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Lee JW, Byun SE, Kim YW, Byun YS, Yoon YC, Sohn HS. Fibular Fixation in Same-Level Distal Third Tibiofibular Fractures: Is Fibular Fracture Regarded as a Secondary Importance? Clin Orthop Surg 2023; 15:704-710. [PMID: 37811504 PMCID: PMC10551684 DOI: 10.4055/cios23036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/19/2023] [Accepted: 06/01/2023] [Indexed: 10/10/2023] Open
Abstract
Background Although most studies focused on the alignment or union of the tibia in same-level distal third tibiofibular fractures, the outcome of a concomitant fibular fracture is generally regarded as being of secondary importance in the literature. This study aimed to assess the outcomes of fibular fractures in same-level distal third tibiofibular fractures. Methods In this retrospective study, we enrolled 111 patients with same-level distal third tibiofibular fractures treated at our institute between January 2016 and August 2020. Tibial fractures were stabilized with intramedullary nailing, and the cases were divided into two groups based on whether they additionally underwent fibular fixation (group 1, 57 cases) or not (group 2, 54 cases). Clinical and radiographic outcomes were used for the evaluation of tibial and fibular alignments, union of the tibia and fibula, number of interlocking screws in the distal tibial fragment, range of motion of the ankle joint, and complications. Results No statistically significant differences in the tibial union rate or mean tibial alignment were observed between the two groups on either the immediate postoperative or final radiographs. The fibular union rate in group 1 was significantly higher than that in group 2 (fibular nonunion, 0 vs. 15; p < 0.001). Statistically significant differences in fibular displacement were observed on immediate postoperative radiographs between patients with fibular union and those without it. At the final follow-up, the mean range of ankle motion and lower extremity functional scale scores did not differ between the two groups. Conclusions Regardless of whether fibular fixation was performed, the overall tibial alignment with intramedullary nailing was well restored and the union rate of the tibia was comparable in the two groups. Fibular nonunion is not uncommon in unfixed fibula fractures. Displacement of the fibula as seen on immediate postoperative radiographs was related to fibular nonunion.
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Affiliation(s)
- Jin-Woo Lee
- Department of Orthopaedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seong-Eun Byun
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Young-Woo Kim
- Department of Orthopaedic Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Young-Soo Byun
- Department of Orthopaedic Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Yong-Cheol Yoon
- Department of Orthopaedic Surgery, Gachon University Gil Hospital, Incheon, Korea
| | - Hoon-Sang Sohn
- Department of Orthopaedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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John M, Mir HR. Extreme nailing and immediate weight bearing constructs in fractures of the distal tibia. OTA Int 2022; 5:e180. [PMID: 37781481 PMCID: PMC10538524 DOI: 10.1097/oi9.0000000000000180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/18/2021] [Indexed: 10/03/2023]
Abstract
Extraarticular fractures of the distal tibia can present as difficult but manageable lower extremity injuries. Historically, these injuries have been fixed in a myriad of ways. Early management with intramedullary nailing had higher complication rates due to the unique anatomical and biomechanical features of the distal tibia. Modern improvements in intramedullary nailing surgical techniques and implant design have significantly decreased complication rates and led to improvement in patient outcomes. Many surgeons protect weight bearing postoperatively, but recent literature suggests that patients may safely weight bear immediately following intramedullary fixation. This article reviews technique and implant design changes that have facilitated immediate safe weight bearing following intramedullary nailing of extraarticular distal tibia fractures.
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Affiliation(s)
- Mitchell John
- University of South Florida, Department of Orthopaedic Surgery
| | - Hassan R Mir
- University of South Florida, Department of Orthopaedic Surgery
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL
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Braun BJ, Orth M, Diebels S, Wickert K, Andres A, Gawlitza J, Bücker A, Pohlemann T, Roland M. Individualized Determination of the Mechanical Fracture Environment After Tibial Exchange Nailing-A Simulation-Based Feasibility Study. Front Surg 2021; 8:749209. [PMID: 34660686 PMCID: PMC8511819 DOI: 10.3389/fsurg.2021.749209] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/01/2021] [Indexed: 01/08/2023] Open
Abstract
Non-union rate after tibial fractures remains high. Apart from largely uncontrollable biologic, injury, and patient-specific factors, the mechanical fracture environment is a key determinant of healing. Our aim was to establish a patient-specific simulation workflow to determine the mechanical fracture environment and allow for an estimation of its healing potential. In a referred patient with failed nail-osteosynthesis after tibial-shaft fracture exchange nailing was performed. Post-operative CT-scans were used to construct a three-dimensional model of the treatment situation in an image processing and computer-aided design system. Resulting forces, computed in a simulation-driven workflow based on patient monitoring and motion capturing were used to simulate the mechanical fracture environment before and after exchange nailing. Implant stresses for the initial and revision situation, as well as interfragmentary movement, resulting hydrostatic, and octahedral shear strain were calculated and compared to the clinical course. The simulation model was able to adequately predict hardware stresses in the initial situation where mechanical implant failure occurred. Furthermore, hydrostatic and octahedral shear strain of the revision situation were calculated to be within published healing boundaries—accordingly the fracture healed uneventfully. Our workflow is able to determine the mechanical environment of a fracture fixation, calculate implant stresses, interfragmentary movement, and the resulting strain. Critical mechanical boundary conditions for fracture healing can be determined in relation to individual loading parameters. Based on this individualized treatment recommendations during the early post-operative phase in lower leg fractures are possible in order to prevent implant failure and non-union development.
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Affiliation(s)
- Benedikt J Braun
- University Hospital Tuebingen on Behalf of the Eberhard-Karls-University Tuebingen, Faculty of Medicine, BG Hospital Tuebingen, Tuebingen, Germany
| | - Marcel Orth
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Stefan Diebels
- Department of Applied Mechanics, Saarland University, Saarbruecken, Germany
| | - Kerstin Wickert
- Department of Applied Mechanics, Saarland University, Saarbruecken, Germany
| | - Annchristin Andres
- Department of Applied Mechanics, Saarland University, Saarbruecken, Germany
| | - Joshua Gawlitza
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Arno Bücker
- Clinic of Diagnostic and Interventional Radiology, Saarland University Hospital, Homburg, Germany
| | - Tim Pohlemann
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Michael Roland
- Department of Applied Mechanics, Saarland University, Saarbruecken, Germany
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Peng J, Long X, Fan J, Chen S, Li Y, Wang W. Concomitant Distal Tibia-Fibula Fractures Treated with Intramedullary Nailing, With or Without Fibular Fixation: A Meta-Analysis. J Foot Ankle Surg 2021; 60:109-113. [PMID: 33218862 DOI: 10.1053/j.jfas.2020.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 04/15/2020] [Accepted: 05/04/2020] [Indexed: 02/03/2023]
Abstract
There is no consensus on whether a fibular fracture should be fixed when a concurrent extra-articular distal tibia fracture is managed with intramedullary nails. We evaluated the use of fibular fixation in a meta-analysis of randomized trials and observational studies. Two researchers independently assessed the quality of eligible studies and extracted the data. We analyzed 4 trials with a pooled sample of 283 patients (mean age, 24 to 43 years; 141 men), 94 who had undergone fibular fixation and 189 who had not. Two randomized trials assessed on the Cochrane risk-assessment criteria were determined to have a moderate risk of bias, and 2 retrospective cohort studies evaluated with the Newcastle-Ottawa Scale were considered to be high quality. Tibia malalignment at follow-up times ranging from 12 to 72 weeks was reported in 20% (19/94) of patients in the fibular-fixation group and 67% (126/189) of patients in the nonfixation group, indicating that fibular fixation was significantly associated with a lower risk of malalignment (risk ratio, 0.34; 95% confidence interval [CI] 0.13 to 0.92; p = .03). The groups did not differ in the proportion of patients with malalignment immediately after surgery, delayed union, nonunion, or infection. When distal extra-articular tibia-fibular fractures are treated with intramedullary nails, fibular fixation may decrease the risk of late malalignment. Further randomized controlled trials with higher quality are required to verify the result.
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Affiliation(s)
- Jing Peng
- Surgeon, Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China
| | - Xiaotao Long
- Surgeon, Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China
| | - Jun Fan
- Surgeon, Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China.
| | - Shiyang Chen
- Surgeon, Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China
| | - Yang Li
- Surgeon, Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China
| | - Wei Wang
- Surgeon, Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China
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The Role of Fibular Fixation in Distal Tibia-Fibula Fractures: A Meta-Analysis. Adv Orthop 2021; 2021:6668467. [PMID: 33708447 PMCID: PMC7932767 DOI: 10.1155/2021/6668467] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/09/2021] [Accepted: 02/19/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The necessity of fibular fixation in distal tibia-fibula fractures remains controversial. This study aimed to assess its impact on radiographic outcomes as well as rates of nonunion and infection. METHODS A systematic search of the electronic databases of PubMed, Embase, and Cochrane library was performed to identify studies comparing the outcomes of reduction and internal fixation of the tibia with or without fibular fixation. Radiographic outcomes included malalignment and malrotation of the tibial shaft. Data regarding varus/valgus angulation, anterior/posterior angulation, internal/external rotation deformity, and the rates of nonunion and infection were extracted and then polled. A meta-analysis was performed using the random-effects model for heterogeneity. RESULTS Additional fibular fixation was statistically associated with a decreased rate of rotation deformity (OR = 0.13; 95% CI 0.02-0.82, p=0.03). However, there was no difference in the rate of malreduction between the trial group and the control group (OR = 0.86; 95% CI 0.27-2.74, p=0.80). There was also no difference in radiographic outcomes of varus-valgus deformity rate (OR = 0.17; 95% CI 0.03-1.00, p=0.05) or anterior-posterior deformity rate (OR = 0.76; 95% CI 0.02-36.91, p=0.89) between the two groups. Meanwhile, statistical analysis showed no significant difference in the nonunion rate (OR = 0.62; 95% CI 0.37-1.02, p=0.06) or the infection rate (OR = 0.81; 95% CI 0.18-3.67, p=0.78) between the two groups. CONCLUSIONS Additional fibular fixation does not appear to reduce the rate of varus-valgus deformity, anterior-posterior deformity, or malreduction. Meanwhile, it does not appear to impair the union process or increase the odds of infection. However, additional fibular fixation was associated with decreased odds of rotation deformity compared to controls.
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Mechanoregulation modeling of bone healing in realistic fracture geometries. Biomech Model Mechanobiol 2020; 19:2307-2322. [DOI: 10.1007/s10237-020-01340-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 05/12/2020] [Indexed: 01/08/2023]
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Liu J, Ji J. Invited commertary on "Immediate weightbearing after intramedullary fixation of extraarticular distal tibial fractures reduces the nonunion rate compared with traditional weight-bearing protocol: A cohort study" [Int. J. Surg. (2020) Mar 10. pii: S1743-9191(20)30205-3]. Int J Surg 2020; 77:205. [PMID: 32244003 DOI: 10.1016/j.ijsu.2020.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 03/21/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Jun Liu
- Department of Traumatic Orthopedics II Ward, Weifang People's Hospital, Weifang, Shandong, 261000, China
| | - Jianqin Ji
- Department of Traumatic Orthopedics II Ward, Weifang People's Hospital, Weifang, Shandong, 261000, China.
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Extreme Nailing: Is It Safe to Allow Immediate Weightbearing After Intramedullary Nail Fixation of Extra-articular Distal Tibial Fractures (OTA/AO 43-A)? J Orthop Trauma 2019; 33:392-396. [PMID: 31116138 DOI: 10.1097/bot.0000000000001484] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether immediate weightbearing after intramedullary (IM) fixation of extra-articular distal tibial fractures (OTA/AO 43-A) results in a change in alignment before healing. DESIGN Retrospective review. SETTING Level 1 trauma center. INTERVENTION IM nailing of distal tibial fractures. PATIENTS/PARTICIPANTS Fifty-three patients with 54 fractures, all of whom could bear weight as tolerated postoperatively. Eighteen fractures were OTA/AO 43-A1, 20 OTA/AO 43-A2, and 16 OTA/AO 43-A3; 20 fractures were open. MAIN OUTCOME MEASUREMENTS Change in fracture alignment or loss of position. RESULTS Average change from initial angulation at final follow-up was 0.52 ± 1.49 degrees of valgus and 0.48 ± 3.14 degrees of extension. Final alignment was excellent in 14, acceptable in 28, and poor in 12; 2 fractures went from acceptable initial alignment to poor final alignment; and 2 fractures went from excellent to acceptable alignment. Seven fractures had an improvement in alignment over time. Two fractures required free-flap coverage and 4 required staged grafting because of bone loss. Ten fractures had an unplanned return to the operating room (5 for infected nonunion requiring implant exchange, 3 for infection requiring debridement without implant revision, and 2 for aseptic nonunion). No patient had revision for implant failure. CONCLUSIONS Immediate weightbearing after IM fixation of extra-articular distal tibial fractures (OTA/AO 43-A) led to minimal change in alignment and seems to be safe for most patients. Complications were consistent with those reported in previous non-weightbearing cohorts. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Van Maele M, Molenaers B, Geusens E, Nijs S, Hoekstra H. Intramedullary tibial nailing of distal tibiofibular fractures: additional fibular fixation or not? Eur J Trauma Emerg Surg 2017; 44:433-441. [PMID: 28584887 DOI: 10.1007/s00068-017-0797-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 05/29/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The anatomy of the distal tibia accounts for reduced biomechanical stability and higher complication rates when treating distal tibiofibular fractures with an intramedullary tibia nail (IMTN). The goal of this study was to identify variables that affect the stability of IMTN. We assessed the value of additional fibular fixation, angular stable interlocking screws (ASLS) and multiplanar screw configuration in IMTN. PATIENTS AND METHODS A retrospective cohort study was performed including 184 distal tibial fractures and associated fibula fracture treated with IMTN. Relevant demographic, fracture-related (type and level of the tibia and fibula fracture) and operative variables (depth of the nail, screw type and configuration, use of polar screws, fibular fixation) were studied. Coronal and sagittal alignment was assessed directly and 3-6 months after IMTN. Loss of reduction (LOR) was classified as 5-9° or ≥10°. RESULTS 48.4% of the patients showed ≥5° LOR in one or both planes. Coronal LOR 5°-9° significantly correlated with low tibial fractures (p = 0.034), AO/OTA type 43 distal tibial fractures (p = 0.049), and sagittal LOR 5°-9° (p = 0.015). Although sagittal LOR 5°-9° was associated with fibular fractures (non-fixated suprasyndesmotic, p = 0.011), conversely we could not demonstrate the added value of (suprasyndesmotic) fibula fixation in IMTN. Coronal LOR ≥10° significantly correlated with AO/OTA type 43 distal tibial fractures (p = 0.009). In contrast to multiplanar configuration, we found a clear benefit of ASLS in distal IMTN locking. CONCLUSIONS The level of the tibial fracture (AO/OTA type) and (suprasyndesmotic) fibular fractures were the main determinants of LOR after IMTN. ASLS was found to increase the stability of IMTN. Due to heterogeneity, however, we could not demonstrate the value of fibular fixation in IMTN. Therefore, a future prospective study with uniform treatment strategy for IMTN of distal tibiofibular fractures, with or without fixation of the fibula, is mandatory.
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Affiliation(s)
- M Van Maele
- Faculty of Medicine, KU Leuven, University of Leuven, 3000, Leuven, Belgium
| | - B Molenaers
- Department of Orthopaedic Surgery, University Hospitals Leuven, 3000, Leuven, Belgium
| | - E Geusens
- Department of Radiology, University Hospitals Leuven, 3000, Leuven, Belgium
| | - S Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, 3000, Leuven, Belgium
| | - H Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Department of Development and Regeneration, KU Leuven, University of Leuven, 3000, Leuven, Belgium.
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Agathangelidis F, Petsatodis G, Kirkos J, Papadopoulos P, Karataglis D, Christodoulou A. Distal Locking Screws for Intramedullary Nailing of Tibial Fractures. Orthopedics 2016; 39:e253-8. [PMID: 26840700 DOI: 10.3928/01477447-20160129-02] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 07/06/2015] [Indexed: 02/03/2023]
Abstract
Recently introduced tibial intramedullary nails allow a number of distal screws to be used to reduce the incidence of malalignment and loss of fixation of distal metaphyseal fractures. However, the number of screws and the type of screw configuration to be used remains obscure. This biomechanical study was performed to address this question. Thirty-six Expert tibial nails (Synthes, Oberdorf, Switzerland) were introduced in composite bone models. The models were divided into 4 groups with different distal locking configurations ranging from 2 to 4 screws. A 7-mm gap osteotomy was performed 72 mm from the tibial plafond to simulate a 42-C3 unstable distal tibial fracture. Each group was divided in 3 subgroups and underwent nondestructive biomechanical testing in axial compression, coronal bending, and axial torsion. The passive construct stiffness was measured and statistically analyzed with one-way analysis of variance. Although some differences were noted between the stiffness of each group, these were not statistically significant in compression (P=.105), bending (P=.801), external rotation (P=.246), and internal rotation (P=.370). This in vitro study showed that, when using the Expert tibial nail for unstable distal tibial fractures, the classic configuration of 2 parallel distal screws could provide the necessary stability under partial weight-bearing conditions.
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Intramedullary Nail and Plate Combination Fixation for Complex Distal Tibia Fractures: When and How? J Orthop Trauma 2016; 30 Suppl 4:S17-S21. [PMID: 27768628 DOI: 10.1097/bot.0000000000000698] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Intramedullary nail and plate combination techniques have been described mostly for use in the proximal tibia. However, the nail and plate combination technique can also be used in the distal tibia, to counteract the deforming forces that cause construct failure and nonunion. In this article, we review pertinent anatomy and biomechanics and offer case examples that highlight the indications and applications of the nail and plate combination technique for distal tibia fractures.
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Galbraith JG, Daly CJ, Harty JA, Dailey HL. Role of the fibula in the stability of diaphyseal tibial fractures fixed by intramedullary nailing. Clin Biomech (Bristol, Avon) 2016; 38:42-9. [PMID: 27566982 DOI: 10.1016/j.clinbiomech.2016.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 05/04/2016] [Accepted: 08/16/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND For tibial fractures, the decision to fix a concomitant fibular fracture is undertaken on a case-by-case basis. To aid in this clinical decision-making process, we investigated whether loss of integrity of the fibula significantly destabilises midshaft tibial fractures, whether fixation of the fibula restores stability to the tibia, and whether removal of the fibula and interosseous membrane for expediency in biomechanical testing significantly influences tibial interfragmentary mechanics. METHODS Tibia/fibula pairs were harvested from six cadaveric donors with the interosseous membrane intact. A tibial osteotomy fracture was fixed by reamed intramedullary (IM) nailing. Axial, torsion, bending, and shear tests were completed for four models of fibular involvement: intact fibula, osteotomy fracture, fibular plating, and resected fibula and interosseous membrane. FINDINGS Overall construct stiffness decreased slightly with fibular osteotomy compared to intact bone, but this change was not statistically significant. Under low loads, the influence of the fibula on construct stability was only statistically significant in torsion (large effect size). Fibular plating stiffened the construct slightly, but this change was not statistically significant compared to the fibular osteotomy case. Complete resection of the fibula and interosseous membrane significantly decreased construct torsional stiffness only (large effect size). INTERPRETATION These results suggest that fixation of the fibula may not contribute significantly to the stability of diaphyseal tibial fractures and should not be undertaken unless otherwise clinically indicated. For testing purposes, load-sharing through the interosseous membrane contributes significantly to overall construct mechanics, especially in torsion, and we recommend preservation of these structures when possible.
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Affiliation(s)
- John G Galbraith
- Department of Trauma and Orthopaedic Surgery, Cork University Hospital, Wilton, Cork, Ireland.
| | - Charles J Daly
- Medical Engineering Design and Innovation Centre, Department of Biomedical Engineering, Cork Institute of Technology, Rossa Avenue, Bishopstown, Cork, Ireland.
| | - James A Harty
- Department of Trauma and Orthopaedic Surgery, Cork University Hospital, Wilton, Cork, Ireland; Department of Surgery, University College Cork, Cork, Ireland.
| | - Hannah L Dailey
- Medical Engineering Design and Innovation Centre, Department of Biomedical Engineering, Cork Institute of Technology, Rossa Avenue, Bishopstown, Cork, Ireland.
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Evers J, Schulze M, Gehweiler D, Lakemeier M, Raschke MJ, Wähnert D, Ochman S. A modified and enhanced test setup for biomechanical investigations of the hindfoot, for example in tibiotalocalcaneal arthrodesis. BMC Musculoskelet Disord 2016; 17:318. [PMID: 27472925 PMCID: PMC4966560 DOI: 10.1186/s12891-016-1177-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 06/28/2016] [Indexed: 11/12/2022] Open
Abstract
Background Tibiotalocalcaneal arthrodesis (TTCA) using intramedullary nails is a salvage procedure for many diseases in the ankle and subtalar joint. Despite “newly described intramedullary nails” with specific anatomical shapes there still remain major complications regarding this procedure. The following study presents a modified biomechanical test setup for investigations of the hindfoot. Methods Nine fresh-frozen specimens from below the human knee were anaysed using the Hindfoot Arthrodesis Nail (Synthes) instrument. Quasi-static biomechanical testing was performed for internal/external rotation, varus/valgus and dorsal/plantar flexion using a modified established setup (physiological load entrance point, sledge at lever arm to apply pure moments). Additionally, a 3D optical measurement system was added to allow determination of interbony movements. Results The mean torsional range of motion (ROM) calculated from the actuator data of a material testing machine was 10.12° (SD 0.6) compared to 10° (SD 2.83) as measured with the Optotrak® system (between tibia and calcaneus). The Optotrak showed 40 % more rotation in the talocrural joint. Mean varus/valgus ROM from the material testing flexion machine was seen to be 5.65° (SD 1.84) in comparison to 2.82° (SD 0.46) measured with the Optotrak. The subtalar joint showed a 70 % higher movement when compared to the talocrural joint. Mean ROM in the flexion test was 5.3° (SD 1.45) for the material testing machine and 2.1° (SD 0.39) for the Optotrak. The movement in the talocrural joint was 3 times higher compared to the subtalar joint. Conclusion The modified test setup presented here for the hindfoot allows a physiological biomechanical loading. Moreover, a detailed characterisation of the bone-implant constructs is possible.
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Affiliation(s)
- Julia Evers
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Martin Schulze
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Dominic Gehweiler
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Martin Lakemeier
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Michael J Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Dirk Wähnert
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Sabine Ochman
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany.
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Saied A, Ostovar M, Mousavi AA, Arabnejhad F. Comparison of intramedullary nail and plating in treatment of diaphyseal tibial fractures with intact fibulae: A randomized controlled trial. Indian J Orthop 2016; 50:277-82. [PMID: 27293288 PMCID: PMC4885296 DOI: 10.4103/0019-5413.181793] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Tibial fracture without concomitant fibular fracture is an injury that has long attracted notice for the fact that it sometimes heals cleanly, other times causes various problems when the bone does not heal, or misaligns. In this randomized clinical trial, we assessed two treatment modalities plating and intramedullary nailing for treatment of closed, noncomminuted tibial fractures with intact fibulae. MATERIALS AND METHODS During the three year period, 1470 patients with leg fractures were treated and out of which, 114 were eligible to enter the study. Of the eligible patients, 73 were recruited to enter the trial, and ultimately 69 of these were followed for at least one year. The patients were randomized into two groups, one of which was treated by plating of the fracture, the other group by intramedullary nailing, both of which are standard surgical procedures. The primary variables that influenced the outcome of the procedures in both treatments were the duration of surgery, the amount of bleeding, the time to union, the need to repeat surgery to achieve union, the need to remove a device, and patients' complaints about pain or discomfort in the limb. RESULTS One case of nonunion occurred in the group treated with intramedullary nailing and one of the patients in this group developed late, deep infection in the screws location, which was resolved by screw removal (P = 0.285 and P = 0.478, respectively). In both groups the tibial fractures achieved union in about 4 months, though the intramedullary group underwent more operations to achieve union (dynamization was performed in 4 patients, representing 12.1% of the patients in this group, P = 0.047). During the followup period, the incidence of implant removal (after union) was not statistically significant between the two groups: two patients (6.1%) in the intramedullary group and four patients (11.1%) in the plate group (P = 0.675) had implants removed. Of the other studied variables, the difference between the two groups was statistically significant only with regard to patients' complaints of pain in the limb and the number of individuals with knee pain (in both cases, P = 0.001). In the intramedullary group, 18 patients had no complaints (54.4%) and 13 complained of knee pain (39.4%), while in the plate group 29 had no complaints (80.6%). CONCLUSION Based upon the findings of the present study, both the methods studied are suitable treatments for closed noncomminuted isolated tibial fractures, but the patients in whom intramedullary nails are used are more likely to require additional surgeries to achieve union, and probably will have more complaints of pain in their limbs or knees.
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Affiliation(s)
- Alireza Saied
- Neuroscience Research Center, Dr. Bahonar Hospital, Kerman University of Medical Sciences, Kerman, Iran,Address for correspondence: Dr. Alireza Saied, Department of Orthopedics, Neuroscience Research Center, Dr. Bahonar Hospital, Kerman, Iran. E-mail:
| | - Mohsen Ostovar
- Department of Orthopedics, Dr. Bahonar Hospital Kerman University of Medical Sciences, Kerman, Iran
| | - Alia Ayatollahi Mousavi
- Neuroscience Research Center, Dr. Bahonar Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Fateme Arabnejhad
- Department of Orthopedics, Dr. Bahonar Hospital Kerman University of Medical Sciences, Kerman, Iran
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Necessity for fibular fixation associated with distal tibia fractures. Injury 2015; 46:2438-42. [PMID: 26477346 DOI: 10.1016/j.injury.2015.09.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 09/14/2015] [Accepted: 09/28/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intramedullary (IM) nailing is a well-accepted treatment for distal third tibia fractures in combination with injury to the fibula. However, the indications for operative stabilisation of the fibula remain controversial. METHODS The authors performed a retrospective review on a consecutive series of patients who underwent intramedullary nailing of a non-comminuted distal third tibia fracture with or without fibular fixation at a Level I urban trauma centre. A review of surgical records identified 120 patients who initially were included in this study, while a total of 98 patients who met the inclusion criteria were included in the final analysis. RESULTS Our results found no difference in the mean value of coronal and sagittal plane alignment in both the immediate post-operative and follow-up time periods. We also saw no statistically significant difference when comparing malalignment between patients treated with or without fibula fixation. There were no deep infections between the two groups. No significant differences were seen between the fibular fixation group and the non-fixation group. Distal screw removal due to prominence or pain was the most common reason for future surgery in both groups. CONCLUSION These findings suggest that the addition of fibular fixation does not affect whether or not alignment is maintained in either the immediate post-operative or short-term follow-up period.
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