractures, providing good clinical, radiological, and functional outcomes with minimal complications.

A Prospective Study on Tibial Shaft Fractures Treated with Suprapatellar Approach

Background

Tibial diaphysis represents the primary location for tibial fractures, accounting for 80% of such cases, often accompanied by fibular fractures. In terms of surgical management, the recommended technique for addressing both displaced and undisplaced tibial shaft fractures in adults is intramedullary nail fixation. Additionally, there is a growing consideration for suprapatellar nailing, which involves performing the procedure with the knee in a semi-extended position, as a potentially safe and efficacious alternative.

Objectives

To evaluate the clinical and functional union amongst tibial shaft fracture cases, managed by nailing in the suprapatellar approach, and to study the complications associated with it.

Materials and Methods

Our study with prospective observational design was conducted for 18 months on 30 patients with tibial shaft fractures. Following comprehensive laboratory assessments and confirmation of surgical fitness, the patients underwent surgical intervention through a specialised suprapatellar approach employing expert tibial nailing.

Results

The mean age of the subjects was 42.83 ± 11.47 years, and the majority were males (70.0%). Notably, there was a statistically significant reduction in Visual Analogue Scale scores and a concurrent increase in Lysholm Knee Scoring Scale scores during the follow-up period, indicating substantial enhancements in both clinical and functional outcomes. Delayed union was the complication observed in three individuals. We found that the younger the age of the subjects, the earlier the surgery after an injury, the better the functional outcome.

Conclusion

Expert tibial nailing with a suprapatellar approach was successful in yielding clinical and functional union amongst the subjects with tibial shaft fractures. In addition, delayed union was the complication observed in the approach, which was evident in a few cases.

Assessment of functional and radiological outcomes of suprapatellar and infrapatellar approaches of tibial nailing in patients with tibial shaft fracture: A randomized control study

Background

The study aimed to assess functional and radiological outcomes of the suprapatellar approach (SPA) and infrapatellar approaches (IPA) of tibial nailing in patients with closed tibia shaft fractures.

Method

After Institutional Ethical Committee (IEC) and Clinical Trials Registry- India (CTRI) approval, patients with Orthopaedic Trauma Association (OTA) fracture type 42 were enrolled from August 2021 and August 2022 at a level I trauma centre and randomized to SPA and IPA with informed consent. Demographics, American Society of Anaesthesiologists (ASA) physical grading, intraoperative fluoroscopy time, operative duration, bleeding, postoperative radiographic alignment, and union were compared among both approaches. Functional parameters like Lysholm knee score, Anterior knee pain (AKP), Visual Analog Scale (VAS) Score upon kneeling, Knee Injury and Osteoarthritis outcome score (KOOS), KOOS Patellofemoral score (KOOS PF), EuroQol (EQ5D5L), Forgotten joint score (FJS), Range of motion (ROM) of knee and any complications were assessed at 3,6 and 12 months postoperatively.

Results

Per protocol analysis of 50 patients (25 SPA, 25 IPA) done at the end of the study. SPA group had significantly lesser fluoroscopy time (91.28 ± 12.40s vs. 105.36 ± 9.23s, p < 0.001) and operative duration (mins) (123.80 ± 24.25 vs. 130.00 ± 18.20, p < 0.001) than IPA. No significant differences were noted in Lysholm knee score at three months (p = 0.094), six months (p = 0.406), and 12 months (p = 0.071). The SPA group showed significantly lower VAS Score upon kneeling at six months (p < 0.0001). Similarly, KOOS (p < 0.001), KOOS PF (p = 0.01), and EQ 5D5L (p = 0.03) were significantly better in the SPA group at six months postoperatively. Lower Coronal translation was found in SPA [0 (0-1.8) vs. 1.4 (0.9-1.8), p = 0.010]. Whereas, IPA had higher range of flexion at 3 months [130.0 (129.0-135.0) vs 123.1 (120.0-130.5), p = 0.047]. However, no significant differences were noted in blood loss, AKP, FJS, EQ-VAS, coronal angulation, sagittal malalignment, time to union, return to work and postoperative complications among the groups.

Conclusion

SPA has lesser surgery time, more straightforward anatomic fracture reduction, better fracture alignment, lesser radiation exposure for both patients and surgeons, quicker recovery time, and promotes early kneeling activities with similar long-term functional outcomes and union rates, and can be considered in routine clinical practice than conventional IPA.

Outcomes and their predictors in suprapatellar nailing for tibia fractures. Multivariable analysis of 293 consecutive cases

PURPOSE

Intramedullary nailing of tibial fractures is one of the most common procedures in orthopedic surgery. It can be technically demanding in proximal or distal fractures, which may be facilitated using semi-extended approaches. The aim of this study is to identify outcomes and their predictors using a semi-extended suprapatellar approach for tibial fracture nailing.

METHODS

This is a retrospective cohort of 293 patients who underwent intramedullary nail fixation of a tibial fracture through a suprapatellar approach, considering a postoperative follow-up of 1 year. Data on patient's baseline characteristics, injuries, treatments, and outcomes regarding alignment, fracture union, and complications were recorded. For multivariable analysis, hierarchical binary (logistic) regression analysis was performed.

RESULTS

The mean patient age was 47.7 years (SD 18.9), with 42A1 the most frequent fracture pattern (n = 98, 33.5%). Correct or anatomical alignment (≤ 5º in both planes) was achieved in 272 (92.8%) of the patients. On multivariate analysis, surgical delay ≥ 7 days (OR = 1.3, 95% CI = 1.3-8.1) and age over 50 years (OR = 3.2, 95% CI = 1.2-8.3) were found as predictors of fracture malalignment. Fracture healing was achieved in 97.6%, and reoperation rate was 6.14%. Overall complication's predictors were proximal fracture (OR = 2.8, 95% CI = 1.1-7.2), temporary external fixation (OR = 2.4, 95% CI = 1.2-4.9), and fracture malalignment (OR = 2.9, 95% CI = 1.1-7.9).

CONCLUSION

The suprapatellar approach is a safe and useful technique for treating tibial fractures, leading to no less than correct reduction in almost all patients and achieving a high fracture healing rate, at very low rates of complications. Pre- and postoperative predictors identified must be taken into account to improve outcomes while treating these fractures.

Long-term patient reported outcome measures and kneeling function in patients with tibial intramedullary nails

INTRODUCTION

Anterior knee pain (AKP) is a common complaint following intramedullary nail (IMN) insertion for tibial shaft fractures. There is a lack of long-term patient reported outcome data following tibial IMN, with conflicting evidence of the role of nail protrusion on AKP. In this study, we assess the long-term patient reported outcome measures and kneeling function in patients with tibial IMNs and compare the results with IMN protrusion, measured radiologically.

MATERIALS AND METHODS

A retrospective cohort of 128 patients, from a single UK centre, were invited to participate in the study, to complete a Kujala score, KOOS, EQ-5D-5L and a four-posture kneeling assessment. We report the outcomes of 45 patients at an average follow-up of 6.9 years.

RESULTS

The mean Kujala score was 80.7. The mean KOOS score was 83.2, 83.9, 85.8, 70.7 and 72.8 for symptoms, pain, daily living, sport and quality of life, respectively. We found 20.5% of patients experienced daily AKP. Pain and fear of pain were the most common limiting factors in the kneeling assessment. No significant correlation was found between the KOOS or Kujala score and nail-plateau distance, nail-anterior cortex distance, or the overall nail prominence.

CONCLUSION

AKP affects a subset of patients more than five years post-tibial IMN, limiting their ability to kneel and other functions of daily living. Tibial IMN prominence does not seem to be associated with AKP.

Prevalence of Rotational Malalignment After Infrapatellar Versus Suprapatellar Intramedullary Nailing of Tibial Shaft Fractures

Background

Up to 30% of patients with a tibial shaft fracture sustain iatrogenic rotational malalignment (RM) after infrapatellar (IP) nailing. Although IP nailing remains the management of choice for most patients, suprapatellar (SP) nailing has been gaining popularity. It is currently unknown whether SP nailing can provide superior outcomes with regard to tibial RM. The aim of this study was to compare the differences in the prevalence of RM following IP versus SP nailing.

Methods

This retrospective study included 253 patients with a unilateral, closed tibial shaft fracture treated with either an IP or SP approach between January 2009 and April 2023 in a Level-I trauma center. All patients underwent a postoperative, protocolized, bilateral computed tomography (CT) scan for RM assessment.

Results

RM was observed in 30% and 33% of patients treated with IP and SP nailing, respectively. These results indicate no significant difference (p = 0.639) in the prevalence of RM between approaches. Furthermore, there were no significant differences in the distribution (p = 0.553) and direction of RM (p = 0.771) between the 2 approaches. With the IP and SP approaches, nailing of left-sided tibial shaft fractures resulted in predominantly internal RM (85% and 73%, respectively), while nailing of right-sided tibial shaft fractures resulted in predominantly external RM (90% and 80%, respectively). The intraobserver reliability for the CT measurements was 0.95.

Conclusions

The prevalence of RM was not influenced by the entry point of tibial nailing (i.e., IP versus SP). Hence, the choice of surgical approach should rely on factors other than the risk of RM.

Level of Evidence

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

Gait and strength assessment following surgical repair by intramedullary nailing of isolated tibial shaft fracture

The objective of the study was to evaluate the long-term strength and gait outcomes after intramedullary nailing of isolated tibial diaphyseal fractures. This retrospective cohort study was conducted at an academic Level I trauma center. Fifteen participants with isolated tibial diaphyseal fractures (OTA/AO 42) at least 2 years postoperative from intramedullary nailing (IMN) provided informed consent. The average age was 40 ± 14 (range, 24-69); there were nine men and six women. Knee flexion-extension strength data were collected. Temporal-spatial, kinematic, and kinetic gait parameters were measured and compared to historic control data. Participants completed the SF-36 and shortened musculoskeletal function assessment questionnaires. The mean length of follow-up between surgery and gait analysis was 6 ± 2 years. The fractured limb demonstrated deficits in quadriceps strength between 9.8% and 23.4% compared to the unaffected limb. Temporal-spatial parameters revealed slower walking speed, shorter stride length, decreased cadence, and shorter single-limb support time in the fractured limb. Altered kinematic and kinetic findings included a knee extension shift during stance, with an increased knee flexor moment demand and decreased total knee power during loading and midstance. These findings represent deficits in concentric and eccentric knee extensor activity. Additionally, the fractured limb demonstrated decreased ankle dorsiflexion during stance and diminished ankle push-off power. Long-term outcomes after IMN of tibial diaphyseal fractures demonstrate decreased quadriceps strength and altered gait parameters that may have implications to the high incidence of knee and ankle pain in the fractured limb.

Suprapatellar tibial nailing: intraoperative arthroscopic evaluation and results at a minimum of 12 months follow-up

To arthroscopically evaluate the intra-articular structures before and after placement of an intramedullary tibial nail using the suprapatellar approach and to assess the 1-year results. All patients with a tibial fracture that underwent intramedullary tibial nailing using the suprapatellar approach with a minimal follow-up of 12 months were included. Diagnostic intraoperative knee arthroscopy was performed before and immediately after insertion of the IMN. A radiological and clinical evaluation and VAS score of the patients was collected postoperatively. In total, 36 patients were included. The mean follow-up period was 14.9 ± 4.9 months. The mean age of the patients was 45.5 ± 18.8 years. The mean visual analog scale (VAS) score at 12 months was 1.0 ± 1.5. The complication rate was 19.4% and the reoperation rate was 16.7%. Union of the fractures was achieved in 33 patients (91.6%) after primary surgery after a mean of 6.1 ± 1.8 months. A change in the patellofemoral cartilage after insertion of the nail was seen in 1 patient. The suprapatellar procedure for tibia fractures resulted in excellent VAS scores and union rates at 1-year follow up, with a complication of articular damage to the PF joint in 2.8%.

Callus formation and bone remodeling in a tibial nonunion after minimal invasive percutaneous screw fixation followed by extracorporeal shockwave therapy 17-months after initial trauma - A case report

INTRODUCTION

The treatment of tibial nonunion is challenging and treatment may be conservative or surgical. Conservative strategies include functional braces and weight bearing, or focused extracorporeal shockwave therapy (fESWT).

CASE DESCRIPTION

A 45-year-old male patient sustained spiral tibial shaft fractures and was treated surgically within 24 hours after the initial accident with intramedullary nails. The tibial fracture was later classified as nonunion after 11 months. Radiologic evaluation 17 months after the initial trauma demonstrated clinical nonunion, and subsequently the patient was offered a conservative approach with fESWT to facilitate an increase in callus formation. The handpiece was fitted with a stand-off II (long), penetration depth of 15 mm. Three cycles were administered in month 17, 19 and 20 after baseline. Each cycle consisted of three treatments sessions spaced with 6-8 days apart, and consisted of 3000 to 4000 impulses each given at 0.25-0.84 mJ/mm2. The number of impulses and the power at the focus point varied according to the pain response.

OUTCOMES

The patient achieved union 23 months after fracture. A clinical important improvement was observed with both Lower Extremity Functional Scale (LEFS) (18-point difference) and Patient Specific Functional Scale (PSFS) (average: 4.7 points,) The "worst pain last 24 hours" was reduced by 5 points. These values express minimal clinically important difference (MCID) values in these functional patient-reported outcome measures.

CONCLUSION

This treatment strategy may be viable in a broader setting, including private practice physiotherapy thereby treating the patient in close proximity to the patient's everyday life.

Evaluation of the trajectory of recovery following surgically treated acetabular fractures

Aims

Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

Methods

Eligible patients at a level I trauma centre were recruited into a longitudinal registry of surgical acetabular fractures between June 2004 and August 2019. Patient-reported outcome measures (PROMs), including the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS), were recorded at baseline pre-injury recall and six months, one year, two years, and five years postoperatively. Comparative analyses were performed for elementary and associated fracture patterns. The proportion of patients achieving minimal clinically important difference (MCID) was determined. The rate of, and time to, conversion to total hip arthroplasty (THA) was also established.

Results

We recruited 251 patients (253 fractures), with a 4:1 male to female ratio and mean age of 46.1 years (SD 16.4). Associated fracture patterns accounted for 56.5% of fractures (n = 143). Trajectory analysis showed all timepoints had significant disability versus baseline, including final follow-up (p < 0.001). Elementary fractures had higher SF-36 PCS at six months (p = 0.023) and one year (p = 0.007) compared to associated fractures, but not at two years (p = 0.135) or five years (p = 0.631). The MCID in SF-36 PCS was observed in 37.3% of patients (69/185) between six months and one year, 26.9% of patients (39/145) between one and two years, and 23.3% of patients (20/86) between two and five years, highlighting the long recovery potential of these injuries. A significant proportion of patients failed to attain the MCID after five years (38.1%; 40/105). Conversion to THA occurred in 13.1% of patients (11/110 elementary and 22/143 associated fractures). Approximately two-thirds of THAs (21/33 patients; 63.6%) were performed within two years of index surgery.

Conclusion

Acetabular fractures significantly impact physical function. Recovery trajectory is often elongated beyond one year, with two-thirds of our patients displaying persistent clinically relevant long-term disability.

Semi-extended extra-synovial (SEES) tibial intramedullary nailing technique: Up to 10 year retrospective analysis of outcomes and anterior knee pain rates

Background

Tibial intramedullary nailing is a common method of fixation for fractures of the tibia, with several approaches described. Anterior knee pain is a common complication following nailing, but the reported incidence of knee pain varies in the literature between 10 % and 86 %. There is considerable variation in incidence between nailing techniques, with an exact aetiology still unknown. We investigated the reported incidence of anterior knee pain in patients undergoing tibial nailing using the semi-extended extra synovial (SEES) technique at a Major Trauma Centre (MTC) in the UK.

Methods

A retrospective review of tibial fractures treated with the SEES technique between December 2012 to February 2021. Data collected included patient demographics, mechanism of injury, fracture characteristics, length of stay, union rates and re-operation rates. Primary outcomes were anterior knee pain rates and patient reported outcome measures (PROM), the Kujala Score. Secondary outcomes were rates of union and complications.

Results

55 fractures were identified in 53 patients. Male: Female ratio was 32:21. The average age was 45.5 years. 96 % were unilateral fractures; with 53 % being right-sided. 21(38 %) fractures were open. Prior to definitive nailing 21 fractures had temporary stabilisation with an external fixator (Ex-Fix) ± wound debridement whilst the rest received plaster backslab immobilisation. 13 of the open fractures required soft tissue cover. 75 % of patients had initial surgery (SEES Nailing/Ex-Fix) within 4 days. There was a 91 % union rate with a median time to full radiographic union of 14 months. One post-operative complication of wound dehiscence was recorded. The mean follow-up time was 13.6 months. 15 % of patients reported anterior knee pain in the postoperative follow-up period. The average Kujala PROM score was 85 (Range: 52-100).

Conclusion/findings

The SEES technique had favourable PROM scores and displayed a lower incidence of anterior knee pain than the traditional infrapatellar approach. Knee pain rates were comparable to suprapatellar approaches without violating the knee joint.

Disclosures

None.

Functional outcomes of the knee and associated factors after intramedullary nailing of tibial diaphysial fractures at Addis Ababa Emergency, burn, and Trauma Hospital (AaEBT) hospital, Ethiopia

BACKGROUND

Tibial shaft fractures are the most common long bone fractures requiring treatment. High-energy trauma often causes tibia bone injuries, causing severe complications and long-term disability due to inadequate soft tissue coverage. Tibial shaft fractures can be treated using casts, external fixators, plating, or intramedullary nails. Intramural nailing leads to faster union and reduced complications like malunion and shortening. However, patients often report subjective and objective difficulties after Surgical Instrument generation network (SIGN) nail fixation, affecting knee range of motion, quality of life, and sport activities. Tibial nails and plates are associated with increased knee pain, which negatively affects functional outcomes. No study has been conducted in a poor resource setting like Ethiopia. This study aims to assess functional outcomes of the knee and associated factors after intramedullary nailing of Tibial Diaphysial Fractures at AaBET hospital in Ethiopia.

METHODS

A retrospective health facility based cross-sectional study was conducted on functional outcomes of the knee and associated factors after intramedullary nailing of tibial diaphysial fractures done at AaBET hospital. A medical record review form and a structured questionnaire from patient chart and SIGN nail database collected data. The study was conducted on 151 patients registered on the SIGN nail database using a simple random sampling. Knee injury and Osteoarthritis Outcome Score (KOOS) was used to assess the knee functional outcome. Descriptive statistics such as frequency and percentage were used to summarize the results and binary logistic regression was used to describe the association between variables. P value < 0.05 was considered statistically significant association.

RESULTS

The study constituted 151 patients with tibial shaft fractures; 113(74.8%) males and 38(25.2%) females with a mean age of 31.4 years, with a standard deviation of [10.5]. The prevalence of patients with good knee functional outcomes was 87(57.6%), while 64(42.4%) patients had poor knee functional outcomes. Associated factors identified include sex, age, soft tissue status, postoperative infection postoperative physiotherapy and comminuted fracture pattern.

CONCLUSION AND RECOMMENDATION

This study determined the magnitude of knee functional outcomes revealed that more than half (57.6% ) of patients had good knee functional outcomes with identified factors increseaes odds of poor knee functional outcomes were sex, age, soft tissue injuries, post operative infection, postoperative physiotherapy and comminuted fracture patterns respectively. Therefore, Policymakers and health planners should closely monitor postoperative physiotherapy treatment courses among tibial shaft fractures treated with intramedullary nailing to increases good knee functional outcomes.

Outcome of tibial shaft fractures treated with the SIGN FIN nail at Addis Ababa Emergency, Burn, and Trauma Hospital (AaEBT) Addis Ababa, Ethiopia

Objectives

To determine the outcome of tibial fractures treated with the SIGN FIN nail.

Study Design

Retrospective case series study.

Study Setting

Trauma center.

Methods and Materials

We included 14 patients aged 18-51 years with 16 tibial fractures in this study. Patients were followed clinically and radiographically, and the minimum time followed was 6 months. Johner and Wruhs criteria with modification were used to assess the outcome.

Result

There were 11 male (78.6%) and three female (21.4%) patients. The mean age was 32.44 ± 8.98 (range 18-51) years. The right-sided tibia was injured in six as compared with the left side in four, and four patients had bilateral injuries. Eight (50%) fractures were closed fractures, whereas the rest eight (50%) were open types of fractures. Among the latter, half (n = 4; 50%) fractures were Gustilo type II fractures, while three (37.5%) fractures were Gustilo type III fractures, and one (12.5%) patient had a Gustilo type I fracture. All patients had radiologic union. There were no infections or secondary surgery for any reason. Excellent, good, and fair results were achieved in 62.5%, 25%, and 12.5%, respectively. All patients were able to return to their preinjury activity except two patients.

Conclusion

SIGN FIN nail is an option for treating tibial shaft fractures with good outcomes and few complications in selected fractures.

Level of evidence

Level IV.

Intramedullary Nailing of Concurrent Bilateral Tibial Stress Fractures Followed by Unilateral Tension Plating for a Nonunion in a Vitamin D-Deficient Elite Football Player

Stress fractures consist of a type of bone fracture that occurs due to repetitive mechanical stress instead of acute forceful injuries that cause common fractures. They are quite common among athletes at all competition levels and in army recruits who are expected to undergo extremely demanding exercises. While stress fractures can occur in any long bone, they are usually associated with the most common weight-bearing sites of lower extremities such as phalanges, metatarsals, tarsal bones, the tibia, and fibula. In this study, we report the surgical management of a 23-year-old African football player who sustained concurrent bilateral anterior cortex tibial midshaft fractures. His initial symptom was persistent subacute pain in both tibias. The initial conservative treatment was not successful and the patient was surgically treated with bilateral tibial intramedullary nails. However, the right tibia subsequently developed nonunion. Both intramedullary nails were removed and a tension plate was applied with an autologous iliac crest graft on the right tibia. Further blood test analysis revealed a significant vitamin D deficiency. The purpose of this article is to report different outcomes of the same primary surgical treatment for concurrent bilateral tibia stress fracture syndrome in an elite athlete due to vitamin D deficiency. To our knowledge, this is the first study that highlights the necessity of revising one of the intramedullary nailed concurrent tibia stress fractures with a tension plate and autologous graft to treat the established nonunion in an elite football player.

Intramedullary Nail Fixation by Suprapatellar and Infrapatellar Approaches for Treatment of Distal Tibial Fractures

Objective

To compare the functional and alignment outcomes of intramedullary nail fixation using suprapatellar and infrapatellar approaches in treating distal tibial fractures.

Methods

In this retrospective study, 132 patients with distal tibial fractures (87 men, 45 women) ranging in age from 20 to 66 years were treated with intramedullary nails using the suprapatellar (69 patients) or infrapatellar (63 patients) approach. The radiographic alignment outcomes and ankle function were compared between the two groups. Multivariate logistic regression analyses were performed to determine which variety influenced ankle functional scores and whether the suprapatellar approach intervention demonstrated a protective effect.

Results

The mean follow‐up time was 14.22 ± 2.31 months. The mean sagittal section angle of the fracture in the suprapatellar and infrapatellar approach groups was 3.20° ± 1.20° and 5.31° ± 1.23°, respectively (P < 0.001). The mean coronal section angle was 3.51° ± 0.89° and 5.42° ± 1.05°, respectively (P < 0.001). Three patients (4.3%) in the suprapatellar approach group and 15 patients (23.8%) in the infrapatellar approach group had poor fracture reduction (P < 0.001). The mean hind foot functional score and ankle pain score were 95.91 ± 4.70 and 35.91 ± 4.70 points, respectively, in the suprapatellar approach group and 85.20 ± 5.61 and 25.20 ± 5.61 points, respectively, in the infrapatellar approach group (P < 0.001 for both). In the comparison of ankle function, the multivariate logistic regression analyses demonstrated that the odds ratio in the suprapatellar approach group was about 7 times that in the infrapatellar approach group (odds ratio, 7.574; 95% confidence interval, 2.148–28.740; P = 0.002). Of the variants measured, the statistically significant risk factors for poor ankle function were AO type A3 (P = 0.016) and diabetes mellitus (P = 0.006). Sex and the operation interval were not statistically significant risk factors for poor ankle function.

Conclusion

Intramedullary nailing using the suprapatellar approach facilitates simple fracture reduction, excellent postoperative fracture alignment, and few complications, giving it obvious advantages over the conventional infrapatellar approach. Additionally, the suprapatellar approach is a prognostic factor associated with postoperative ankle joint function.

Controlling the angle between the distal locking screw and tibiotalar joint tangent helps to reduce the occurrence of misalignment of distal tibial fractures treated with intramedullary nail fixation

BACKGROUND

Studies have shown that on the coronal plane, whether the direction of the distal locking screw is parallel to the tangent line of the tibiotalar joint can be used to determine whether there is varus or valgus deformity after the treatment of distal tibial fractures with intramedullary nail (IMN) fixation. However, there has been no statistical analysis of the included angle on the coronal plane, and there have been no reports on whether there is a relationship between the direction of the distal locking screw on the sagittal plane or the included angle of the tangent line of the tibiotalar joint and the postoperative alignment of distal tibial fractures treated with IMN fixation.

OBJECTIVE

Our aim was to evaluate the relationship between the angles formed by the distal locking screw and the tibiotalar joint tangent (ADTTs) on the sagittal and coronal planes and postoperative alignment in the treatment of distal tibial fractures with IMN fixation.

METHODS

We performed a retrospective analysis of 100 patients with distal tibial fractures treated with IMN fixation using the suprapatellar approach. On the coronal and sagittal planes, the ADTTs were arranged from small to large and divided into 4 groups, namely, groups A, B, C and D. One-way ANOVA was used to compare the lateral distal tibial angle (LDTA) and anterior distal tibial angle (ADTA) among all groups, and the chi-square test was used to compare the incidence of postoperative tibial misalignment among all groups. Univariate analysis was performed using chi-square tests to identify factors that might be associated with dislocation, including fibular open reduction and internal fixation (ORIF), limited open reduction, ADTT, IMN diameter, injury mechanism, open vs. closed fracture, comminution, and fibular fracture level. Then, the statistically significant variables in the univariate analysis were included in a multivariate logistic regression equation to evaluate the independent factors related to misalignment.

RESULTS

On the coronal plane, the ADTTs of groups A, B, C and D were < 0°, 0°-1.3°, 1.3°-2.7° and > 2.7°, respectively. The mean LDTAs of groups B and C (0°-1.3° and 1.3°-2.7°), group A (< 0°) and group D (> 2.7°) were 89.5 ± 1.6°, 92.0 ± 3.2° and 85.8 ± 3.5°, respectively (P < 0.01). Deformity greater than 5° were more likely in groups A and D than groups B and C [14 of 50 (28%) vs. 1 of 50 (2%), P < 0.001]. On the sagittal plane, the ADTTs of groups A, B, C and D were < 8.9°, 8.9°-10.4°, 10.4°-11.7° and > 11.8°, respectively. The average ADTAs of groups B and C (8.9°-10.4° and 10.4°-11.7°), group A (< 8.9°) and group D (> 11.8°) were 80.4 ± 1.3°, 83.1 ± 3.7° and 77.9 ± 2.5°, respectively (P < 0.01). Deformity greater than 5° was more likely in groups A and D than groups B and C [13 of 50 (26%) vs. 0 of 50 (0%), P < 0.001]. An ADTT of 0°-2.7° on the coronal plane and 8.9°-11.7° on the sagittal plane (OR: 0.08, P = 0.02) and limited open reduction (OR: 0.21, P < 0.01) were independent factors that reduced the likelihood of misalignment.

CONCLUSION

The alignment of distal tibial fractures after surgery is sensitive to the ADTT and use of limited open reduction. Controlling the ADTT between 0° and 2.7° on the coronal plane and between 8.9° and 11.7° on the sagittal plane is helpful to reduce the occurrence of misalignment after the treatment of distal tibial fractures by IMN fixation.

Comparison of Patient-Reported Outcomes After Suprapatellar Versus Infrapatellar Nailing Techniques for Tibial Shaft Fractures: A Systematic Review and Meta-analysis

OBJECTIVES

To compare patient-reported outcome measures (PROMs) between patients who underwent intramedullary nail (IMN) fixation for tibial shaft fractures using an infrapatellar (IP) or the newer suprapatellar (SP) approach. Secondary outcomes included fluoroscopic radiation exposure, operative time, and radiographic outcomes.

DATA SOURCES

A systematic literature search of the databases Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials Study Selection.

STUDY SELECTION

Level I to III studies in which patients over the age of 18 years with acute tibial shaft fractures who underwent tibial IMN fixation using an IP or SP approach for fracture fixation were assessed for inclusion. Studies with a minimum of 10 patients in each cohort that reported on postoperative patient-reported outcomes with at least 6 months of follow-up were included for analysis.

DATA EXTRACTION AND SYNTHESIS

Twelve studies that reported PROMs and compared IP and SP intramedullary nailing of tibial shaft fractures were analyzed. This included 654 patients who underwent IP IMN fixation and 542 patients who underwent SP IMN fixation. A random-effects model for unadjusted/crude study estimates were pooled using inverse variance (IV) weighting for continuous variable analysis.

CONCLUSIONS

This review found a significant improvement in PROM for patients with tibial shaft fractures when the SP IMN technique was used. In addition, there was a significant decrease in intraoperative fluoroscopy time consistent with other radiographic findings demonstrating improved start point accuracy and reduction with SP IMN fixation of tibial shaft fractures.

LEVEL OF EVIDENCE

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

A Review of Proximal Tibia Entry Points for Intramedullary Nailing and Validation of The Lateral Parapatellar Approach as Extra-articular

Tibial shaft fractures are the most common long bone injury and are often treated surgically in an attempt to minimize complications. Although treatment options for tibial shaft fractures vary based on factors including open injury, severity of fracture, and soft tissue status, intramedullary nailing in adults has emerged as the preferred definitive option for stabilization. Therefore, the primary purposes of this review and cadaveric study were to evaluate the entry points for reamed tibial nails and the risks, benefits, and advantages of each approach. Due to concerns of violating the joint capsule and the generalized applicability to everyday practice of the extra-articular lateral parapatellar semi-extended technique, the secondary goal of this manuscript was to evaluate whether an intramedullary tibial nail can be consistently placed extra-articularly using the lateral parapatellar technique described by Kubiak et al. and generalizability to surgeons of varying experience.

Dilemma of Supra- or Infrapatellar Tibial Nailing: Anterior Knee Pain vs. Intra-Articular Damage

AIM

Intramedullary nailing (IMN) is widely accepted as the treatment of choice for tibial fractures, and a suprapatellar method has been described to prevent common problems associated with the typical infrapatellar IMN technique, such as anterior knee pain. However, in the suprapatellar technique, injury to intra-articular structures is a concern. The aim of this study was to compare the clinical and radiological results of suprapatellar and infrapatellar IMN in terms of union, complications, and function.

METHODS

A retrospective evaluation of 61 patients who had undergone suprapatellar (n = 29, Group A) or infrapatellar (n = 31, Group B) tibial IMN was conducted. For the suprapatellar group, magnetic resonance imaging scans were acquired on the sixth month follow-up. Complications, radiological findings, functional outcomes, surgery duration, and differences in a range of motion (ROM) were compared.

RESULTS

Surgery duration was significantly shorter in Group A (81 mins vs. 107 mins, p < 0.001), and visual analog scale (VAS) values were significantly higher in Group B (0.17 vs. 1.62, p < 0.001). In Group A, the patients' Lysholm scores were significantly higher (95.6 vs. 92, p=0.006). In terms of anterior knee pain, none was experienced in Group A (0%), while 11 patients (26.1%) reported about it in Group B. There were no statistically significant differences between the two groups in SF-36 score (p=0.925), the radiographic union scale in tibial (RUST) fractures score (p=0.454), union time (p=0.110), or ROM (p=0.691). In Group A, two cases of patellofemoral cartilage degeneration were observed.

CONCLUSION

If performed with sufficient expertise, the suprapatellar IMN technique is a safe, reliable technique with a low frequency of anterior knee pain for treating tibial fractures. There is no clear evidence that it causes damage to intra-articular structures. The possibility of patellofemoral cartilage degeneration due to this technique should be further evaluated by prospective studies including pre- and postoperative radiologic assessments.

Recovery of gait and function during the first six months after tibial shaft fractures

BACKGROUND

Tibial shaft fractures require surgical stabilization preferably by intramedullary nailing. Recovery is often unsatisfactory due to limited knee function and pain, resulting in reduced quality of life. The extent of these functional limitations with respect to gait deficits has not been sufficiently recognized.

RESEARCH QUESTION

Are there functional limitations during gait and squat performance during the first six months after surgically treated tibial shaft fractures?

METHODS

Twenty-three patients (BMI: 24 ± 3, Age:39 ± 15) with tibial shaft fractures and 23 healthy, matched controls (BMI: 24 ± 3, Age: 40 ± 14) were assessed using instrumented motion analysis two, three and six months after surgery. Kinematic and kinetic data of the lower extremities were collected during level walking and squat performance. Data were compared among follow-up time intervals and between groups.

RESULTS

Significant improvements were found for all spatiotemporal parameters and most kinetic parameters. Even six months after surgery functional deficits persisted when compared to healthy controls. There were only slight improvements in sagittal knee and ankle kinematics as well as knee moments and power within the follow-up period. A significant difference compared to the healthy controls can still be observed in these parameters.

SIGNIFICANCE

Although patients with tibia fractures demonstrated functional improvements over the early course of healing, some residual deficits in lower extremity movement biomechanics were identified at six months post surgery. In particular knee kinematics in squatting as well as knee kinematics and kinetics during walking only recovered incompletely. This result can help explain the often-reported functional limitations.

CLINICAL TRIAL REGISTRATION NUMBER

German register for clinical trials (DRKS00023790).

An Approach to Intraoperatively Identify the Coronal Plane Deformities of the Distal Tibia When Treating Tibial Fractures with Intramedullary Nail Fixation: a Retrospective Study

Objective

To develop a new approach to intraoperatively identify the presence of coronal plane deformities (both valgus and varus) when treating tibial fractures with closed reduction and intramedullary nail fixation.

Methods

A retrospective analysis was conducted by enrolling 33 consecutive patients with tibial fractures who received closed reduction and intramedullary nail fixation from January 2018 to January 2019 at our trauma center. Out of the 33 patients, 23 were males and 10 were females and the average age was 41 years (ranging 22 to 69 years of age). Standard anteroposterior and lateral preoperative radiographs were routinely performed. After intraoperatively inserting the tibial intramedullary nail through the standard entry point, the parallel relationship between the distal horizontal interlocking screw and the tibiotalar joint surface on the anteroposterior fluoroscopy was used to determine the occurrence of valgus or varus deformities of the distal tibial fragment. Radiographic and clinical outcomes were analyzed using the average interval from injury to surgery, the lateral distal tibial angle (LDTA) of the unaffected and affected sides, complications and the Olerud–Molander ankle score.

Results

All 33 patients were postoperatively followed for 13 to 25 months (mean 18.7 months). The fractures achieved bone union at an average of 4.3 months (ranging from 3 to 6 months). The total complication rate was 60.6% (20 cases), including four cases that showed deep vein thrombosis, one case showing an infection and delayed union and 15 cases showing slight to moderate anterior knee pain. The postoperative LDTA of the unaffected side measured 87.3° to 89.6 ° (average 88.7° ± 0.8°), and the LDTA of the affected side was 87.5° to 90.4° (average 88.9° ± 1.1°). There was no significant difference between the unaffected and affected sides (t = −1.865, P = 0.068). The intraoperative measurement indicated six cases of valgus angulation and three cases of varus angulation deformities, and all deformities were corrected during surgery. According to the Olerud–Molander ankle score, clinical outcomes demonstrated 22 excellent cases, eight good cases, two fair cases, and one poor case 12 months after surgery.

Conclusion

The parallel relationship between the distal horizontal interlocking screw and tibiotalar joint surface on intraoperative anteroposterior films were able to determine the onset of valgus or varus angulations of the distal tibial fragment in the fracture zone after the tibial intramedullary nail was inserted through the standard entry point.

Do Poller screws effect union in tibial shaft fractures treated with intramedullary nailing?

INTRODUCTION

Tibial shaft fractures are a commonly encountered challenge presented to orthopaedic trauma surgeons. Intramedullary nailing (IMN) is often the treatment of choice and whilst effective, complications of delayed and/or non-union can cause significant morbidity and necessitate additional operative procedures. The use of Poller screws during IMN are a recognised way of aiding fracture reduction, however the clinical benefits of this are debated. This study evaluated the outcome of tibial shaft fractures treated with IMN with or without the addition of Poller screws.

METHODS

Retrospective cohort study of all patients undergoing IMN following tibial shaft fractures over a 5-year period. 154 operated tibial shaft fractures were identified, with patients divided into 3 groups - Group 1: IM nailing alone, Group 2: IMN + 1 conventional Poller screw, or Group 3: IMN + 2 Poller screws placed Epicentrically across the fracture site. Data collected included demographics, length of stay, fracture type, position and AO classification grade, operative time, and operating surgeons' grade. Primary outcome measure was the incidence of delayed and/or non-union. Secondary outcomes were differences in rates of infection and additional orthopaedic procedures between the 3 groups.

RESULTS

Overall 139/154 fractures (90.3%) achieved a timely union. There was a statistically significant difference (p = 0.05) in fracture union between the 3 groups, with 75/88 fractures healing in group 1 (IMN alone) compared to 44/46 in Group 2 (IMN + 1 Poller screw) and 20/20 in group 3 (IMN + 2 Poller screws). There was no statistical difference in the incidence of superficial infection, (p = 0.95) additional procedures (p = 0.23) or deep infection (p = 0.65) between the 3 groups.

CONCLUSION

The addition of Poller screws appear to be a safe and effective adjunct in the treatment of tibial shaft fractures via IMN. Further prospective randomised trials are needed to fully elucidate both the role and potential benefits of Poller screw augmentation in acute lower limb fracture management.

[Prophylactic fasciotomy in tibial osteotomies: functional results]

Hintergrund

Bei Tibia-Osteotomien (TO) mit Marknagelfixierung kann eine minimal-invasive, prophylaktische Fasziotomie (PF) der Extensorenloge zur Prävention eines postoperativen akuten Kompartmentsyndroms (KS) erfolgen. Bislang sind keine Studien über die Effekte von TO oder PF auf spezifische Funktionen der Extensoren bekannt.

Ziel der Arbeit

Die Untersuchung der Funktion nach PF und TO an Patient*innen ohne präoperative funktionelle Einschränkung.

Material und Methoden

In 41 Fällen (28 Frauen, 13 Männer) erfolgte durchschnittlich 6,1 Jahre nach elektiver TO mit PF und Marknagelfixierung eine Befragung zur klinischen Funktion. In 23 Fällen wurden die isometrische Kraft und der „range of motion“ (ROM) der Dorsalextension (DE) des oberen Sprunggelenks (OSG) gemessen. Die Kraft wurde als Test auf klinische Relevanz mit der 10 %-Normperzentile verglichen, sowie zur Gegenseite.

Ergebnisse

In durchschnittlich 86 % der Fälle wurde von keinen oder geringen funktionellen Einschränkungen der Extensoren berichtetet. Die mittlere Kraft zeigte keine signifikante Abweichung von der geschlechterspezifischen 10 %-Normperzentile, aber war im Seitenvergleich auf der operierten Seite mit 16,0 ± 6,5 kgf signifikant geringer als auf der Gegenseite mit 17,5 ± 6,3 kgf (p < 0,01). Die subjektive Einschränkung der DE im OSG korrelierte deutlich negativ mit der ROM (r_s = −0,46, p < 0,05).

Diskussion

Die Ergebnisse lassen auf eine geringe Häufigkeit subjektiv relevanter funktioneller Einschränkungen der Extensoren schließen. Die vorgefundene Kraftminderung war nicht klinisch relevant. Subjektive Einschränkungen scheinen vorrangig durch Abnahme des ROM verursacht zu sein.

Tibial alignment following intramedullary nailing via three approaches

PURPOSE

The purpose of this study is to evaluate the incidence of malalignment in patients undergoing IMN for tibial shaft fractures treated with the extra-articular lateral parapatellar, suprapatellar, and infrapatellar approaches.

METHODS

A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical centre. Quality of reduction was assessed using the following three parameters: (1) < 10°of angulation in orthogonal radiographic views (2) < 5 mm of displacement between the major fracture fragments (3) < 5 mm of gap between the major fracture fragments. A good reduction was one that met all 3 criteria, an acceptable reduction met 2 criteria, and a bad reduction met one or none of the criteria. All patients treated consecutively for tibial shaft fractures between June 1, 2019 and June 1, 2020 were identified. The final cohort included 57 tibia fractures in 56 patients. Of the 57 tibia fractures, 8 (14%) were proximal third, 32 (56%) were middle third, and 17 (30%) were distal third fractures.

RESULTS

We found no significant difference in angulation, displacement, or gapping with respect to surgical approach utilized or location of fracture (proximal or distal tibia fractures) on one-way ANOVA. Quality of reduction was rated as "good" in 48 (84%) of the cases (19 supra, 13 infra, and 16 lateral). Nine reductions (16%) met only two of the three reduction quality criteria and were considered acceptable reductions. These included 2 suprapatellar (1 > 5 mm displacement, 1 > 5 mm gapping), 4 infrapatellar (4 > 5 mm displacement), and 3 lateral extra-articular parapatellar (2 > 5 mm displacement and 1 > 5 mm gapping). No reductions were determined to be bad according the Baumgaertner et al. criteria. There was no significant difference in the rate of combined fibula fractures or the rate of fibular fixation between the three cohorts.

CONCLUSIONS

In conclusion, no significant difference was found in fracture reduction angulation, displacement, and gapping in patients treated with an IMN with respect to approach for diaphyseal or metadiaphyseal tibial shaft fractures.

Large Individual Bilateral Differences in Tibial Torsion Impact Accurate Contralateral Templating and the Evaluation of Rotational Malalignment

OBJECTIVE

To determine individual bilateral differences (IBDs) in tibial torsion in a diverse population.

METHODS

Computed tomography scans of uninjured bilateral tibiae were used to determine tibial torsion and IBDs in torsion using 4 measurement methods. Age, sex, and self-identified race/ethnicity were also recorded for each subject. Mean tibial torsion and IBDs in torsion were compared in the overall cohort and when stratified by sex and race/ethnicity. Simple and multiple linear regression models were used to correlate demographic variables with tibial torsion and IBDs in torsion.

RESULTS

One hundred ninety-five patients were evaluated. The mean tibial torsion was 27.5 ± 8.3 degrees (range -3 to 47.5 degrees). The mean IBD in torsion was 5.3 ± 4.0 degrees (range 0-23.5 degrees, P < 0.001). 12.3% of patients had IBDs in torsion of ≥10 degrees. In the regression analysis, patients who identified as White had greater average torsion by 4.4 degrees compared with Hispanic/Latinx patients (P = 0.001), whereas age and sex were not significantly associated with absolute torsion. Demographics were not associated with significant differences in IBDs in torsion.

CONCLUSIONS

Tibial torsion varies considerably and individual side-to-side differences are common. Race/ethnicity was associated with differences in the magnitude of tibial torsion, but no factors were associated with bilateral differences in torsion. The results of this study may be clinically significant in the context of using the uninjured contralateral limb to help establish rotational alignment during medullary nail stabilization of diaphyseal tibia fractures. In addition, these findings should be considered in the evaluation of tibia rotational malalignment.

LEVEL OF EVIDENCE

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

Results following prolonged recovery show satisfactory functional and patient-reported outcome after intramedullary nailing of a tibial shaft fracture: a prospective 5-year follow-up cohort study

INTRODUCTION

Although a large number of previous studies have investigated the outcome in patients following tibial shaft fractures, the literature provides limited information on prospectively reported patients with mid- to long-term follow-up. The present study aimed to investigate prospectively the 5-year development in patient-reported quality of life after intramedullary nailing of a tibial shaft fracture.

MATERIAL AND METHODS

The design was a prospective, 5-year follow-up cohort study. Quality of life (QOL) was measured with the questionnaire Eq5d-5L and compared to the 1-year outcome reported by the same patients. Secondary outcome measurements were the Knee Injury and Osteoarthritis Outcome Score (KOOS), recordings of pain, gait and muscle strength.

RESULTS

Twenty-nine patients were eligible for participation. Mean patient age at the time of the 5-year follow-up was 46.3 years. The 5-year postoperative mean Eq5d-5L index was 0.864 (95% CI 0.809-0.918). The mean Eq5d-5L VAS was 88.4 (95% CI 83.4-93.5). Compared with the same patients' Eq5d-5L index scores at the 1-year follow-up (0.784), a significant increase was observed (P = 0.014). A comparison to the Danish Eq.5D reference population showed no statistically significant difference.

CONCLUSIONS

Patient-reported quality of life among patients treated with intramedullary nailing following a tibial shaft fracture increased significantly between the 1-year and 5-year follow-up. In contrast to the 1-year patient-reported quality of life, results are comparable to those of a reference population at the 5-year follow-up. In a clinical setting, these results highlight that patients may expect a prolonged period to recover. However, of most importance is that patients can expect a satisfactory outcome years after fracture and treatment.

Difference in Pain, Complication Rates, and Clinical Outcomes After Suprapatellar Versus Infrapatellar Nailing for Tibia Fractures? A Systematic Review of 1447 Patients

OBJECTIVES

To assess the effectiveness of suprapatellar (SP)-nailing versus infrapatellar (IP)-nailing of tibia fractures in anterior knee pain, complications (retropatellar chondropathy, infection, and malalignment) and physical functioning and quality of life. A clinical question-driven and thorough systematic review of current literature is provided.

DATA SOURCE

PubMed and Embase databases were searched for studies published between 2010 and 2020 relating to SP and IP-nailing of tibia fractures. The study is performed in concordance with PRISMA-guidelines.

STUDY SELECTION

Studies eligible for inclusion were randomized controlled trials, prospective and retrospective observational studies reporting on outcomes of interest.

DATA EXTRACTION

Data extraction was performed independently by 2 assessors. Methodological quality and risk of bias was assessed according to the guidelines of the McMaster Critical Appraisal.

DATA SYNTHESIS

Continuous variables are presented as means with SD and dichotomous variables as frequency and percentages. The weighted mean, standardized weighted mean differences, and 95% confidence interval were calculated. A pooled analysis could not be performed because of differences in outcome measures, time-points, and heterogeneity.

RESULTS

Fourteen studies with 1447 patients were analyzed. The weighted incidence of anterior knee pain was 29% after SP-nailing and 39% after IP-nailing, without reported significance. There was a significant lower rate of malalignment after the SP-approach (4% vs. 26%) with small absolute differences in all planes. No substantial differences were observed in retropatellar chondropathy, infection, physical functioning, and quality of life.

CONCLUSIONS

This systematic review does not reveal superiority of either technique in any of the respective outcomes of interest. Definitive choice should depend on the surgeon's experience and available resources.

LEVEL OF EVIDENCE

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

Radiographic cortical thickness parameters as predictors of rotational alignment in proximal tibial shaft fractures: a cadaveric study

AIM

The treatment of tibial fractures with an intramedullary nail is an established procedure. However, torsional control remains challenging using intraoperatively diagnostic tools. Radiographic tools such as the Cortical Step Sign (CSS) and the Diameter Difference Sign (DDS) may serve as tools for diagnosing a relevant malrotation. The aim of this study was to investigate the effect of torsional malalignment on CSS and DDS parameters and to construct a prognostic model to detect malalignment.

METHODS

A proximal tibial shaft fracture was set in human tibiae. Torsion was set stepwise from 0° to 30° in external and internal torsion. Images were obtained with a C-arm and transferred to a PC for measuring the medical cortical thickness (MCT), lateral cortical thickness (LCT), tibial diameter (TD) in AP and the anterior cortical thickness (ACT) as well as the posterior cortical thickness (PCT) and the transverse diameter (TD) of the proximal and the distal main fragment.

RESULTS

There were significant differences between the various degrees of torsion for each of the absolute values of the examined variables. The parameters with the highest correlation were TD, LCT and ACT. A model combining ACT, LCT, PCT and TD lateral was most suitable model in identifying torsional malalignment. The best prediction of clinically relevant torsional malalignment, namely 15°, was obtained with the TD and the ACT.

CONCLUSION

This study shows that the CSS and DDS are useful tools for the intraoperative detection of torsional malalignment in proximal tibial shaft fractures and should be used to prevent maltorsion.

Saphenous Nerve Entrapment Neuropathy After Closed Tibial Fracture: A Case Report

CASE

A 43-year-old man who underwent intramedullary nailing for a closed tibial fracture developed saphenous nerve entrapment neuropathy. He developed severe medial leg pain, which was worse on walking or standing, 2 years postoperatively. Surgical neurolysis resulted in complete pain relief and functional recovery of the limb without recurrence of symptoms.

CONCLUSION

Clinicians should consider several etiologies in the diagnostic evaluation of a patient with chronic pain after limb trauma. If a patient complains of lower extremity pain after intramedullary fixation of closed fractures of the tibial shaft, the possibility of saphenous nerve entrapment neuropathy should be considered.

Smoking, Obesity, and Disability Benefits or Litigation Are Not Associated with Clinically Important Reductions in Physical Functioning After Intramedullary Nailing of Tibial Shaft Fractures: A Retrospective Cohort Study

BACKGROUND

Forty percent of long bone fractures involve the tibia. These fractures are associated with prolonged recovery and may adversely affect patients' long-term physical functioning; however, there is limited evidence to inform what factors influence functional recovery in this patient population.

QUESTION/PURPOSE

In a secondary analysis of a previous randomized trial, we asked: What fracture-related, demographic, social, or rehabilitative factors were associated with physical function 1 year after reamed intramedullary nailing of open or closed tibial shaft fractures?

METHODS

This is a secondary (retrospective) analysis of a prior randomized trial (Trial to Re-evaluate Ultrasound in the Treatment of Tibial Fractures; TRUST trial). In the TRUST trial, 501 patients with unilateral open or closed tibial shaft fractures were randomized to self-administer daily low-intensity pulsed ultrasound or use a sham device, of which 15% (73 of 501) were not followed for 1 year due to early study termination as a result of futility (no difference between active and sham interventions). Of the remaining patients, 70% (299 of 428) provided full data. All fractures were fixed using reamed (298 of 299) or unreamed (1 of 299) intramedullary nailing. Thus, we excluded the sole fracture fixed using unreamed intramedullary nailing. The co-primary study outcomes of the TRUST trial were time to radiographic healing and SF-36 physical component summary (SF-36 PCS) scores at 1-year. SF-36 PCS scores range from 0 to 100, with higher scores being better, and the minimum clinically important difference (MCID) is 5 points. In this secondary analysis, based on clinical and biological rationale, we selected factors that may be associated with physical functioning as measured by SF-36 PCS scores. All selected factors were inserted simultaneously into a multivariate linear regression analysis.

RESULTS

After adjusting for potentially confounding factors, such as age, gender, and injury severity, we found that no factor showed an association that exceeded the MCID for physical functioning 1 year after intramedullary nailing for tibial shaft fractures. The independent variables associated with lower physical functioning were current smoking status (mean difference -3.0 [95% confidence interval -5 to -0.5]; p = 0.02), BMI > 30 kg/m2 (mean difference -3.0 [95% CI -5.0 to -0.3]; p = 0.03), and receipt of disability benefits or involvement in litigation, or plans to be (mean difference -3.0 [95% CI -5.0 to -1]; p = 0.007). Patients who were employed (mean difference 4.6 [95% CI 2.0 to 7]; p < 0.001) and those who were advised by their surgeon to partially or fully bear weight postoperatively (mean difference 2.0 [95% CI 0.1 to 4.0]; p = 0.04) were associated with higher physical functioning. Age, gender, fracture severity, and receipt of early physical therapy were not associated with physical functioning at 1-year following surgical fixation.

CONCLUSION

Among patients with tibial fractures, none of the factors we analyzed, including smoking status, receipt of disability benefits or involvement in litigation, or BMI, showed an association with physical functioning that exceeded the MCID.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Infrapatellar versus suprapatellar approach for intramedullary nailing of the tibia: a systematic review and meta-analysis

BACKGROUND

Intramedullary nailing (IMN) is a conventional technique for the treatment of tibial shaft fractures. It has been suggested that the suprapatellar (SP) approach holds advantages over the traditional infrapatellar (IP) approach. Current literature lacks adequate data to provide robust clinical recommendations. This meta-analysis aims to determine the efficacy of infrapatellar versus suprapatellar techniques for IMN.

METHODS

An up-to-date literature search of the Embase, Medline, and registry platform databases was performed. The search was conducted using a predesigned search strategy and all eligible literature was critically appraised for methodological quality via the Cochrane's collaboration tool. Fluoroscopy time, operative time, pain score, knee function, deep infection, non-union and secondary operation rates were all considered.

CONCLUSION

A total of twelve studies were included in the meta-analysis. The results of this analysis show that suprapatellar nailing is associated with reduced post-operative pain scores and improved functional outcomes. The data suggest no significant difference in terms of operative times, fluoroscopy times, rates of deep infection, non-union or secondary procedures when compared to infra-patellar techniques. Further studies are required to confirm these findings and assess long-term results.

Long-Term Patient-Reported Knee Outcomes After Suprapatellar Intramedullary Tibial Nailing

BACKGROUND

Suprapatellar nailing of tibial fractures has not been shown to affect short-term knee outcomes, however long-term outcomes are unknown. The purpose of this study was to report long-term patient-reported knee outcomes after suprapatellar nailing.

METHODS

Thirty-five adult patients with 37 tibial shaft fractures treated with suprapatellar nailing completed the Tegner-Lysholm Knee Score (TLKS) at an average of 5 years (range, 4-9 years) follow-up.

RESULTS

The median TLKS was 98 (interquartile range, 85-100): Scores were considered excellent in 24 (68%), good in 3 (9%), fair in 3 (9%), and poor in 5 (14%). Based on patient responses, 28 (80%) patients did not have a limp, 32 (91%) ambulated without assistance, 22 (63%) were pain free, 29 (83%) had no knee instability, 30 (86%) endorsed no catching or locking, 27 (77%) could climb stairs with no issue, and 24 (69%) had no problems with squatting. Patients with poor/fair outcomes on the TLKS were more likely to have had a complication [3 (38%) vs. 1 (4%), difference 34%, 95% confidence interval 1-65%] and had no detectable difference in age, gender, open fracture, fracture classification, or worker's compensation.

CONCLUSION

At long-term follow-up a majority of patients undergoing suprapatellar nailing had good/excellent knee outcomes. Poor/fair knee outcomes were associated with the development of complications.

LEVEL OF EVIDENCE

III, Retrospective cohort study.

Prognostic factors for predicting health-related quality of life after intramedullary nailing of tibial fractures: a randomized controlled trial

Aims

Using tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery.

Methods

The Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trial examined adults with an open or closed tibial shaft fracture who were treated with either reamed or unreamed intramedullary nails. HRQoL was assessed at hospital discharge (for pre-injury level) and at 12 months post-fracture using the Short Musculoskeletal Functional Assessment (SMFA) Dysfunction, SMFA Bother, 36-Item Short Form 36 (SF-36) Physical, and SF-36 Mental Component scores. We used multiple linear regression analysis to determine if baseline and surgical factors, as well as post-intervention procedures within one year of fracture, were associated with these HRQoL outcomes. Significance was set at p < 0.01. We hypothesize that, irrespective of the four measures used, prognosis is guided by both modifiable and non-modifiable factors and that patients do not return to their pre-injury level of function, nor HRQoL.

Results

For patient and surgical factors, only pre-injury quality of life and isolated fracture showed a statistical effect on all four HRQoL outcomes, while high-energy injury mechanism, smoking, and race or ethnicity, demonstrated statistical significance for three of the four HRQoL outcomes. Patients who did not require reoperation in response to infection, the need for bone grafts, and/or the need for implant exchanges had statistically superior HRQoL outcomes than those who did require intervention within one year after initial tibial fracture nailing.

Conclusion

We identified several baseline patient factors, surgical factors, and post-intervention procedures within one year after intramedullary nailing of a tibial shaft fracture that may influence a patient’s HRQoL.

Cite this article: Bone Jt Open 2021;2(1):22–32.

Intraoperative torsion control using the cortical step sign and diameter difference in tibial mid-shaft fractures

AIM

Intramedullar nailing of tibial mid-shaft fractures is a common surgical treatment. Fracture reduction, however, remains challenging and maltorsion is a common discrepancy which aggravates functional impairment of gait and stability. The use of radiographic tools such as the cortical step sign (CSS) and the diameter difference sign (DDS) could improve fracture reduction. Therefore, the validity of the CSS and DDS was analyzed to facilitate detection of maltorsion in tibial mid-shaft fractures.

METHODS

Tibial mid-shaft fractures were induced in human cadaveric tibiae according to the AO classification type A3. Torsional discrepancies from 0° to 30° in-/external direction were enforced after intramedullary nailing. Fluoroscopic-guided fracture reduction was assessed in two planes via analysis of the medical cortical thickness (MCT), lateral cortical thickness (LCT), tibial diameter (TD), anterior cortical thickness (ACT), posterior cortical thickness (PCT) and the transverse diameter (TD) of the proximal and distal fracture fragment.

RESULTS

The TD, LCT and ACT have shown a highly significant correlation to predict tibial maltorsion. While a model combining ACT, LCT, PCT and TD lateral was most suitable model to identify tibial maltorsion, a torsional discrepancy of 15°was most reliably detected with use of the TD and ACT.

CONCLUSION

The present study has shown, that maltorsion can be reliably assessed by the CSS and DDS during fluoroscopy. Thus, torsional discrepancies in tibial mid-shaft fractures can be most reliably assessed in the lateral plane by analysis of the LCT and TD.

Comparison between infrapatellar and suprapatellar approaches for intramedullary nailing for the fractures of the tibial shaft

INTRODUCTION

This study aimed to compare the outcomes at the clinical and functional levels of suprapatellar (SP) and infrapatellar (IP) approaches for intramedullary nailing in treating tibial shaft fracture.

METHODS

Patients who underwent tibial shaft fracture intramedullary nailing by the SP approach or IP approach in a trauma center were retrospectively reviewed. The demographics, intraoperative fluoroscopy time, operation time, blood loss, irrigation volume, postoperative X-ray alignment, and complications of patients were compared between the two groups under different approaches. Lysholm knee score, visual analog score (VAS), and incidence of anterior knee pain (AKP) were assessed 1 year after surgery.

RESULTS

The study finally included well-documented 81 patients (38 SP versus 43 IP). The SP group exhibited significantly shorter intraoperative fluoroscopy time than that of the IP group (81.7 ± 14.5 s vs. 122.0 ± 24.3 s, P < 0.001). Both aspects recorded a precise reduction of the fracture: angulation (2.1 ± 1.2° vs 3.1 ± 1.5°, P < 0.05) and translation (0.6 ± 0.8 mm vs 1.4 ± 1.5 mm, P < 0.05) in the coronal plane in the SP group. However, the sagittal plane recorded no such change (P > 0.05). The Lysholm knee score was higher in the SP group than that of the IP group (87 ± 8 vs. 80 ± 15, P < 0.05). The SP group displayed an evidently lower average VAS score than that of the IP approach group (0.3 ± 0.8 vs 1.3 ± 1.4, P < 0.001). Six cases (16%) in the SP group and 16 cases (37%) in the IP group experienced AKP 1-year post-operation (P < 0.05). As far as complications are concerned, neither group showed any significant difference (P > 0.05).

CONCLUSION

Compared with the IP approach, the application of intramedullary nailing through the SP approach in treating tibial shaft fractures can effectively shorten the intraoperative fluoroscopy time, correct coronal plane angulation and translation deformity, reduce the incidence of AKP and improve postoperative function.

Taylor Spatial Frame or Reamed Intramedullary Nailing for Closed Fractures of the Tibial Shaft: A Randomized Controlled Trial

OBJECTIVES

To compare a modern ring fixator [Taylor Spatial Frame (TSF)] and reamed intramedullary nailing (IMN) for the treatment of closed tibial shaft fractures.

DESIGN

Randomized controlled trial.

SETTING

Two university hospitals.

PATIENTS

Patients between 18 and 70 years of age surgically treated for an acute tibial shaft fracture.

INTERVENTION

TSF (n = 31) versus a reamed intramedullary nail (n = 32). The patients were followed up for 2 years.

MAIN OUTCOME MEASUREMENTS

The physical component summary of Short Form 36 (SF-36) at 2 years was the primary outcome measure. Secondary outcomes included the other components of the SF-36, pain assessed by a visual analogue scale (VAS), complications, and resource consumption.

RESULTS

The mean age was 43 years (SD 14.0), and 42 (67%) were men. The physical component summary at 2 years was 52.4 (SD 6.3) in the TSF group and 53.3 (SD 8.0) in the IMN group (P = 0.35). There were modest differences in the other SF-36 scores during the follow-up period. Up to and including 12 months, the TSF group had less knee pain [at 12 months: VAS 0.5 (SD 1.2) vs. VAS 2.4 (SD 2.2; P < 0.001)], but this was not statistically significant at 24 months [VAS 0.7 (SD 1.4) vs. VAS 1.5 (SD 2.0; P = 0.11)]. Superficial skin infections were more frequent in the TSF group [22 (71%) vs. 4 (13%); P < 0.001]. The number of other complications was similar between the groups.

CONCLUSIONS

Both TSF and IMN provided good clinical results. TSF had more pin-track infections but less knee pain the first year.

LEVEL OF EVIDENCE

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

Minimally invasive plate osteosynthesis for short oblique diaphyseal tibia fractures: does fracture site affect the outcomes?

OBJECTIVE

To report the results of patients with short oblique diaphyseal tibia fractures treated with minimally invasive plate osteosynthesis (MIPO). The secondary aim was to understand the effect of fracture location (midshaft or distal 1/3) on outcomes.

METHODS

Twenty-eight patients with short oblique (>30°) tibial shaft fractures (AO/OTA 42A2) treated with plate and MIPO technique between 2015 and 2019 were retrospectively assessed. Age, gender, follow-up time, fracture type (open or closed), operation time, postoperative infection rate, union time, ankle joint range of motion, and complications were analyzed. Patients' radiographs at a minimum 1-year follow-up were evaluated for malunion, nonunion, and implant-related complications.

RESULTS

Mean age and follow-up time were 47.0 ± 15.7 years and 18.3 ± 12.1 months, respectively. Mean bone union time was 3.66 ± 1.04 months in middle 1/3 diaphysis and 4.23 ± 1.48 months in distal 1/3 tibia fractures. Seven (25%) patients developed superficial infections. Mean union time, malunion rate, coronal and sagittal angulation, operation length, and infection rate were similar between the groups.

CONCLUSION

MIPO is an effective method for treatment of short oblique diaphyseal tibia fractures, and results in few complications. Both distal and midshaft fractures have similar union and malunion rates.

Supra-patellar nailing for isolated closed tibial shaft fractures: Medium term functional outcomes from an Academic Level 1 Trauma centre

Aims The aim of this study was to assess functional outcome, at medium-term follow up, in patients undergoing intra-medullary nailing of tibial shaft fractures, using the supra-patellar approach. Materials and methods The study included patients with intra-medullary nailing, for diaphysial tibia fractures, between March 2013 to August 2015. An initial audit compared short-term functional outcomes at 15 months, between the supra and infra-patellar approaches, using a cohort of 20 patients (10 in each group). Subsequently, a larger cohort of 22 patients with supra-patellar nailing, were reviewed for medium term assessment of their functional outcomes at average 60 months (50 - 78 months) and the results between all 3 groups were compared. All patients were assessed using the Kujala and Oxford Knee Scores. Results The mean age of the cohorts was 38 years (18-87years). The mean follow-up was 15 months for the initial audit and 60 months for the medium-term results. The initial audit showed that the supra-patellar group had statistically significantly better Oxford and Kujala scores when compared to infra-patellar group (p < 0.05). At 5 years following supra-patellar nailing, the medium-term cohort showed improved outcome scores compared to the infra-patellar group at 1 year (p < 0.01) but showed no difference with the supra-patellar group at 1 year (p value >0.1). Conclusion Our study suggests that patients undergoing supra-patellar tibial nailing have better outcomes at 15 months compared to traditional infra-patellar nailing and more importantly, they continue to do well even at 5 years, despite perceived risks associated with this technique.

Suprapatellar versus infrapatellar approaches in the treatment of tibia intramedullary nailing: a retrospective cohort study

Background

Tibial shaft fractures are routinely managed with intramedullary nailing (IMN). An increasingly accepted technique is the suprapatellar (SP) approach. The purpose of this study was to compare the clinical and functional outcomes of knee joint after tibia IMN through an suprapatellar (SP) or traditional infrapatellar (IP) approach.

Methods

Retrospective analysis was performed in patients with tibial shaft fractures that were treated with IMN through a SP or IP approach between 01/01/2014 and 31/12/2016. The clinical and functional outcomes of the knee were assessed with the Hospital for Special Surgery (HSS) Knee Score. Secondary outcomes included the operation time and intraoperative blood loss.

Results

A total of 50 patients/fractures (26 IP and 24 SP) with a minimum follow-up of 15 months were evaluated. All fractures were OTA 42. No significant differences were found between the two groups in age, gender, side of fractures, operation time, intra-operative blood loss, and follow-up time. No significant difference was seen in HSS score (P = 0.62) between them. Sub analysis of all the HSS components scores revealed no significant differences between pain (P = 0.57), the stand and walk (P = 0.54), the need for walking stick (P = 0.60) and extension lag (P = 0.60). The other HSS components showed full scores (IP 10 vs. SP 10) in both approaches, including muscle force, flexion deformity and stability components. The range of motion (ROM) component score was superior in the IP group (P = 0.04) suggesting a higher ROM.

Conclusions

Both SP and IP approach results in equivalent overall HSS knee scores. However, for the HSS component, the IP approach was superior to SP approach regarding the ROM.