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Oladipo V, Portney D, Haber J, Baker H, Strelzow J. Lactic acid levels are associated with morbidity, length of stay, and total treatment costs in urban trauma patients with lower extremity long bone fractures. Eur J Orthop Surg Traumatol 2024; 34:1963-1970. [PMID: 38480531 DOI: 10.1007/s00590-024-03877-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 02/18/2024] [Indexed: 05/19/2024]
Abstract
INTRODUCTION Lactic acid is well studied in the trauma population and is frequently used as a laboratory indicator that correlates with resuscitation status and has thus been associated with patient outcomes. There is limited literature that assesses the association of initial lactic acid with post-operative morbidity and hospitalization costs in the orthopedic literature. The purpose of this study was to assess the association of lactic acid levels and alcohol levels post-operative morbidity, length of stay and admission costs in a cohort of operative lower extremity long bone fractures, and to compare these effects in the ballistic and blunt trauma sub-population. METHODS Patients presenting as trauma activations who underwent tibial and/or femoral fixation at a single institution from May 2018 to August 2020 were divided based on initial lactate level into normal, (< 2.5) intermediate (2.5-4.0), and high (> 4.0). Mechanism of trauma (blunt vs. ballistic) was also stratified for analysis. Data on other injuries, surgical timing, level of care, direct hospitalization costs, length of stay, and discharge disposition were collected from the electronic medical record. The primary outcome assessed was post-operative morbidity defined as in-hospital mortality or unanticipated escalation of care. Secondary outcomes included hospital costs, lengths of stay, and discharge disposition. Data were analyzed using ANOVA and multivariate regression. RESULTS A total of 401 patients met inclusions criteria. Average age was 34.1 ± 13.0 years old, with patients remaining hospitalized for 8.8 ± 9.5 days, and 35.2% requiring ICU care during their hospitalization. Patients in the ballistic cohort were younger, had fewer other injuries and had higher lactate levels (4.0 ± 2.4) than in the blunt trauma cohort (3.4 ± 1.9) (p = 0.004). On multivariate regression, higher lactate was associated with post-operative morbidity (p = 0.015), as was age (p < 0.001) and BMI (p = 0.033). ISS, ballistic versus blunt injury mechanism, and other included laboratory markers were not. Lactate was also associated with longer lengths of stay, and higher associated direct hospitalization cost (p < 0.001) and lower rates of home disposition (p = 0.008). CONCLUSION High initial lactate levels are independently associated with post-operative morbidity as well as higher direct hospitalization costs and longer lengths of stay in orthopedic trauma patients who underwent fixation for fractures of the lower extremity long bones. Ballistic trauma patients had significantly higher lactate levels compared to the blunt cohort, and lactate was not independently associated with increased rates of post-operative morbidity in the ballistic cohort alone. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Victoria Oladipo
- Department of Orthopaedic Surgery, University of Chicago, Chicago, USA
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, USA
| | - Daniel Portney
- Department of Orthopaedic Surgery, University of Chicago, Chicago, USA.
| | - Jordan Haber
- Department of Orthopaedic Surgery, University of Chicago, Chicago, USA
- Ohio State University School of Medicine, Columbus, USA
| | - Hayden Baker
- Department of Orthopaedic Surgery, University of Chicago, Chicago, USA
| | - Jason Strelzow
- Department of Orthopaedic Surgery, University of Chicago, Chicago, USA
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Kim TH, Heo YM, Kim KK, Kang C, Kim TG, Lee GS, Shin WJ, Song JH. Fracture gap and working length are important actionable factors affecting bone union after minimally invasive plate osteosynthesis for the treatment of simple diaphyseal or distal metaphyseal tibia fractures. Orthop Traumatol Surg Res 2024; 110:103770. [PMID: 37979671 DOI: 10.1016/j.otsr.2023.103770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/28/2022] [Accepted: 10/20/2023] [Indexed: 11/20/2023]
Abstract
INTRODUCTION Indirect reduction of minimally invasive plate osteosynthesis (MIPO) can often result in delayed union in tibia fractures. This study evaluated several factors in MIPO in relation to bone union. HYPOTHESIS We hypothesized that the fracture gap, plate - tibia distance, or working length would have a substantial effect on the tibia union rate. MATERIALS AND METHODS Forty-one patients with simple diaphyseal or distal metaphyseal tibia fractures who underwent internal fixation surgery using the MIPO technique were divided into two groups: patients with delayed union and patients without delayed union. Non-actionable factors involving AO/OTA classification, fibula fracture and actionable factors including postoperative fracture gap, plate - tibia distance, working length in relation to parameters of bone union were compared between the two groups. Also cumulative rates of bone union and risk factors of delayed union according to variables of interest were investigated. RESULTS AO/OTA classification, site of fibula fracture, postoperative fracture gap, working length, and bone union rate of the two groups significantly differed (p<0.05). The cumulative rate of bone union during 1-year follow-up according to 43A tibia fracture, distal fibula fracture, fracture gap, and working length significantly differed between the two groups (p<0.05). By univariate Cox proportional hazards model, 43A tibia fracture, distal fibula fracture, facture gap, and short working length were risk factors for delayed union (p<0.05). DISCUSSION Non-actionable factors involving AO/OTA classification, distal fibula fracture and actionable factors including postoperative fracture gap, working length were significant factors affecting bone union after MIPO. The present study indicated that small fracture gap and long working length during MIPO might facilitate bone healing in tibia fracture. LEVEL OF EVIDENCE IV; single-center retrospective cohort study.
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Affiliation(s)
- Tae Hyeong Kim
- Department of Orthopedic Surgery, Konyang University Hospital, 158 Gwanjeodong-ro, Seo-gu, 35365 Daejeon, Republic of Korea
| | - Youn Moo Heo
- Department of Orthopedic Surgery, Konyang University Hospital, 158 Gwanjeodong-ro, Seo-gu, 35365 Daejeon, Republic of Korea
| | - Kwang Kyoun Kim
- Department of Orthopedic Surgery, Konyang University Hospital, 158 Gwanjeodong-ro, Seo-gu, 35365 Daejeon, Republic of Korea
| | - Chan Kang
- Department of Orthopedic Surgery, Chungnam National University Hospital, 282 Munwha-ro, Jung-gu, 35015 Daejeon, Republic of Korea
| | - Tae Gyun Kim
- Department of Orthopedic Surgery, Konyang University Hospital, 158 Gwanjeodong-ro, Seo-gu, 35365 Daejeon, Republic of Korea
| | - Gi Soo Lee
- Department of Orthopedic Surgery, Chungnam National University Hospital, 282 Munwha-ro, Jung-gu, 35015 Daejeon, Republic of Korea
| | - Woo Jin Shin
- Department of Orthopedic Surgery, Konyang University Hospital, 158 Gwanjeodong-ro, Seo-gu, 35365 Daejeon, Republic of Korea
| | - Jae Hwang Song
- Department of Orthopedic Surgery, Konyang University Hospital, 158 Gwanjeodong-ro, Seo-gu, 35365 Daejeon, Republic of Korea.
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Teixidor-Serra J, Andrés-Peiró JV, García-Sanchez Y, Selga-Marsa J, Garcia-Martínez MC, Carbonell-Rosell C, García-Albó E, Tomás-Hernández J. Outcomes and their predictors in suprapatellar nailing for tibia fractures. Multivariable analysis of 293 consecutive cases. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02476-0. [PMID: 38472386 DOI: 10.1007/s00068-024-02476-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 02/19/2024] [Indexed: 03/14/2024]
Abstract
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.
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Affiliation(s)
- Jordi Teixidor-Serra
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - José Vicente Andrés-Peiró
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.
| | - Yaiza García-Sanchez
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Jordi Selga-Marsa
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | | | - Carla Carbonell-Rosell
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Enrique García-Albó
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jordi Tomás-Hernández
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
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Agres AN, Alves SA, Höntzsch D, El Attal R, Pohlemann T, Schaser KD, Joeris A, Hess D, Duda GN. Improved weight bearing during gait at 6 weeks post-surgery with an angle stable locking system after distal tibial fracture. Gait Posture 2024; 107:169-176. [PMID: 37845132 DOI: 10.1016/j.gaitpost.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 07/12/2023] [Accepted: 09/25/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Functional recovery after intramedullary nailing of distal tibial fractures can be monitored using ipsilateral vertical ground reaction forces (vGRF), giving insight into recovery of patients' gait symmetry. Previous work compared patient cohorts to healthy controls, but it remains unclear if these metrics can identify treatment-based differences in return to function post-surgery. RESEARCH QUESTION Is treatment of a distal tibial fracture with intramedullary nailing with an angle stable locking system (ASLS) associated with higher ipsilateral vGRF and improved symmetry compared to conventional intramedullary nailing at an early time point? METHODS Thirty-nine patients treated with ASLS intramedullary nailing were retrospectively compared to thirty-nine patients with conventional locking. vGRFs were collected at 1, 6, 12, 26, and 52 weeks post-surgery during standing and gait. Discrete metrics of ipsilateral vGRF (maximal force, impulse) and asymmetry were compared between treatments at each time point. Time-scale comparisons of ipsilateral vGRF and lower limb asymmetry were additionally performed for gait trials. Mann-Whitney Test or a two-way analysis of variance tested discrete comparisons; statistical non-parametric mapping tested time-scale data between treatment groups. RESULTS During gait, ASLS-treated patients applied more load on the operated limb (17-38% stance, p = 0.015) and consequently loaded limbs more symmetrically (8-37% stance, p = 0.008) during the loading response at 6 weeks post-surgery compared to conventional IM treatment. Discrete measures of symmetry at the same time point identified treatment-based differences in maximal force (p = 0.039) and impulse (p = 0.012), with ASLS-treated patients exhibiting more symmetry. No differences were identified in gait trials at later time points nor from all standing trials. SIGNIFICANCE During the initial loading response of gait, increased ipsilateral vGRF and improved weightbearing symmetry were identified in ASLS patients at 6 weeks post-surgery compared to conventional IM nailing. Early and objective metrics of dynamic movement are suggested to identify treatment-based differences in functional recovery.
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Affiliation(s)
- Alison N Agres
- Julius Wolff Institute, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Sónia A Alves
- Julius Wolff Institute, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Dankward Höntzsch
- BG Unfallklinik and University Hospital Tübingen, Schnarrenbergstraße 95, 72076 Tübingen, Germany
| | - René El Attal
- Orthopaedics, Traumatology and Sport Traumatology, Akademisches Lehrkrankenhaus, Carinagasse 47, 6800 Feldkirch, Austria
| | - Tim Pohlemann
- Department for Trauma, Hand and Reconstructive Surgery, Saarland University Medical Center, Kirrbergerstr. 1, 66421 Homburg, Germany
| | - Klaus-Dieter Schaser
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Fetscherstraße 74, 01307 Dresden, Germany
| | - Alexander Joeris
- AO Innovation Translation Center, AO Foundation, Stettbachstrasse 6, 8600 Dübendorf, Switzerland
| | - Denise Hess
- AO Education Institute, AO Foundation, Stettbachstrasse 6, 8600 Dübendorf, Switzerland
| | - Georg N Duda
- Julius Wolff Institute, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Minhas A, Berkay F, Ehlers CB, Froehle AW, Krishnamurthy AB. The statistical fragility of intramedullary reaming in tibial nail fixation: a systematic review. Eur J Trauma Emerg Surg 2023; 49:2347-2354. [PMID: 36879152 DOI: 10.1007/s00068-023-02254-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 02/19/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE To report the statistical stability of prospective clinical trials evaluating the effect of intramedullary reaming on rates of non-union in tibial fractures through calculation of the fragility metrics for non-union rates and all other dichotomous outcomes. METHODS Literature search was conducted for prospective clinical trials evaluating the effect of intramedullary reaming on non-union rates in tibial nailing. All dichotomous outcomes were extracted from the manuscripts. The fragility index (FI) and reverse fragility index (RFI) were calculated by determining the number of event reversals required for a statistically significant outcome to lose significance and vice-versa. The fragility quotient (FQ) and reverse fragility quotient (RFQ) were calculated by dividing the FI or RFI by the sample size, respectively. Outcomes were defined as "fragile" if the FI or RFI was found to be less than or equal to the number of patients lost to follow-up. RESULTS Literature search identified 579 results which produced ten studies meeting the criteria for review. There were 111 outcomes identified for analysis, of which 89 (80%) exhibited statistical fragility. For reported outcomes across the studies the median and mean FI was 2, the median FQ was 0.019, the mean FQ was 0.030, the median RFI was 4, the mean RFI was 3.95, the median RFQ was 0.045, and the mean RFQ was 0.030. Four studies reported outcomes which were found to have an FI of 0. CONCLUSIONS The studies evaluating the effect of intramedullary reaming on tibial nail fixation demonstrate considerable fragility. On average, two event reversals for significant findings, and four event reversals for insignificant findings are sufficient to alter statistical significance. LEVEL OF EVIDENCE Level II, systematic review of Level I and Level II studies.
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Affiliation(s)
- Arjun Minhas
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, 45409, USA.
- Department of Orthopaedic Surgery, Miami Valley Hospital, 30 E. Apple Street, Suite 2200, Dayton, OH, 45409, USA.
| | - Fehmi Berkay
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, 45409, USA
| | - Cooper B Ehlers
- Department of Orthopaedic Surgery, University of California San Diego School of Medicine, San Diego, CA, 92103, USA
| | - Andrew W Froehle
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, 45409, USA
| | - Anil B Krishnamurthy
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, 45409, USA
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Yang CY, Tay ST, Kuo LT. Suprapatellar vs infrapatellar approaches for intramedullary nailing of distal tibial fractures: a systematic review and meta-analysis. J Orthop Traumatol 2023; 24:14. [PMID: 37041367 PMCID: PMC10090252 DOI: 10.1186/s10195-023-00694-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/19/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND This review was conducted to compare the efficacy of suprapatellar (SP) and infrapatellar (IP) approaches for treating distal tibial fractures with intramedullary nailing. METHOD This systematic review included studies comparing the outcomes of patients receiving nailing for distal tibial fractures using the SP and IP approaches. We searched the Cochrane CENTRAL, MEDLINE and Embase databases for relevant studies till 18th Sep. 2022. We used the Newcastle Ottawa Scale to assess study quality and a random-effects meta-analysis to synthesize the outcomes. We used the mean difference (MD) or standardized mean difference (SMD) with the 95% confidence interval (CI) for continuous data and the odds ratio (OR) with the 95% CI for dichotomous data. RESULTS Four studies with 586 patients (302 in the SP group and 284 in the IP group) were included in this systematic review. The SP group may have had little or no difference in pain and slightly better knee function (MD 3.90 points, 95% CI 0.83 to 5.36) and better ankle function (MD: 8.25 points, 95% CI 3.35 to 13.15) than the IP group 12 months after surgery. Furthermore, compared to the IP group, the SP group had a lower risk of malalignment (OR: 0.22, 95% CI 0.06 to 0.75; number needed to treat (NNT): 6), a lower risk for open reduction (OR: 0.58, 95% CI 0.35 to 0.97; NNT: 16) and a shorter surgical time (MD: - 15.14 min, 95% CI - 21.28 to - 9.00). CONCLUSIONS With more advantages, the suprapatellar approach may be the preferred nailing technique over the infrapatellar approach when treating distal tibial fractures. LEVEL OF EVIDENCE Level III, systematic review of non-randomized studies.
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Affiliation(s)
- Chen-Yuan Yang
- Department of Orthopedics, Kuang Tien General Hospital, Taichung, 433, Taiwan
- Department of Nursing, Hungkuang University, Taichung, 433, Taiwan
| | - Soon-Tzeh Tay
- School of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Liang-Tseng Kuo
- School of Medicine, Chang Gung University, Taoyuan, 333, Taiwan.
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, No. 6 Western Sec., Chia-Pu Road, Putzi City, Chiayi, 613, Taiwan.
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Kikuchi K, Haneda M, Hayashi S, Maeda T, Nakano N, Kuroda Y, Tsubosaka M, Kamenaga T, Fujita M, Ikuta K, Anjiki K, Tachibana S, Onoi Y, Matsumoto T, Kuroda R. P21 deficiency exhibits delayed endochondral ossification during fracture healing. Bone 2022; 165:116572. [PMID: 36180020 DOI: 10.1016/j.bone.2022.116572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Endochondral ossification is a complex biological phenomenon involving a variety of factors and cells. Cyclin-dependent kinase inhibitor 1 (p21) inhibits cell cycle progression and is affected by external stress. We recently reported that embryonic endochondral ossification is unaffected by endogenous p21 deficiency. In this study, we evaluated whether p21 expression affects endochondral ossification during fracture healing. METHODS Tibial fractures were introduced into p21 knockout (p21-/-) (n = 24) and wild-type C57BL/6 (p21+/+) (n = 24) mice at age 10 weeks. Fracture healing was evaluated using radiological, histological, and immunohistochemical (IHC) analyses. The effect of p21 small interfering RNA (siRNA) on ATDC5 cells was assessed in vitro. RESULTS The Allen score for fracture healing was lower in p21-/- mice than in p21+/+ mice. In addition, p21-/- mice exhibited larger calluses and lower bone mineral density. IHC analyses showed that p21-/- mice exhibited delayed endochondral ossification via the Ihh-Runx2-Osterix pathway in vivo. Down-regulation of p21 expression in ATDC5 cells delayed endochondral ossification in vitro. CONCLUSIONS p21 deficiency leads to delayed endochondral ossification by attenuating the Ihh-Runx2-Osterix pathway in vivo, and p21 deficiency in hypertrophic chondrocytes causes delayed differentiation of hypertrophic chondrocytes in vitro. p21 plays a role in endochondral ossification during fracture healing.
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Affiliation(s)
- Kenichi Kikuchi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiko Haneda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shinya Hayashi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Toshihisa Maeda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoki Nakano
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichi Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masanori Tsubosaka
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoyuki Kamenaga
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiro Fujita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kenmei Ikuta
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kensuke Anjiki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shotaro Tachibana
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuma Onoi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Yoon YC, Kim Y, Song HK, Yoon YH. Efficacy of Staged Surgery in the Treatment of Open Tibial Fractures with Severe Soft Tissue Injury and Bone Defect. Yonsei Med J 2022; 63:915-926. [PMID: 36168244 PMCID: PMC9520038 DOI: 10.3349/ymj.2022.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/12/2022] [Accepted: 07/28/2022] [Indexed: 11/27/2022] Open
Abstract
PURPOSE We aimed to report the clinical and radiological outcomes of staged surgery using the acute induced membrane technique with an antibiotic-impregnated cement spacer (ACS) and soft-tissue reconstructive surgery and to identify factors affecting clinical outcomes. MATERIALS AND METHODS Thirty-two patients with severe open tibia fractures were treated via staged surgery from January 2014 to December 2019 and followed up for ≥1 year. In the first surgery, an ACS was inserted into the bone defect site along with debridement and irrigation and was temporarily fixed in place with an external fixator. The internal fixator was placed, and flap surgery and cement spacer changes were performed during the next surgery. In the third surgery, an autogenous bone graft was performed. Radiologic and functional results were investigated according to the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria, and factors affecting the ASAMI score were analyzed. RESULTS The average bone defect width was 43.9 mm, and the size of soft-tissue defect was 79.3 cm² . Bone union was achieved in all cases except one and required 9.4 months on average. Complications occurred in 10 cases (31.2%). Good or better clinical effects, in terms of ASAMI radiologic and functional scores, were observed in 29 and 24 cases, respectively. Complications and additional surgery were common factors affecting the two scores. CONCLUSION Staged surgery using the acute induced membrane technique and soft-tissue reconstructive surgery is an efficacious treatment for open tibial fractures with bone defects.
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Affiliation(s)
- Yong-Cheol Yoon
- Orthopedic Trauma Division, Trauma Center, Gachon University College of Medicine, Incheon, Korea
| | - Youngwoo Kim
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Hyung Keun Song
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, Korea.
| | - Young Hyun Yoon
- Department of Orthopaedic Surgery, Gachon University College of Medicine, Incheon, Korea
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Rohilla R, Arora S, Kundu A, Singh R, Govil V, Khokhar A. Functional and radiological outcomes of primary ring fixator versus antibiotic nail in open tibial diaphyseal fractures: A prospective study. Injury 2022; 53:3464-3470. [PMID: 36008173 DOI: 10.1016/j.injury.2022.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 07/25/2022] [Accepted: 08/06/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Management of open fractures of tibia is still a matter of debate due to high incidence of infections. Traditionally external fixators have been advocated in managing open tibial fractures. Due to limited efficacy of systemic antibiotics, recently antibiotic coated intramedullary interlocking nails have been developed for the management of open tibia fractures. Therefore, we conducted this prospective randomized study to compare the functional and radiological outcomes of primary ring fixator versus antibiotic coated nail in open diaphyseal tibial fractures. METHODS The study included 32 patients with Gustilo-Anderson type II and type IIIA fractures of tibial diaphysis. Out of them 16 patients were managed with Ring External Fixator (Group I) and 16 were managed with OssiproÒ gentamicin intramedullary interlocking tibial nail (Group II). The radiological and functional outcomes were assessed at final follow-up according to and SMFA criteria. Statistical analysis of the data was performed using IBM SPSS statistics 2.0 software. Chi square test and independent student t-test were used and a P value <0.05 was considered statistically significant RESULTS: Union was achieved in 15 patients (93.8%) in group I and 13 patients (81.2%) in group II. Pin tract infection was seen in 6 patients (37.5%) in group I, whereas infection was present in 2 patients (12.5%) in group II. Bone results were excellent in 13 patients (81.3%), good in 2 patients (12.5%), poor in one patient (6.3%). In group II, bone results were excellent in 12 patients (75%), good in one patient (6.2%), poor in 3 patients (18.8%). At 1 year of final follow up, mean SMFA score was 24.41±5.87 in group I, whereas mean SMFA score was 23.703±8.02 in group II. CONCLUSION Ring fixator as well as antibiotic coated tibial interlocking nail achieved comparable rates of union in the present study. Complication rates were similar in both the groups and the functional and radiological outcomes were comparable in both groups. Results of this study indicate that although ring fixation is an established option for management of open tibial fractures, antibiotic-coated intramedullary nail is also a reliable option in open Grade II and grade IIIA injuries. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Rajesh Rohilla
- Department of Sports Medicine, Pt. BD Sharma PGIMS, Rohtak, India
| | - Sahil Arora
- Department of Orthopedics, Pt. BD Sharma PGIMS, Rohtak, India.
| | - Ankush Kundu
- Department of Orthopedics, Pt. BD Sharma PGIMS, Rohtak, India
| | - Roop Singh
- Department of Orthopedics, Pt. BD Sharma PGIMS, Rohtak, India
| | - Vasudha Govil
- Department of Anaesthesia, Pt. BD Sharma PGIMS, Rohtak, India
| | - Arya Khokhar
- Homestead High School, Cupertino, CA 95014, United States
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10
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Steflik MJ, Griswold BG, Patel DV, Blair JA, Davis JM. Antibiotic cement-coated intramedullary nail is cost-effective for the initial treatment of GAⅢ open tibia fractures. Injury 2022; 53:3471-3474. [PMID: 35948512 DOI: 10.1016/j.injury.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of antibiotic cement-coated intramedullary nails (IMN) in the initial management of Gustilo-Anderson type Ⅲ (GAIII) open tibia fractures. METHODS A break-even equation was used to analyze the costs associated with antibiotic cement-coated IMN and postoperative infection following GAⅢ open tibia fractures. This equation produced a new infection rate, which defines what percentage the antibiotic coated IMN needs to decrease the initial infection rate for its prophylactic use to be cost-effective. The postoperative infection rate used for calculations was 30%, a value established in current literature for these fracture types (6-33%). The institutional costs associated with a single operative debridement and resultant inpatient stay and treatment were determined. A sensitivity analysis was conducted to demonstrate how various total costs of infection and different infection rates affected the break-even rate, the absolute risk reduction (ARR), and the number needed to treat (NNT). RESULTS Financial review yielded an average institutional cost of treating a postoperative infection to be $13,282.85. This number was inclusive of all procedures during an inpatient stay. The added cost of the antibiotic coated implant to the hospital is $743.42. Utilizing the break-even formula with these costs and a 30% initial infection rate, antibiotic coated IMN was economically viable if it decreased infection rate by 0.056% (NNT = 1,785.714). CONCLUSION This break-even analysis model suggests the initial use of an antibiotic coated IMN in the setting of GAⅢ open tibia fractures is cost-effective.
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Affiliation(s)
- Michael J Steflik
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, United States.
| | - B Gage Griswold
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, United States
| | - Dhara V Patel
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, United States
| | - James A Blair
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, United States
| | - Jana M Davis
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, United States
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11
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Kim RG, An VVG, Petchell JF. Fibular fixation in mid and distal extra-articular tibia fractures - A systematic review and meta-analysis. Foot Ankle Surg 2022; 28:809-816. [PMID: 34836719 DOI: 10.1016/j.fas.2021.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/06/2021] [Accepted: 11/11/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The surgical management of extra-articular mid and distal tibia fractures has primarily focused on reducing rates of non-union and malunion, preserving hip-knee-ankle alignment and improving functional outcomes. Fibular fractures commonly accompany these injuries and the contributory role of fixation of these fractures has been increasingly studied. A systematic review and meta-analysis were performed to determine whether concurrent fibular fixation (FF) during extra-articular mid and distal tibia fracture fixation (AO/OTA 42 and 43-A) altered the risk of malunion, non-union and post-operative complications when compared to no fibular fixation (NF). METHODS A systematic search of literature in the databases of MEDLINE (via OvidSP), PubMed, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) from the dates of inception was performed for randomised and non-randomised controlled trials. All studies published in English were included. Risk of Bias in Non-randomised Studies (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05. RESULTS A total of ten studies with 1174 patients were included for analysis. There was a statistically significant reduced risk of overall malunion in the FF group compared to the NF group (11.8% vs 21.9%, RR 0.63, 95% CI: 0.41-0.98, p = 0.04) and this was supported through a sensitivity analysis of only randomised controlled trials (21.8% vs 40.3%, RR 0.37, 95% CI: 0.18-0.76, p = 0.006). There was no statistically significant difference in rates of non-union between groups (p > 0.05). Overall, there were similar incidences of diabetes, open fractures and smoking history between groups (p > 0.05). Detailed information regarding methods of tibial fixation were not available for subgroup analysis. CONCLUSION In conclusion, in extra-articular mid and distal tibia (AO/OTA 42 and 43-A) fracture fixation, additional fibular fixation (FF) appears to significantly reduce the risk of overall malunion (RR, 0.37, 95% CI: 0.18-0.76, p = 0.006) without increasing the risk of non-union. These results should be interpreted with caution given the lack of subgroup analysis for methods of tibial fixation. Future high-quality randomised controlled trials should therefore delineate between types of tibial fixation.
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Affiliation(s)
- Raymond G Kim
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW, Australia.
| | - Vincent V G An
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW, Australia
| | - Jeffrey F Petchell
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW, Australia
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Fanelli D, Perrotta G, Stocco F, Agilinko J, Castioni D, Mercurio M, Gasparini G, Barker S. Outcomes and complications following flexible intramedullary nailing for the treatment of tibial fractures in children: a meta-analysis. Arch Orthop Trauma Surg 2022; 142:1469-82. [PMID: 33635402 DOI: 10.1007/s00402-021-03839-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/15/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Tibial shaft fractures are common occurrence in children and surgical treatment is sometimes required, particularly in unstable or open fractures, and in polytrauma. The aim of this study was to investigate the available evidence on the efficacy and safety of flexible intramedullary nailing (FIN) for both open and closed tibia fractures in children, exploring the main surgical outcomes and rate of complications. MATERIALS AND METHODS Pubmed/Medline, Scopus and Cochrane Central databases were searched following the PRISMA guideline. Studies reporting on the outcomes of FIN for paediatric tibia shaft fractures were included. Weighted means were evaluated for surgical outcomes. Meta-analysis of proportion and odd ratios were used to analyse total complication rates and differences between open and closed fractures. RESULTS Twenty-eight studies (835 patients) were included; the mean age was 11.0 ± 3.0 years. The mean follow-up was 22.5 ± 13.5 months; the mean time to full weight-bearing was 7.5 ± 3.7 weeks. The total complication rate was 28.1% (minor = 20.7%, major = 6.3%); this was greater in open fractures (13.6% vs 5.1%, p = 0.007). The rate of union was 97.5%, with a mean time to union of 11.9 ± 7.2 weeks. Malunion was found in 8.5% cases, delayed union in 3.8%, non-union in 1.4%, symptomatic hardware in 5.1%, leg-length discrepancy in 5.0%, superficial infections in 2.3%, deep infections in 1.0%, compartment syndromes in 1.4%, and refracture in 0.2%. Almost all patients returned to unrestricted physical activity. CONCLUSIONS FIN offers excellent outcomes for the treatment of paediatric tibia shaft fractures. Patients presenting with an open fracture have a higher but acceptable complication rate. Comparative studies are needed to clarify if other treatments have superior outcomes.
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13
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Konda SR, Littlefield CP, Carlock KD, Ganta A, Leucht P, Egol KA. Autogenous iliac crest bone grafting for tibial nonunions revisited: does approach matter? Arch Orthop Trauma Surg 2022; 142:961-8. [PMID: 33417030 DOI: 10.1007/s00402-020-03735-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/19/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Tibial nonunion remains a considerable burden for patients and the surgeons who treat them. In recent years, alternatives to autogenous grafts for the treatment of tibial nonunions have been sought. The purpose of this study was to evaluate the efficacy of autogenous iliac crest bone graft (ICBG) in the treatment of tibial shaft nonunions. MATERIAL AND METHODS Sixty-nine patients were identified who underwent ICBG for repair of atrophic or oligotrophic tibial nonunion and had complete data with at least one year of follow-up (mean 27.9 months). Surgical treatments consisted of revision/supplemental fixation ± ICBG. Surgical approaches for graft placement were either posterolateral (PL), anterolateral (AL), or direct medial (DM). Healing status, time to union, postoperative pain, and functional outcomes were assessed. RESULTS Bony union was achieved by 97.1% (67/69) of patients at a mean time of 7.8 ± 3.2 months postoperatively. There was no significant difference in mean time to union between the three surgical approach groups: (PL (44.9%) = 7.3 months, AL (20.3%) = 9.2 months, DM (34.8%) = 7.6 months; p = 0.22). Intraoperative cultures obtained at the time of nonunion surgery were positive in 27.5% of patients (19/69). Positive cultures were associated with need for secondary surgery as 8/19 patients (42.1%) with positive cultures required re-operation. Two out of four patients that developed iliac donor site hematomas/infections requiring washout had positive intraoperative cultures as well. There was no difference in final SMFA among the three surgical approach groups. CONCLUSIONS Autogenous ICBG remains the gold standard in the management of persistent tibial nonunions regardless of surgical approach. There is a small risk for complication at the iliac crest donor site. Given the high union rate, autogenous iliac crest bone grafting for tibial nonunion remains the gold standard for this difficult condition. LEVEL OF EVIDENCE Level III.
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14
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Lu K, Wang HZ, Qian RX, Wu ZQ, Li C, Gao YJ. Removing a suprapatellar intramedullary nail via a suprapatellar approach: a retrospective cohort study. Int Orthop 2022; 46:1145-54. [PMID: 35124710 DOI: 10.1007/s00264-022-05329-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/27/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Over the last 20 years, suprapatellar (SP) intramedullary nailing has gained considerable attention for treating tibia fractures and is believed to improve fracture alignments, decrease anterior knee pain, and facilitate intraoperative fluoroscopy. However, it is associated with various concerns, including the need to make another infrapatellar (IP) incision to remove the nail. AIMS This study was aimed at developing a new technique for the removal of SP tibial nails through an SP approach using a cannulated extraction system. The efficiency of the novel SP approach was compared to that of the traditional IP approach for the removal of SP tibial nails. PATIENTS AND METHODS This was a retrospective cohort study from a prospectively collected clinical registry. The data for 69 consecutive patients who received surgery to remove a previous SP intramedullary nail using an SP approach (n = 30, SP cohort) or an IP approach (n = 39, IP cohort) were analyzed. Intra-operative evaluations included intraoperative blood loss, operation time, and changes in the surgical procedures. At six months follow-up, post-operative Lysholm knee score, visual analog scale (VAS) score, and the active range of motion (ROM) of the affected knee and complications were assessed. RESULTS Patients in the SP cohort exhibited an increased post-operative Lysholm knee score (β, 2.6; 95% confidence interval [CI], 0.6 to 4.6; P = 0.012), decreased post-operative VAS score (β, - 0.7; 95% CI, - 1.1 to - 0.2; P = 0.004), and increased operation time (β, 9.8 minutes; 95% CI, 5.7 to 14.0 minutes; P < 0.001) compared with those treated with the IP approach after adjustment for baseline characteristics. There were no statistically significant differences in blood loss, post-operative ROM, or complications between the two cohorts. CONCLUSIONS Compared with the IP technique, the SP approach for the removal of an SP tibial nail was independently associated with an increased post-operative Lysholm knee score and decreased VAS score, although the surgery was longer in duration. The novel technique offers a reliable and minimally invasive option for the removal of an SP tibial nail.
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15
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Söylemez MS, Cepni SK, Kemah B, Batar S. Posteromedial plate application using medial midline incision for complex tibia plateau fractures: a retrospective study. BMC Musculoskelet Disord 2022; 23:129. [PMID: 35139836 PMCID: PMC8826707 DOI: 10.1186/s12891-022-05087-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 02/03/2022] [Indexed: 11/30/2022] Open
Abstract
Background Application of a posterior plate for tibia plateau fractures associated with posterior column involvement is becoming a widespread standard practice as previous studies have shown that additional fixation of the posterior column with a posteromedial buttress plate creates strongest fixation in terms of fracture stabilization This study evaluated the clinical and radiological results of patients undergoing surgery for complex tibial plateau fractures involving the posterior column with a posteromedial plate applied via a medial midline incision. Methods Medical records of patients undergoing surgery for Schatzker type IV, V, and VI tibia plateau fractures involving the posterior column in our institution were reviewed retrospectively. Patients with a follow-up of less than 1 year, pathological fractures, posterolateral column fractures requiring separate fixation, and open fractures were excluded from the study. Three-dimensional computed tomography (3D CT) was performed in all patients before surgery. The study population consisted of 25 patients (21 males and 4 females) with a mean age of 41.5 (19–66) years. The etiologies of the fractures were traffic accidents in seven cases, pedestrian falls in five cases, falls from a height in seven cases, and motor vehicle accidents in six cases. Results The mean follow-up period was 15.9 months (12–25), mean time to union was 14.32 (9–20) weeks, mean Knee Society score (KSS) was 88 (81–95), and range of movement (ROM) was 123° (95°–140°). Loss of reduction was detected in only one patient (4%). A superficial incisional infection occurred in an anterolateral incision in only one patient (4%), and it recovered after oral antibiotic therapy. None of the patients required early implant removal and none had vascular or nerve complications in the postoperative period. Postoperatively, 23 (92%) patients had anatomical reduction and 2 (8%) had acceptable reduction in the sagittal plane CT sections. Acceptable reduction was achieved in 6(24%) patients and anatomical reduction was achieved in 19 (76%) in the coronal plane CT sections (Table 2). Conclusions Clinical results of posteromedial plate application using a single medial midline incision is promising as complication rates were very low and knee scores were high.
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Affiliation(s)
- Mehmet Salih Söylemez
- Umraniye Training and Research Hospital, Department of Orthopaedics and Traumatology, Health Sciences University, Yaprak street, Acıbadem district, No 32, D:12, 34660, Istanbul, Turkey.
| | - Serdar Kamil Cepni
- Umraniye Training and Research Hospital, Department of Orthopaedics and Traumatology, Health Sciences University, Yaprak street, Acıbadem district, No 32, D:12, 34660, Istanbul, Turkey
| | - Bahattin Kemah
- Umraniye Training and Research Hospital, Department of Orthopaedics and Traumatology, Health Sciences University, Yaprak street, Acıbadem district, No 32, D:12, 34660, Istanbul, Turkey
| | - Suat Batar
- Umraniye Training and Research Hospital, Department of Orthopaedics and Traumatology, Health Sciences University, Yaprak street, Acıbadem district, No 32, D:12, 34660, Istanbul, Turkey
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Kellam PJ, Dekeyser GJ, Haller JM, Higgins TF, Rothberg DL, Marchand LS. Determining your implant: Templating a nail for the distal tibia fracture. Injury 2022; 53:789-797. [PMID: 34836630 DOI: 10.1016/j.injury.2021.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 11/10/2021] [Accepted: 11/14/2021] [Indexed: 02/02/2023]
Abstract
The goal of this article is to aid the orthopedic surgeon in determining whether an intra-medullary (IM) device for fixation of a distal tibia fracture is feasible. Using Computed Tomography (CT) scans of the fracture, this review demonstrates a simple way to determine whether two or even three distal interlocking screws are achievable in stable bone. Additionally, this paper offers a summary chart of commonly used tibial nails which can be used for planning purposes. Finally, a clinical summary of very distal tibial shaft fractures treated with IM fixation is provided.
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Affiliation(s)
- Patrick J Kellam
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Graham J Dekeyser
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Thomas F Higgins
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - David L Rothberg
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Lucas S Marchand
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA.
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Lu Y, Yang J, Xu Y, Ma T, Li M, Ren C, Huang Q, Zhang C, Wang Q, Li Z, Zhang K. An Approach to Intraoperatively Identify the Coronal Plane Deformities of the Distal Tibia When Treating Tibial Fractures with Intramedullary Nail Fixation: a Retrospective Study. Orthop Surg 2021; 14:365-373. [PMID: 34964267 PMCID: PMC8867441 DOI: 10.1111/os.13194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 11/07/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Yao Lu
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Jie Yang
- Department of Orthopedics Surgery II, Langfang People's Hospital, Langfang, China
| | - Yibo Xu
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Teng Ma
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Ming Li
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Cheng Ren
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Qiang Huang
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Congming Zhang
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Qian Wang
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Zhong Li
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Kun Zhang
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
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Baker HP, Strelzow J, Dillman D. Tibial alignment following intramedullary nailing via three approaches. Eur J Orthop Surg Traumatol 2021; 32:1247-1255. [PMID: 34420095 DOI: 10.1007/s00590-021-03101-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept 4B, Chicago, IL, 60637, USA.
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Ma CH, Chiu YC, Wu CH, Tsai KL, Wen TK, Tu YK. Ipsilateral vascularised fibula with external locking plate for treatment of massive tibial bone defects. Injury 2021; 52:1629-1634. [PMID: 33648739 DOI: 10.1016/j.injury.2021.02.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/01/2021] [Accepted: 02/14/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Management of massive tibial bone defects remains challenging for orthopaedic doctors. This study aimed to ascertain the viability and reliability of utilising an ipsilateral vascularised fibula with an external locking plate for the difficult situation. MATERIALS AND METHODS Between January 2012 and December 2017, eight patients (7 men) with a mean age of 32.3 (19-54) years who presented with massive tibial bone defects were treated using the described technique. The mean length of the bone defect was 12.4 (8-20) cm. The patients were assessed for clinical and radiographic results, hypertrophy of the fibular graft with DeBoer and Wood's method, and SF-36 functional score. RESULTS The mean follow-up period was 40.3 (26-60) months. The average time for union was 5.6 (3-8) months. At the final follow-up, all patients had fully united grafts and walked without restriction. The mean graft hypertrophy index was 98.2 %. The SF-36 score was > 75 % in five patients, and 50-75 % in three. Three patients had a leg length discrepancy of > 1.5 cm. Two patients with equinus foot were treated using tibiotalocalcaneal fusion. Three patients had pin-tract infections. Four screws were broken in two cases. CONCLUSION Ipsilateral vascularised fibular transfer combined with an external locking plate as a definitive external fixator provides a simple and comfortable treatment, and appropriate mechanical loading and vascularisation of the graft site to achieve hypertrophy of the fibular graft. Hence, our technique can serve as a valuable alternative for the treatment of massive tibial bone defects.
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Affiliation(s)
- Ching-Hou Ma
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
| | - Yen-Chun Chiu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chin-Hsien Wu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
| | - Kun-Ling Tsai
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tsung-Kai Wen
- Department of Post-Baccalaureate Chinese Medicine, Tzu Chi University Hualien, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
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Piedra-Calle CA, García-Sánchez Y, Teixidor-Serra J, Tomás-Hernández J, Selga-Marsá J, Porcel-Vázquez JA, Molero-García V, Andrés-Peiró JV. Challenges and outcomes in the treatment of floating knees. A case series of ipsilateral femur and tibia fractures around the knee. Eur J Orthop Surg Traumatol 2021; 32:325-331. [PMID: 33884493 DOI: 10.1007/s00590-021-02981-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ipsilateral femur and tibia fractures around the knee (floating knee) are rare injuries that threaten both limb viability and patient life. A correct surgical strategy is essential to reduce complications and sequelae. The aim of this study was to evaluate characteristics and results of treatment in patients with a floating knee treated at a single trauma center. MATERIAL AND METHODS This is a retrospective and non-consecutive case series of 18 floating knees occurred in 17 patients. All patients were operated in a single third-level public and university hospital from December 2010 to December 2018. Data on demographics, injuries, treatment and follow-up were collected. A general health questionnaire (SF-12) and a knee functional questionnaire (KOOS-PS) were used to display results. RESULTS We identified 13 men and 4 women, aged between 16 and 52. Mean follow-up period was 16.49 months. High-energy trauma following a traffic collision was the most frequent mechanism. Mean Injury Severity Score (ISS) was 39.05, and a damage control strategy was used in 15 (83.33%) injuries. Extra-articular fractures (Fraser I) largely predominated, resulting in double intramedullary nailing in 72.22% of cases. Eleven injuries (61.11%) presented with an open fracture. Complications appeared in 6 (33.33%) injuries, being 3 infections. Mean score for the SF-12 was 35.59 for the physical dimension and 50.44 for mental dimension. Mean score for the KOOS-PS was 43.64. CONCLUSION Floating knee injuries usually occur in polytrauma contexts. Visceral involvement and exposed fractures are common, so the most appropriate strategy is usually a staged treatment. Complications and sequelae are frequent.
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Affiliation(s)
| | | | - Jordi Teixidor-Serra
- Orthopaedic Surgery Department, Orthopaedic Trauma Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jordi Tomás-Hernández
- Orthopaedic Surgery Department, Orthopaedic Trauma Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jordi Selga-Marsá
- Orthopaedic Surgery Department, Orthopaedic Trauma Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Juan-Antonio Porcel-Vázquez
- Orthopaedic Surgery Department, Orthopaedic Trauma Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Vicente Molero-García
- Orthopaedic Surgery Department, Orthopaedic Trauma Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - José Vicente Andrés-Peiró
- Orthopaedic Surgery Department, Orthopaedic Trauma Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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Abstract
AIMS The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols. METHODS A biomechanical model of distal metaphyseal tibial fractures was created using a fourth-generation composite bone model. Three fracture patterns were tested: spiral, oblique, and multifragmented. Each fracture extended to within 4 cm to 5 cm of the plafond. The models were nearly-anatomically reduced and stabilized with an intramedullary nail and three distal locking screws. Cyclic loading was performed to simulate normal gait. Loading was completed in compression at 3,000 N at 1 Hz for a total of 70,000 cycles. Displacement (shortening, coronal and sagittal angulation) was measured at regular intervals. RESULTS The spiral and oblique fracture patterns withstood simulated weight-bearing with minimal displacement. The multifragmented model had early implant failure with breaking of the distal locking screws. The spiral fracture model shortened by a mean of 0.3 mm (SD 0.2), and developed a mean coronal angulation of 2.0° (SD 1.9°) and a mean sagittal angulation of 1.2° (SD 1.1°). On average, 88% of the shortening, 74% of the change in coronal alignment, and 75% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. The oblique fracture model shortened by a mean of 0.2 mm (SD 0.1) and developed a mean coronal angulation of 2.4° (SD 1.6°) and a mean sagittal angulation of 2.6° (SD 1.4°). On average, 44% of the shortening, 39% of the change in coronal alignment, and 79% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. CONCLUSION For spiral and oblique fracture patterns, simulated weight-bearing resulted in a clinically acceptable degree of displacement. Most displacement occurred early in the test period, and the rate of displacement decreased over time. Based on this model, we offer evidence that early weight-bearing appears safe for well reduced oblique and spiral fractures, but not in multifragmented patterns that have poor bone contact. Cite this article: Bone Joint J 2021;103-B(2):294-298.
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Affiliation(s)
- Michael M Hadeed
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Hans Prakash
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Seth R Yarboro
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - David B Weiss
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
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Ponugoti N, Rudran B, Selim A, Nahas S, Magill H. Infrapatellar versus suprapatellar approach for intramedullary nailing of the tibia: a systematic review and meta-analysis. J Orthop Surg Res 2021; 16:94. [PMID: 33509237 PMCID: PMC7844899 DOI: 10.1186/s13018-021-02249-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/19/2021] [Indexed: 01/14/2023] Open
Abstract
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.
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Tetzel L, Guyard M. Saving the lower limb with GlassBONE™ - Successful surgical revision of pseudarthrosis after infected open proximal tibia fracture type IIIC with bioactive glass grafting - A case report. Trauma Case Rep 2020; 31:100382. [PMID: 33426259 PMCID: PMC7779823 DOI: 10.1016/j.tcr.2020.100382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2020] [Indexed: 12/04/2022] Open
Abstract
Background The management of bone defect due to trauma or surgical debridement is a current problem in orthopedic trauma surgery, often complicated by infection and bone nonunion. The graft is one of the most challenging variables in surgical treatment. Bioactive Glass (BAG) as a biocompatible and osteogenic product is a promising bone substitute showing good results in maxillo-facial-, spine surgery and treatment of osteomyelitis. Surprisingly, there is very little data on BAG use in trauma surgery. Case presentation A 51-year-old male patient, involved in a motorcycle accident, suffered an open proximal tibia fracture, type IIIC, of the left leg. Patient was admitted in January of 2013 to a general orthopedic department for surgical treatment. After several surgical revisions due to infection, vascular damage, and bone nonunion, the patient was successfully treated with Masquelet therapy followed by GlassBONE™ grafting (GlassBONE™ 45S5; Norarker). The patient demonstrated excellent results over the course of a two-year follow-up. Conclusions In our experience, GlassBONE™ 45S5 has proven to be an effective bone substitute even in difficult grafting conditions, including multiple surgical revisions for bone nonunion and infection. In our case, at the end of 2 years and 3 months of follow-up, the patient reported no pain, and had no signs of infection. Bone union and full weight bearing was achieved. This case report is oriented by the CARE guidelines for clinical case reports; the patient gave consent for publication. GlassBONE™ 45S5 has proven to be an effective bone substitute even in difficult grafting conditions. Bone nonunion was successfully treated with Masquelet therapy followed by GlassBONE™ grafting. Bone loss due to fracture or surgical debridement is a current problem in orthopedic trauma surgery. Bone fractures are the most widespread trauma in humans.
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Affiliation(s)
- L Tetzel
- Orthopedic Department, University Children's Hospital Basel, Switzerland
| | - M Guyard
- Orthopedic Department, Centre Hospitalier Saint Joseph Saint Luc, Lyon, France
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Eken G, Ermutlu C, Durak K, Atici T, Sarisozen B, Cakar A. Minimally invasive plate osteosynthesis for short oblique diaphyseal tibia fractures: does fracture site affect the outcomes? J Int Med Res 2020; 48:300060520965402. [PMID: 33086906 PMCID: PMC7585894 DOI: 10.1177/0300060520965402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Gokay Eken
- Bursa Acibadem Hospital, Orthopedics and Traumatology Department, Nilufer Bursa, Turkey
| | - Cenk Ermutlu
- Uludag University Faculty of Medicine, Orthopedics and Traumatology Department, Nilufer Bursa, Turkey
| | - Kemal Durak
- Uludag University Faculty of Medicine, Orthopedics and Traumatology Department, Nilufer Bursa, Turkey
| | - Teoman Atici
- Uludag University Faculty of Medicine, Orthopedics and Traumatology Department, Nilufer Bursa, Turkey
| | - Bartu Sarisozen
- Uludag University Faculty of Medicine, Orthopedics and Traumatology Department, Nilufer Bursa, Turkey
| | - Adnan Cakar
- Uludag University Faculty of Medicine, Orthopedics and Traumatology Department, Nilufer Bursa, Turkey
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Tian R, Zheng F, Zhao W, Zhang Y, Yuan J, Zhang B, Li L. Prevalence and influencing factors of nonunion in patients with tibial fracture: systematic review and meta-analysis. J Orthop Surg Res 2020; 15:377. [PMID: 32883313 PMCID: PMC7469357 DOI: 10.1186/s13018-020-01904-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 08/20/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The aim of this study is to assess the prevalence of nonunion in patients with tibia fracture and the association between influencing factors and tibia fracture nonunion. METHOD A database searches of PubMed, the Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Weipu database, and Wanfang database from inception until June 2019 was conducted. The pooled prevalence, odds ratio (OR), and 95% confidence intervals (CI) were calculated with Stata software. RESULTS In this study, 111 studies involving 41,429 subjects were included. In the study of the relationship between influencing factors and tibia fracture nonunion, 15 factors significantly influenced the fracture union, including > 60 years old, male, tobacco smoker, body mass index > 40, diabetes, nonsteroidal anti-inflammatory drugs (NSAIDs) user, opioids user, fracture of middle and distal tibia, high-energy fracture, open fracture, Gustilo-Anderson grade IIIB or IIIC, Müller AO Classification of Fractures C, open reduction, fixation model, and infection. CONCLUSION The prevalence of nonunion in patients with tibia fracture was 0.068 and 15 potential factors were associated with the prevalence. Closed reduction and minimally invasive percutaneous plate osteosynthesis (MIPPO) have the low risks of nonunion for the treatment of tibial fractures.
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Affiliation(s)
- Ruifeng Tian
- Department of Orthopaedics, No.1 Hospital of China Medical University, Shenyang, China
| | - Fang Zheng
- Department of Orthopaedics, No.1 Hospital of China Medical University, Shenyang, China
- Department of Orthopaedics, Shenyang Orthopaedic Hospital, Shenyang, China
| | - Wei Zhao
- Department of Orthopaedics, No.1 Hospital of China Medical University, Shenyang, China
- Department of Orthopaedics, No.4 Hospital of China Medical University, Guangzhou, China
| | - Yuhui Zhang
- Department of Dermatology, No.1 Hospital of China Medical University, Guangzhou, China
| | - Jinping Yuan
- Department of Dermatology, No.1 Hospital of China Medical University, Guangzhou, China
| | - Bowen Zhang
- Department of Orthopaedics, No.1 Hospital of China Medical University, Shenyang, China
| | - Liangman Li
- Department of Orthopaedics, No.1 Hospital of China Medical University, Shenyang, China.
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Alpert M, Grigorian A, Scolaro J, Learned J, Dolich M, Kuza CM, Lekawa M, Nahmias J. Fat embolism syndrome in blunt trauma patients with extremity fractures. J Orthop 2020; 21:475-480. [PMID: 33716415 PMCID: PMC7923246 DOI: 10.1016/j.jor.2020.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/02/2020] [Accepted: 08/25/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE This study sought to provide a national, descriptive analysis to determine fat embolism syndrome (FES) risk factors, hypothesizing that femur fractures and multiple fractures are associated with an increased risk. METHODS The Trauma Quality Improvement Program was queried (2010-2016) for patients with extremity fractures. A multivariable logistic regression analysis model was used. RESULTS From 324,165 patients, 116 patients (0.04%) were diagnosed with FES. An age ≤30, closed femur fracture, and multiple long bone fractures were associated with an increased risk of FES. CONCLUSION Future research to validate these findings and develop a clinical risk stratification tool appears warranted.
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Affiliation(s)
- Miriam Alpert
- Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, 309 E. Second St, Pomona, CA, 91766, USA
| | - Areg Grigorian
- University of California, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 333 the City Blvd West, Suite 1600, Orange, CA, 92868, USA
| | - John Scolaro
- University of California, Department of Orthopaedic Surgery, Division of Trauma, 101 the City Blvd South, Building 29A, Orange, CA, 92868, USA
| | - James Learned
- University of California, Department of Orthopaedic Surgery, Division of Trauma, 101 the City Blvd South, Building 29A, Orange, CA, 92868, USA
| | - Matthew Dolich
- University of California, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 333 the City Blvd West, Suite 1600, Orange, CA, 92868, USA
| | - Catherine M. Kuza
- University of Southern California, Keck School of Medicine, Department of Anesthesiology, 1450 San Pablo St, Suite 3600, Los Angeles, CA, 90033, USA
| | - Michael Lekawa
- University of California, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 333 the City Blvd West, Suite 1600, Orange, CA, 92868, USA
| | - Jeffry Nahmias
- University of California, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 333 the City Blvd West, Suite 1600, Orange, CA, 92868, USA
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Roulet S, De Luca L, Bulla A, Casoli V, Delgove A. The medial adipofascial flap for infected tibia fractures reconstruction: 10 years of experience with 59 cases. ANN CHIR PLAST ESTH 2020; 66:234-241. [PMID: 32800463 DOI: 10.1016/j.anplas.2020.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/12/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the results of the medial adipofascial flap (MAF) in infected tibia fractures reconstruction and to identify criteria for success or failure. PATIENTS AND METHODS Fifty-nine patients treated with a MAF were enrolled. Age, BMI, tobacco use and bone status were recorded. Early and late postoperative complications were assessed. Bone healing and flap success were systematically evaluated at 12 months. RESULTS Tibia fractures were initially open in 48 cases (81%) and closed in 11 cases (19%). Infection was acute (<30 days) in 9 cases (15%) and chronic in 50 (85%). Thirty-one patients (53%) experienced no early postoperative complications (<30 days). There were 10 (17%) cases of necrosis of the skin graft, 2 (3%) cases of necrosis and 4 (7%) haematomas in the harvesting area, 7 (12%) cases of partial flap necrosis at its tip and 4 (7%) flap failures. None of the criteria was statistically correlated with the occurrence of a complication. At 12 months, 53 flaps (90%) were successful. Immediate skin graft were significantly correlated with flap success (P=0.05). Forty-six patients (78%) had complete bone healing documented by CT scan. CONCLUSION The MAF provides a reliable alternative for lower leg reconstruction. Its major advantages are sparing of the major leg vessels, no donor site morbidity and relatively easy and rapid dissection.
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Affiliation(s)
- S Roulet
- Plastic Surgery and Burns Unit, Centre François-Xavier Michelet, Bordeaux University Hospital, 33076 Bordeaux, France; Department of Orthopaedic Surgery 1 and 2, Trousseau University Hospital, Medical University François-Rabelais, Tours, France.
| | - L De Luca
- Plastic Surgery and Burns Unit, Centre François-Xavier Michelet, Bordeaux University Hospital, 33076 Bordeaux, France
| | - A Bulla
- Plastic Surgery Unit, Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Italy
| | - V Casoli
- Plastic Surgery and Burns Unit, Centre François-Xavier Michelet, Bordeaux University Hospital, 33076 Bordeaux, France; School of Surgery, University of Bordeaux, 33076 Bordeaux, France
| | - A Delgove
- Plastic Surgery and Burns Unit, Centre François-Xavier Michelet, Bordeaux University Hospital, 33076 Bordeaux, France; School of Surgery, University of Bordeaux, 33076 Bordeaux, France
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Kulkarni MS, Tummala M, Aroor MN, Vijayan S, Rao SK. Suprapatellar nailing in proximal third tibial fractures - Clinicoradiological outcome. Injury 2020; 51:1879-86. [PMID: 32482425 DOI: 10.1016/j.injury.2020.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/14/2020] [Accepted: 05/03/2020] [Indexed: 02/02/2023]
Abstract
AIMS AND OBJECTIVES To evaluate the clinical and radiological outcome of proximal third tibia fractures managed by suprapatellar nailing with a minimum follow-up of 12 months. METHODOLOGY In our retrospective cohort study of 43 consecutive proximal third tibia fractures from January 2015 to September 2018 treated with intramedullary nailing through suprapatellar approach in semiextended knee position were included. The patients were followed up regularly at 6 weeks, 3 months, 4.5 months, 6 months, 12 months and every 6 months thereafter. At each visit patients were assessed for union, shortening and rotational alignment. The clinical outcome was analysed using Lower Extremity Functional Scale (LEFS) and anterior knee pain. The radiological outcomes are analysed by evaluating the radiographs for progression of fracture union and tibial alignments. RESULTS After fulfilling the exclusion and inclusion criteria, 43 out of 60 consecutive proximal third tibia fracture were included in the study with an average age of 38.4 years (20-71 years), follow up of 20.4 months (12-45 months) after the index procedure. The radiological union was achieved in 7.3 months (4-13 months). At the end of 1 year follow up, the average LEFS was 89.4% (60%-95%). 4 patients had Malunion - with 1 valgus and 3 anterior angulations, 8 delayed unions and 1 non-union (with bone loss- which required bone grafting). All the fractures united eventually. No incidence of anterior knee pain. CONCLUSION We recommend suprapatellar nailing in proximal third tibial fractures when meticulously performed using the current surgical principles and techniques with proper implant selection. It results in excellent clinical and radiological outcomes with minimal complications when compared to other modalities of management. Suprapatellar nailing is a viable option for proximal third tibia fractures due to its inherent advantages of positioning, perfect nail entry and placement. Additionally, noteworthy absence of anterior knee pain is an additional benefit of this technique.
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Li M, Chang H, Wei N, Chang W, Yan Y, Jin Z, Chen W. Biomechanical Study on the Stress Distribution of the Knee Joint After Tibial Fracture Malunion with Residual Varus-Valgus Deformity. Orthop Surg 2020; 12:983-989. [PMID: 32462810 PMCID: PMC7307236 DOI: 10.1111/os.12668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/04/2020] [Accepted: 03/11/2020] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To investigate the effect of residual varus and valgus deformity on the stress distribution of the knee joint after tibial fracture malunion. METHODS Fourteen adult cadaver specimens were selected to establish the models of tibial fractures, which were fixed subsequently at neutral position (anatomical reduction) and malunion positions (at 5°, 10°, and 15° valgus positions, and 5°, 10°, and 15° varus positions). The stress distribution on the medial and lateral plateau of the tibia was quantitatively measured using ultra-low-pressure sensitive film technology. The changes in the stress distribution of the knee joint after tibial fracture malunion and the relationship between the stress values and the residual varus or valgus deformity were analyzed. RESULTS Under 400 N vertical load, the stress values on the medial and lateral plateau of the tibia at the neutral position were 1.137 ± 0.139 MPa and 1.041 ± 0.117 MPa, respectively. When compared with the stress values measured at the neutral position, the stress on the medial plateau of the tibia was significantly higher at varus deformities and lower at valgus deformities, and the stress on the lateral plateau was significantly higher at valgus deformities and lower at varus deformities (all P < 0.05). The stress values on the medial plateau of the tibia were significantly higher than the corresponding data on the lateral plateau at neutral and 5°, 10°, and 15° varus deformities, respectively (all P < 0.05), and significantly lower than the corresponding data on the lateral plateau at 5°, 10°, and 15° valgus deformities, respectively (all P < 0.05). CONCLUSION Residual varus and valgus deformity after tibial fracture malunion can lead to obvious changes of the stress distribution of the knee joint. Therefore, tibial fractures should be reduced anatomically and fixed rigidly to avoid residual varus-valgus deformity and malalignment of lower limbs.
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Affiliation(s)
- Ming Li
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hengrui Chang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ning Wei
- Department of Orthopedic Surgery, The Fourth Hospital of Shijiazhuang, Shijiazhuang, China
| | - Wenli Chang
- Department of Orthopedic Surgery, Cangzhou Hospital of Integrated TCM-WM Hebei, Cangzhou, China
| | - Ying Yan
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zeyue Jin
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wei Chen
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China
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Devendra A, Gupta NP, Zackariya Jaffrulah M, Armstrong BRW, Dheenadhayalan J, Rajasekaran S. Management of Tibial Shaft Fractures Distal to TKA Prosthesis by Intramedullary Nail: A Report of Three Cases. Indian J Orthop 2020; 54:901-908. [PMID: 33133414 PMCID: PMC7573001 DOI: 10.1007/s43465-020-00142-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 05/10/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Diaphyseal tibial fractures distal to a well-fixed tibial component although rare present a significant challenge and optimal treatment remains controversial. Displaced periprosthetic tibial shaft fractures are ideally treated with open reduction internal fixation with plate osteosynthesis. However, this treatment method is associated with weight-bearing restrictions, which can be difficult for elderly patients with multiple comorbidities and balance impairment. We present our experience of internal fixation with an intramedullary nail that uses an inferior entry point, standard intramedullary tibial nail, and conventional instrumentation. MATERIALS AND METHODS Between 2017 and 2018, three patients with acute tibial shaft fractures distal to a TKA (Felix Type 3A) were treated with an intramedullary nail. Preoperative planning involved assessing proximal tibia to ensure adequate room for implant and instrumentation. The average patient age was 66.3 years (range 59-72 years) and all patients were males. All the patients sustained fractures of distal tibial and fibula diaphysis, after a road traffic accident. There were no complications intraoperatively, and all procedures were completed uneventfully. One patient underwent additional fixation of the fibula. RESULTS All patients achieved a radiological fracture union after an average of 20.6 weeks. There were no fixation failures, or nonunions postoperatively. There were no new symptoms relative to the TKA that could be attributed to the tibial nailing procedure. CONCLUSION We recommend that this technique can be used primarily for this fracture pattern distal to a TKA, provided there is adequate space to accommodate the nail and instrumentation proximally anterior to the tibial tray.
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Affiliation(s)
- A. Devendra
- grid.415287.d0000 0004 1799 7521Division of Orthopaedics And Trauma, Ganga Hospital, 313 Mettupalayam Road, Coimbatore, 641043 India
| | - Nishith P Gupta
- grid.415287.d0000 0004 1799 7521Division of Orthopaedics And Trauma, Ganga Hospital, 313 Mettupalayam Road, Coimbatore, 641043 India
| | - Mohd Zackariya Jaffrulah
- grid.415287.d0000 0004 1799 7521Division of Orthopaedics And Trauma, Ganga Hospital, 313 Mettupalayam Road, Coimbatore, 641043 India
| | - B. R. W. Armstrong
- grid.415287.d0000 0004 1799 7521Division of Orthopaedics And Trauma, Ganga Hospital, 313 Mettupalayam Road, Coimbatore, 641043 India
| | - J. Dheenadhayalan
- grid.415287.d0000 0004 1799 7521Division of Orthopaedics And Trauma, Ganga Hospital, 313 Mettupalayam Road, Coimbatore, 641043 India
| | - S. Rajasekaran
- grid.415287.d0000 0004 1799 7521Division of Orthopaedics And Trauma, Ganga Hospital, 313 Mettupalayam Road, Coimbatore, 641043 India
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Byun SE, Maher MH, Mauffrey C, Parry JA. The standard sagittal starting point and entry angle for tibia intramedullary nails results in malreduction of proximal tibial fractures. Eur J Orthop Surg Traumatol 2020; 30:1057-1060. [PMID: 32303842 DOI: 10.1007/s00590-020-02669-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 04/04/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The aim of this study was to determine the sagittal starting point and entry angle necessary for anatomic reduction in proximal tibial fractures and to compare reductions obtained using a standard versus modified sagittal entry angle. METHODS Extra-articular proximal tibial fracture sawbone models were divided into three groups. The first group was used to determine the sagittal starting point and entry angle necessary for an anatomic reduction by inserting nails into the distal fragment and then reducing the proximal fragment over the nail. The second and third groups had nails inserted through the standard coronal and sagittal starting point using the standard sagittal entry angle (parallel to the anterior cortex) versus a more posteriorly directed modified sagittal entry angle (directed at the center of the tibia at the level of the tibia tubercle prominence). Fracture gapping and translation in the sagittal plane were measured for each group. RESULTS Anatomic reduction was only possible with a sagittal starting point that was too posterior for actual use. The standard sagittal entry angle resulted in greater posterior fracture translation and less anterior fracture gapping then the modified sagittal entry angle, 10.6 ± 1.1 versus 1.6 ± 2.8 mm (p < 0.01) and 1.3 ± 0.5 versus 5.3 ± 2.5 mm (p = 0.01), respectively. CONCLUSION Anatomic reduction was not achieved with the standard sagittal starting point and entry angle. Considering these finding, surgeons should have a low threshold to utilize adjunct reduction methods for these injuries.
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Affiliation(s)
- Seong-Eun Byun
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
| | - Mike H Maher
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
| | - Cyril Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
| | - Joshua A Parry
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA.
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Park S, Moon SW, Lee J, Kim JW. Intramedullary tibia nailing with external fixation. Eur J Trauma Emerg Surg 2020; 47:1947-1955. [PMID: 32221638 DOI: 10.1007/s00068-020-01351-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 03/16/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE This study introduces an intramedullary nailing technique with external fixation and aims to determine the safest position of Schanz screws for this technique. METHODS Patients undergoing intramedullary nailing were evaluated by computed tomography to assess the anteroposterior (AP) length of the medullary canal and the distance between the posterior cortex and the posterior border of the nail at the level of interest in the proximal and distal tibia. In this cadaveric study, screws were inserted at the level of interest, followed by a determination of the anatomical relationship between inserted screws and nearby neurovascular structures. RESULTS The safe area for inserting Schanz screws in the medial to lateral direction in the proximal tibia was found to be 1.5-4.5 cm distal to the knee joint line on the AP view, 1 cm anterior to the posterior cortex at the distal 4.5 cm level, and ≤ 24 mm from the posterior cortex on the lateral view. In males, the area 1.5-3.0 cm proximal to the tibial plafond and 0.5 cm anterior to the posterior cortex on the lateral view was found to be a safe zone. However, in females, the safe zone was defined as an area 1.5 cm proximal to the tibial plafond and just anterior to the posterior cortex. CONCLUSION This study defined the safe zones of Schanz screws for intramedullary nailing with an external fixator. These safe zones would be helpful for external fixation during intramedullary tibia nailing.
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Affiliation(s)
- Sehan Park
- Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sang Won Moon
- Department of Orthopedic Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jaehyung Lee
- Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Brito A, Godat LN, Costantini TW, Smith AM, Doucet JJ, Berndtson AE. The Effects of Cross-Border Transport on Patients With Tibia Fractures. J Surg Res 2020; 249:91-8. [PMID: 31926401 DOI: 10.1016/j.jss.2019.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/12/2019] [Accepted: 12/12/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Tibia fractures are common after trauma. Prior studies have shown that delays in treatment are associated with poor outcomes. A subpopulation of our patients are transported from Mexico, adding barriers to prompt care. We hypothesized that patients with tibia fractures crossing from Mexico would have delays in treatment and subsequently worse outcomes. METHODS The trauma registry of an American College of Surgeons-verified level 1 trauma center was retrospectively reviewed for all tibia fractures admitted from 2010 to 2015. Data collection included demographics, country of injury, characterization of injuries, interventions, complications, and outcomes. Patients were subdivided into those injured in the United States and in Mexico, and the two groups were compared. RESULTS A total of 498 patients were identified, 440 from the United States and 58 from Mexico. Mexico patients were more severely injured overall, with higher injury severity scores and a higher percentage of patients with abbreviated injury scale scores ≥3 for both head and chest regions. Mexico patients had longer times from injury to admission, as well as increased times to both debridement of open fractures and operative fixation after admission. On subgroup analysis of patients with isolated tibia fractures (other system abbreviated injury scale < 3), times from arrival to treatment and injury severity score were no longer statistically different. CONCLUSIONS Patients crossing the border from Mexico with tibia fractures have delays in time to admission and from admission to operative management, although this is primarily due to other severe injuries. Ongoing systems development is required to minimize delays in care and optimize outcomes.
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Józsa G, Fülöp BD, Kovács L, Czibere B, Szegeczki V, Kiss T, Hajdú T, Tamás A, Helyes Z, Zákány R, Reglődi D, Juhász T. Lack of Pituitary Adenylate Cyclase-Activating Polypeptide (PACAP) Disturbs Callus Formation. J Mol Neurosci 2021; 71:1543-55. [PMID: 31808034 DOI: 10.1007/s12031-019-01448-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/13/2019] [Indexed: 12/20/2022]
Abstract
Pituitary adenylate cyclase–activating polypeptide (PACAP) is a naturally secreted signaling peptide and has important regulatory roles in the differentiation of the central nervous system and its absence results in disorders in femur development. PACAP has an important function in prevention of oxidative stress or mechanical stress in chondrogenesis but little is known about its function in bone regeneration. A new callus formation model was set to investigate its role in bone remodeling. Fracturing was 5 mm distal from the proximal articular surface of the tibia and the depth was 0.5 mm. Reproducibility of callus formation was investigated with CT 3, 7, and 21 days after the operation. Absence of PACAP did not alter the alkaline phosphatase (ALP) activation in PACAP KO healing process. In developing callus, the expression of collagen type I increased in wild-type (WT) and PACAP KO mice decreased to the end of healing process. Expression of the elements of BMP signaling was disturbed in the callus formation of PACAP KO mice, as bone morphogenic protein 4 (BMP4) and 6 showed an early reduction in bone regeneration. However, elevated Smad1 expression was demonstrated in PACAP KO mice. Our results indicate that PACAP KO mice show various signs of disturbed bone healing and suggest PACAP compensatory and fine tuning effects in proper bone regeneration.
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Llorente Pelayo S, Rodríguez Fernández J, Leonardo Cabello MT, Rubio Lorenzo M, García Alfaro MD, Arbona Jiménez C. [Current diagnosis and management of toddler's fracture]. An Pediatr (Barc) 2019; 92:262-267. [PMID: 31311775 DOI: 10.1016/j.anpedi.2019.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/14/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Toddler's fracture is an accidental spiral tibial fracture, characteristic of the early childhood. The objective of this study is to determine the incidence and current diagnosis and management of this disorder. PATIENTS AND METHODS A retrospective study was conducted on a sample of patients aged 0-3 years diagnosed with a toddler's fracture in a tertiary hospital between years 2013 and 2017. RESULTS A total of 53 patients were registered (10.6 cases per year). The median age was 2 years, with a slight male predominance. The initial radiograph was normal in 24.5% of patients. With the initial approach, 69.8% of patients were diagnosed with fracture, 11.3% with suspected fracture, and 18.9% with contusion. A follow-up was required in 22% required a control test, using radiographs in 10 patients (pathological 90%), and ultrasound in 5 (pathological 80%, 3 of them with normal initial radiography). The large majority (80.8%) of the patients were immobilised with a cast, while flexible immobilisation or non-immobilisation was used in 19.2%. Complications were found in a 21.4% of patients immobilised with splint, mainly skin injuries (19%). These were more frequent in this group than in those that were not immobilised (21.4% vs. 0%, P=.006); with no significant differences in time to weight-bearing. CONCLUSIONS Radiography has a limited sensitivity for the diagnosis of toddler's fracture. In the group of patients with normal radiography, the use of ultrasound can be helpful to the diagnosis and avoid additional radiation. Even though the most common treatment continues to be immobilisation with a splint, the alternative without rigid immobilisation does not seem to give worse results, even with lower morbidity associated with the treatment.
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Affiliation(s)
| | - Juan Rodríguez Fernández
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | | | - Mónica Rubio Lorenzo
- Unidad de Ortopedia Infantil, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - M Dolores García Alfaro
- Unidad de Ortopedia Infantil, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Carmelo Arbona Jiménez
- Unidad de Ortopedia Infantil, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
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Ladurner A, Acklin YP, Mueller TS, Sommer C. Decrease surgery time by using an alternative lateral parapatellar approach for tibia shaft fracture nailing. Arch Orthop Trauma Surg 2019; 139:943-949. [PMID: 30847622 DOI: 10.1007/s00402-019-03154-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Medial parapatellar or transpatellar ligament approaches are commonly used for nail osteosynthesis in tibia shaft fractures. The lower leg is normally in a hanging position to allow guide wire insertion and reaming of the tibia. However, this position complicates fracture reduction and retention, as well as image intensification throughout the procedure. A lateral parapatellar approach with the lower leg in a semi-extended, horizontal position has been previously described for proximal tibial fracture fixation. The purpose of the presented study was to share the lateral parapatellar approach technique used in our institution and to analyse its feasibility for tibia shaft fracture fixation when compared to a medial parapatellar and transpatellar incision technique. MATERIALS AND METHODS All patients with tibial shaft fractures treated at our institution between 2009 and 2012 by intramedullary nailing through either a transpatellar, a medial parapatellar or a lateral parapatellar approach were reviewed. Demographics, injury pattern and the operative procedure, especially operation and fluoroscopy time, were analysed. RESULTS 73 patients were enrolled into the study. Twenty-six patients were treated by use of a lateral parapatellar approach, whilst a transpatellar or a medial parapatellar approach was chosen in 29 and 18 cases, respectively. Patients' characteristics were similar regarding gender and body mass index. When compared to the transpatellar (126 ± 30 min) or the medial parapatellar approach (105 ± 29 min), surgical time was significantly shorter in the lateral parapatellar approach group (96 ± 29 min). Likewise, shorter image intensifier time was documented when a lateral parapatellar approach was chosen (211 ± 189 s) compared to the transpatellar (347 ± 204 s) or the medial parapatellar approach (241 ± 222 s). CONCLUSION The extra-articular semi-extended tibial nailing technique using a lateral parapatellar approach was associated with a significant decrease in time of surgery, while fluoroscopy time was shorter but not significantly different between the three groups.
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Affiliation(s)
- Andreas Ladurner
- Department of Trauma Surgery, Kantonsspital Graubünden, Loestrasse 170, 7000, Chur, Switzerland.
| | - Yves P Acklin
- Department of Trauma Surgery, Kantonsspital Graubünden, Loestrasse 170, 7000, Chur, Switzerland
| | - Thomas S Mueller
- Department of Trauma Surgery, Kantonsspital Graubünden, Loestrasse 170, 7000, Chur, Switzerland
| | - Christoph Sommer
- Department of Trauma Surgery, Kantonsspital Graubünden, Loestrasse 170, 7000, Chur, Switzerland
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Rausch V, Hackl M, Oppermann J, Leschinger T, Scaal M, Müller LP, Wegmann K. Peroneal nerve location at the fibular head: an anatomic study using 3D imaging. Arch Orthop Trauma Surg 2019; 139:921-926. [PMID: 30737594 DOI: 10.1007/s00402-019-03141-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Injuries to the peroneal nerve are a common complication in operative treatment of proximal tibial or fibular fractures. To minimize the risk of iatrogenic injury to the nerve, detailed knowledge of the anatomy of the peroneal nerve is essential. Aim of this study was to present a detailed description of the position and branching of the peroneal nerve based on 3D-images to assist preparation for surgical approaches to the fibular head and the tibial plateau. METHODS The common peroneal nerve, the deep and the superficial peroneal nerve were marked with a radiopaque thread in 18 formalin-embalmed specimens. Three-dimensional X-ray scans were then acquired from the knee and the proximal lower leg in full extension of the knee. In 3D-reconstructions of these scans, distances of the common peroneal nerve and its branches to clearly defined osseous landmarks were measured digitally. Furthermore, the height of the branching of the common peroneal nerve was measured in relation to the landmarks. RESULTS The mean distance of the common peroneal nerve at the level of the tibial plateau to its posterior osseous limitation was 7.92 ± 2.42 mm, and 1.31 ± 2.63 mm to the lateral osseous limitation of the tibia. In a transversal plane, distance of the common peroneal nerve branching was 27.56 ± 3.98 mm relative to the level of the most proximal osseous extension of fibula and 11.77 ± 6.1 mm relative to the proximal extension of the tibial tuberosity. The deep peroneal nerve crossed the midline of the fibular shaft at a distance of 22.14 mm ± 4.35 distally to the most proximal extension of the fibula, the superficial peroneal nerve at a distance of 33.56 mm ± 6.68. CONCLUSION As the course of the peroneal nerve is highly variable in between individuals, surgical dissection for operative treatment of proximal posterolateral tibial or fibular fractures has to be done carefully. We defined an area were the peroneal nerve and its branches are unlikely to be found. However, specific safe zones should not be utilized due to the individual anatomic variation.
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Affiliation(s)
- V Rausch
- Center for Orthopedic and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital, Kerpener Str. 62, 50937, Cologne, Germany.
| | - M Hackl
- Center for Orthopedic and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital, Kerpener Str. 62, 50937, Cologne, Germany
| | - J Oppermann
- Center for Orthopedic and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital, Kerpener Str. 62, 50937, Cologne, Germany
| | - T Leschinger
- Center for Orthopedic and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital, Kerpener Str. 62, 50937, Cologne, Germany
| | - M Scaal
- Department of Anatomy II, Medical Faculty, University of Cologne, Cologne, Germany
| | - L P Müller
- Center for Orthopedic and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital, Kerpener Str. 62, 50937, Cologne, Germany
| | - K Wegmann
- Center for Orthopedic and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital, Kerpener Str. 62, 50937, Cologne, Germany
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Abstract
The suprapatellar nailing technique is an important adjunct in the armamentarium of an orthopedic surgeon. Although a variety of new instrumentations are required for insertion of the suprapatellar nail, most companies now carry these instruments. Easier positioning, maintenance of reduction, ease of intraoperative fluoroscopy, more anatomic starting trajectory, decreased malreduction rates, and possible decrease in anterior knee pain are all benefits of suprapatellar nailing, thus making mastery of this technique essential for an orthopedic surgeon.
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Affiliation(s)
- Gennadiy A Busel
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 5 Tampa General Circle, Suite 710, Tampa, FL 33606, USA
| | - Hassan Mir
- Department of Orthopaedic Surgery, Florida Orthopaedic Institute, 5 Tampa General Circle, Suite 710, Tampa, FL 33606, USA.
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Le Baron M, Vivona JP, Maman P, Volpi R, Flecher X. Can the Reamer/Irrigator/Aspirator System replace anterior iliac crest grafting when treating long bone nonunion? Orthop Traumatol Surg Res 2019; 105:529-533. [PMID: 30885818 DOI: 10.1016/j.otsr.2018.12.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 10/05/2018] [Accepted: 12/11/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Autologous bone graft is the gold standard for filling bone defects associated with diaphyseal nonunions. It is typically harvested from the anterior iliac crest (AIC) despite the high complication rate. The Reamer/Irrigator/Aspirator System (RIA) was developed to recover the reaming aspirate and use it as autograft. Initially described for harvesting bone from the femur, the bone volume available is similar to the AIC site; however, its use directly at nonunion sites has been studied very little. HYPOTHESES Compared to AIC harvesting, RIA at a non-union site will result in (1) sufficient bone volume, (2) similar time to union and union rate, (3) lower morbidity. RESULTS Two groups of patients received an autograft for aseptic nonunion of the tibia or femur for a bone defect up to 2cm: the RIA group (n=30) was followed prospectively and received an autograft by RIA while the AIC group (n=29) was reviewed retrospectively and received an autograft by AIC. We compared the time to union and union rate, operative time, intake of analgesics, duration of hospital stay and complication rate between groups. The RIA provided sufficient bone, 60cm3 on average in a reliable manner. The union rate was similar between groups: 90% (RIA) and 89.7% (CIA) (p=0.965), while the time to union was shorter in the RIA group (8.63±1.47months vs. 10.08±1.7 months) (p=0.006). The operative time (p<0.0001), analgesic intake (p=0.013), length of stay (p<0.0001) and immediate complication rate (p=0.0195) were higher in the AIC group. DISCUSSION For the treatment of aseptic long bone nonunion, autograft harvested by the RIA from the nonunion site results in similar union rate and time to union as AIC grafts without additional complications. LEVEL OF EVIDENCE IV, comparative retrospective study.
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Affiliation(s)
- Marie Le Baron
- Institut du mouvement et de l'appareil locomoteur, CHU Marseille Nord, chemin des Bourrely, 13015 Marseille, France.
| | - Jean-Philippe Vivona
- Polyclinique du Parc-Rambot - Provençale, 67, cours Gambetta, 13100 Aix-en-Provence, France
| | - Pascal Maman
- Institut du mouvement et de l'appareil locomoteur, CHU Marseille Nord, chemin des Bourrely, 13015 Marseille, France
| | - Richard Volpi
- Institut du mouvement et de l'appareil locomoteur, CHU Marseille Nord, chemin des Bourrely, 13015 Marseille, France
| | - Xavier Flecher
- Institut du mouvement et de l'appareil locomoteur, CHU Marseille Nord, chemin des Bourrely, 13015 Marseille, France
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Liu YB, Lin LP, Zou R, Zhao QH, Lin FQ. Silencing long non-coding RNA MEG3 accelerates tibia fraction healing by regulating the Wnt/β-catenin signalling pathway. J Cell Mol Med 2019; 23:3855-3866. [PMID: 30955246 PMCID: PMC6533481 DOI: 10.1111/jcmm.14229] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 01/21/2019] [Accepted: 01/25/2019] [Indexed: 02/06/2023] Open
Abstract
As fracture healing is related to gene expression, fracture healing is prospected to be implicated in long non‐coding RNAs (lncRNAs). This study focuses on the effects of epigenetic silencing of long non‐coding RNA maternally expressed gene 3 (lncRNA MEG3) on fracture healing by regulating the Wnt/β‐catenin signalling pathway. Genes expressed in fracture were screened using bioinformatics and the subcellular location of MEG3 was determined using FISH. Next, we successfully established tibia fracture (TF) models of C57BL/6J and Col2a1‐ICAT mice and the effect of silencing lncRNA MEG3 on fracture healing was detected after TF mice were treated with phosphate buffer saline (PBS), MEG3 siRNA and scramble siRNA. X‐ray imaging, Safranin‐O/fast green and haematoxylin‐eosin (HE) staining and histomorphometrical and biomechanical analysis were adopted to observe and to detect the fracture healing conditions. Additionally, the positive expression of collagen II and osteocalcin was examined using immunohistochemistry. At last, in the in vitro experiment, the relationship of MEG3 and the Wnt/β‐catenin signalling pathway in fraction healing was investigated. MEG3 was located in the cell nucleus. In addition, it was found that MEG3 and the Wnt/β‐catenin signalling pathway were associated with fraction healing. Moreover, silencing MEG3 was proved to elevate callus area and maximum bending load and to furthermore enhance the recanalization of bone marrow cavity. Finally, MEG3 knockdown elevated levels of Col10a1, Runx2, Osterix, Osteocalcin, Wnt10b and β‐catenin/β‐catenin whereas it reduced p‐GSK‐3β/GSK‐3β levels. Taken together, our data supported that epigenetic silencing of lncRNA MEG3 could promote the tibia fracture healing by activating the Wnt/β‐catenin signalling pathway.
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Affiliation(s)
- Yu-Bao Liu
- Department of Orthopaedics, Luhe People's Hospital of Nanjing, Nanjing, P.R. China
| | - Lu-Pan Lin
- Department of Orthopaedics, Luhe People's Hospital of Nanjing, Nanjing, P.R. China
| | - Rui Zou
- Department of Orthopaedics, Luhe People's Hospital of Nanjing, Nanjing, P.R. China
| | - Qing-Hua Zhao
- Department of Orthopaedics, Luhe People's Hospital of Nanjing, Nanjing, P.R. China
| | - Fu-Qing Lin
- Department of Orthopaedics, Luhe People's Hospital of Nanjing, Nanjing, P.R. China
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Ull C, Jansen O, Seybold D, Königshausen M, Schildhauer TA, Gessmann J. Differences between primary and secondary definitive osteosynthesis for fractures of the lower leg with concomitant acute compartment syndrome. Eur J Trauma Emerg Surg 2019; 46:1167-1173. [PMID: 30747274 DOI: 10.1007/s00068-019-01089-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To analyze the differences in outcomes between primary and secondary definitive osteosynthesis for fractures of the lower leg with concomitant acute compartment syndrome (ACS). METHODS From our trauma database, we identified a total of 107 patients with 126 fractures of AO/OTA type 41-44 and 120 ACS from January 01, 2001 to December 31, 2015 who were treated with primary or secondary definitive osteosynthesis after concomitant fasciotomy. RESULTS Seventy-one patients with 77 fractures of AO/OTA classification type 41-44 suffering ACS received primary definitive osteosynthesis at the time of compartmental incision (POCI) and were compared to 36 patients with 49 fractures of AO/OTA type 41-44 and ACS, who received secondary definitive osteosynthesis after compartmental incision and soft tissue coverage (SOCI). Patients with POCI had a significantly shorter length of hospital stay with significantly fewer necessary surgeries to achieve definitive fracture treatment and soft tissue closure than SOCI patients (p ≤ 0.001). The overall rate of infections in both groups was 13%, without any difference between POCI and SOCI. CONCLUSIONS POCI for AO/OTA fractures type 41-44 with ACS is a safe and effective procedure without increasing the infection rate compared to a gradual treatment (SOCI). However, the possible selection bias due to the retrospective study design needs to be considered.
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Affiliation(s)
- Christopher Ull
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.
| | - Oliver Jansen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Dominik Seybold
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Matthias Königshausen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Thomas Armin Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Jan Gessmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.
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Rafael Arceo S, Runner RP, Huynh TD, Gottschalk MB, Schenker ML, Moore TJ. Disparities in follow-up care for ballistic and non-ballistic long bone lower extremity fractures. Injury 2018; 49:2193-2197. [PMID: 30314632 DOI: 10.1016/j.injury.2018.09.053] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 09/27/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To describe differences in follow-up compliance and emergency department (ED) visits between ballistic and non-ballistic operative lower extremity fracture patients. DESIGN Retrospective study. SETTING Urban level 1 trauma center. PATIENTS/PARTICIPANTS Patients age ≥18 years with ≥1 tibia or femur fractures treated with ORIF or intramedullary nailing (IMN) between September 1, 2013 and August 31, 2015. MAIN OUTCOME MEASURE A compliance fraction calculated as ([number of attended follow-up visits] / [number of attended follow-up visits + number of missed follow-up visits]) and ED visits in the post-operative period. RESULTS 612 patients were studied. Patients with ballistic lower extremity fractures had a younger mean age (30.8 years v. 41.6 years; p < 0.0001); a shorter length of stay (5.00 days v. 8.00 days; p < 0.0001); and were more likely to be male (92.6% v. 68%; p < 0.0001) and African-American (90.1% v. 63.1%; p < 0.0001) when compared to non-ballistic long bone injuries. Increased follow-up compliance (defined as a compliance fraction ≥0.75) was associated with having a non-ballistic fracture (OR 1.73, 1.13-2.64; p = 0.01), not having an ED visit (OR 2.08, 1.30-3.33; p = 0.002), and being female (OR 1.82, 1.27-2.61; p = 0.001). Increased ED utilization (≥ 1 ED visit) was associated with ballistic mechanism (OR 1.95, 1.20-3.16; p = 0.006), a low follow-up compliance fraction (OR 2.08, 1.30-3.33; p = 0.0019), homelessness (OR 3.91, 1.53-9.98; p = 0.006), and African-American race (OR 2.26, 1.26-4.05; p = 0.05). Scheduling a specific follow-up visit on the discharge summary did not predict higher compliance (OR 1.51, 0.98-2.33; p = 0.06). Conversely, the lack of a specific follow-up visit scheduled on the discharge summary did not predict ED utilization (OR 0.63, 0.34-1.17; p = 0.14). CONCLUSION The results of this study demonstrate that increased utilization of the ED was associated with ballistic fractures, homelessness, decreased clinic compliance, and African American race. Furthermore, patients with non-ballistic injuries, women, and those without any ED visit were more likely to have higher outpatient clinic compliance.
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Affiliation(s)
- S Rafael Arceo
- Emory University School of Medicine, Department of Medicine, United States
| | - Robert P Runner
- Emory University School of Medicine, Department of Orthopaedics, United States
| | | | | | - Mara L Schenker
- Emory University School of Medicine, Department of Orthopaedics, United States
| | - Thomas J Moore
- Emory University School of Medicine, Department of Orthopaedics, United States.
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Wennergren D, Bergdahl C, Ekelund J, Juto H, Sundfeldt M, Möller M. Epidemiology and incidence of tibia fractures in the Swedish Fracture Register. Injury 2018; 49:2068-2074. [PMID: 30220634 DOI: 10.1016/j.injury.2018.09.008] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 09/05/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There is a lack of epidemiological studies of fractures in all segments of the tibia classified by orthopaedic surgeons according to the AO/OTA classification. Since 2011, the Swedish Fracture Register (SFR) has provided prospectively collected, population-based data on fractures of all types, treated both surgically and non-surgically. The aim of this study was to describe the epidemiology and incidence of fractures in all segments of the tibia in a cohort of consecutive tibia fractures over a period of five years at Sahlgrenska University Hospital, Gothenburg, Sweden. METHODS Information on age, gender, date and mechanism of injury, fracture classification according to AO/OTA, affected side and high- or low-energy trauma was extracted from the SFR for all patients, aged 16 years and above, with tibia fractures treated at Sahlgrenska University Hospital, Gothenburg, during the five-year period 1 January 2011 to 31 December 2015. RESULTS 1325 patients sustained 1371 tibia fractures. There were 712 proximal tibia fractures, 417 tibial shaft fractures and 242 distal tibia fractures. Patients with proximal tibia fractures had a higher mean age (54.3) and 58% were women, whereas patients with shaft and distal fractures had a slightly lower mean age (47.0 and 48.7 respectively) and a dominance of men (59% and 54% respectively). The overall incidence of tibia fractures was 51.7 per 100,000 and year. The incidence of proximal, diaphyseal and distal tibia fractures was 26.9, 15.7 and 9.1 respectively per 100,000 and year. Among women, tibia fractures showed an increasing incidence with age in all segments, whereas men had a fairly flat incidence curve, except for tibial shaft fractures, which displayed a peak among young males. The incidence of tibia fractures and graphs for age-specific incidence for each segment of the tibia are presented. CONCLUSIONS This study describes the epidemiology and incidence of fractures in the whole of the tibia classified by orthopaedic surgeons according to the AO/OTA classification.
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Affiliation(s)
- David Wennergren
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden.
| | - Carl Bergdahl
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
| | - Jan Ekelund
- Centre of Registers, Western Healthcare Region, Gothenburg, Sweden
| | - Hans Juto
- Department of Surgical and Perioperative Science (Orthopaedics), Sunderby Research Unit, Umeå University, Umeå, Sweden
| | - Mikael Sundfeldt
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
| | - Michael Möller
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
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Erinç S, Esenkaya İ, Poyanlı OŞ, Özturan B, Ayaz M, Öztürk AT. Ultrasonographic comparison of bilateral patellar tendon dimensions in patients treated via intramedullary tibial nailing using a transpatellar approach. Acta Orthop Traumatol Turc 2018; 52:423-427. [PMID: 30177451 PMCID: PMC6318500 DOI: 10.1016/j.aott.2018.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 07/20/2018] [Accepted: 07/30/2018] [Indexed: 12/03/2022]
Abstract
Objective One of the most common complications following intramedullary nailing of a tibial shaft fracture is anterior knee pain. The etiology of pain remains unclear. Patellar tendon entry point is the most suspected reason for anterior knee pain. This study, sonographically examined the patellar tendons of patients treated via intramedullary nailing. Methods Thirty-two patients with a tibial shaft fracture requiring intramedullary nailing via a transpatellar approach were included in the study. After all patients were grouped by reference to the presence of anterior knee pain, bilateral patellar tendon ultrasonography was performed. Results Thirty-two patients were included in the study. Patients were measured postop average in 38.3 months (10th months - 84th months). It was determined that 10 patients of total 32 (31.3%) had anterior knee pain. There were no statistically differences between study groups in the length of patellar tendon. In the painless group; patellar tendon was wider and thicker in the operated side than the non operated side. The mean differences in the thickness between operated side versus non – operated side of the painless group were 5.3 ± 1.8 in the operated side and 3.9 ± 1.4 in the non – operated side (p = 0.007 < 0.05). The corresponding values for width of the patellar tendon was 29.6 ± 3.3 in the operated side and 27.6 ± 3.8 in the non – operated side (p = 0.007 ˂ 0.05). As a result, there were no statistically significant differences between width and thickness of the patellar tendons in the painful group, on the contrary, in the painless group; patellar tendons were wider and thicker in the operated side than those in the non - operated side. Mean values for thickness of the operated and non-operated side were 5.9 ± 2.3 and 4.2 ± 2.0, respectively (p = 0.059 > 0.05). Mean values for width of the operated and non-operated side were 30.2 ± 4.5 and 28.5 ± 4.0, respectively (p = 0.103 > 0,05). Conclusion Based on the ultrasonographic investigation of their patellar tendons after intramedullary nailing of a tibial shaft fracture, in the painless patients group; the patellar tendon was wider and thicker in the operated side than the non – operated side, however, in the painful patients there were no statistically significant differences between this parameters. Although the number of patients was not sufficient to conclude precise relation between patellar tendon entry point and anterior knee pain, we determined that thicker and wider tendon might be less related to anterior knee pain. Level of evidence Level IV, therapeutic study.
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Affiliation(s)
- Samet Erinç
- Department of Orthopedics and Traumatology Service, Şişli Hamidiye Etfal Research and Training Hospital, Istanbul, Turkey.
| | - İrfan Esenkaya
- Istanbul Medeniyet University, Faculty of Medicine, Department of Orthopaedics and Traumatology, Istanbul, Turkey.
| | - Oğuz Şükrü Poyanlı
- Istanbul Medeniyet University, Faculty of Medicine, Department of Orthopaedics and Traumatology, Istanbul, Turkey.
| | - Burak Özturan
- Department of Orthopedics and Traumatology Service, Nizip State Hospital, Gaziantep, Turkey.
| | - Muzaffer Ayaz
- Istanbul Medeniyet University, Göztepe Training and Research Hospital, Department of Radiology, Istanbul, Turkey.
| | - Afşar Timuçin Öztürk
- Istanbul Medeniyet University, Göztepe Training and Research Hospital, Department of Orthopedics and Traumatology, Istanbul, Turkey.
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Williamson M, Iliopoulos E, Williams R, Trompeter A. Intra-operative fluoroscopy time and radiation dose during suprapatellar tibial nailing versus infrapatellar tibial nailing. Injury 2018; 49:1891-1894. [PMID: 30017180 DOI: 10.1016/j.injury.2018.07.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/15/2018] [Accepted: 07/04/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fractures of the tibial shaft are routinely managed with intramedullary nailing. An increasingly accepted technique is the suprapatellar extended leg method. The aim of this study was to investigate whether the suprapatellar tibial nailing technique offers shorter intraoperative fluoroscopy times and lower radiation doses when compared to the traditional infrapatellar technique. STUDY DESIGN AND METHODS Data from 200 consecutive intramedullary tibial nailing operations in our level 1 Major Trauma Centre were retrospectively collected from a prospective database (January 2014-December 2017). Only acute diaphyseal nailing procedures were included. The operations were performed by seven senior trauma consultants experienced in both suprapatellar and infrapatellar tibial nailing. The operations were divided into two groups: infrapatellar and suprapatellar. Intraoperative radiation time and dose data were collected. RESULTS A total of 90 cases were included and analysed. The majority of the patients were male (82%). 37 operations were infrapatellar and 53 were suprapatellar. Independent samples t-test revealed lower radiation time and dose for the suprapatellar group. The infrapatellar group had a mean radiation time of 129.7 ± 56.6 s versus 94.4 ± 47.9 s for the suprapatellar group. The infrapatellar group had a mean radiation dose (Dose Area Product) 53.6 ± 34.2 cGY cm2 versus 38.2 ± 26.7 cGY cm2 for the suprapatellar group. The difference in mean radiation time and mean radiation dose were both significant (p = 0.002 and p = 0.02 respectively). CONCLUSIONS Suprapatellar tibial nailing is an increasingly accepted technique in the management of tibial fractures. It is shown here that amongst surgeons experienced in both suprapatellar and infrapatellar nailing techniques, the suprapatellar approach trends towards lower use of intra-operative fluoroscopy as measured by time and dose and thus potentially lower radiation exposure to the operating surgeon, assistants and patient.
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Affiliation(s)
- M Williamson
- Trauma & Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| | - E Iliopoulos
- Trauma & Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| | - R Williams
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| | - A Trompeter
- Trauma & Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
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Ozcan C, Turkmen I, Sokucu S. Comparison of three different approaches for anterior knee pain after tibia intramedullary nailing. Eur J Trauma Emerg Surg 2018; 46:99-105. [PMID: 30039307 DOI: 10.1007/s00068-018-0988-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 07/17/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The aim of this study was to compare anterior knee pain and functional outcomes in patients who underwent intramedullary tibial nailing using transpatellar, medial parapatellar or suprapatellar nail entry methods. METHODS We retrospectively reviewed patients who underwent tibial fracture repair in our clinic between January 2010 and March 2017. After applying the exclusion criteria, 58 patients were included in the study. Patients were divided into 3 groups based on the nailing approach: medial parapatellar, transpatellar or suprapatellar. Age, body mass index, follow-up duration, Kujala Score, Lysholm Knee Score, anterior knee pain, length of hospitalization and surgical duration were assessed. RESULTS Of the 58 patients studied, 21 underwent a transpatellar (TP) approach, 16 a medial parapatellar (MP) approach, and 21 a suprapatellar (SP) approach. The mean Kujala Score of patients who had the TP approach was 80 ± 7.15 (72-93) and the average Lysholm Knee Score was 80.23 ± 8.74 (70-95). There was no statistically significant difference between Kujala Scores (p = 0.38) or Lysholm Knee Scores (p 0.06) among the groups; similarly, no statistically significant difference was found among the three groups in terms of anterior knee pain, length of hospitalization or surgical duration (p > 0.05). CONCLUSION The suprapatellar tibia nailing method is as safe and reliable as transpatellar and medial parapatellar methods in terms of effect on postoperative anterior knee pain and functional outcomes. LEVEL OF EVIDENCE Level 3 case-control study.
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Affiliation(s)
- Cagri Ozcan
- Department of Orthopaedics and Traumatology, SBU Umraniye Training and Research Hospital, Elmalikent mh, Umraniye, 34764, Istanbul, Turkey.
| | - Ismail Turkmen
- Department of Orthopaedics and Traumatology, SBU Umraniye Training and Research Hospital, Elmalikent mh, Umraniye, 34764, Istanbul, Turkey
| | - Sami Sokucu
- Department of Orthopaedics and Traumatology, Istanbul Aydın University Medical Park Florya Hospital, Akasya Sk, Kucukcekmece, 34295, Istanbul, Turkey
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Stenroos A, Brinck T, Handolin L. Recommendation of use of checklists in tibial intramedullary nail removal: Retrospective study of mechanical complications related to nail removal. Injury 2018; 49:1341-7. [PMID: 29793696 DOI: 10.1016/j.injury.2018.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 05/09/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The removal of implants such as intramedullary nails is one of the most common operations in orthopedic surgery. The indications for orthopedic implants removal will always remain a subject of conversation and hardly supported by literature. The aim of this study to report injuries of treatment in tibial nail removal and to determine if there are fracture characteristics, patient demographics, or surgical details that may predict a complication. METHODS This is a retrospective seven-year (2010-2016) study including a total of 389 tibial intramedullary nail removals at the Helsinki University Hospital's orthopedic unit. Patients with tibial fracture and removal of intramedullary nail were identified from the hospital discharge register and analyzed. RESULTS A total of 21 (5,4%) nail removal related mechanical complications (iatrogenic fractures, nerve injuries, failures to remove the nail) were noted. The most common complication was iatrogenic fracture (n = 15, 3,8%). In 6/15 cases the fracture was caused by broken interlocking screws, In 5/15 cases the iatrogenic fracture was caused accidentally by extracting the nail without prior removal of all distal interlocking screws. In one case, new condensed bone had formed around the nail's distal end and case the forced nail extraction caused a re-fracture in both tibia and fibula. CONCLUSION Nail removal can be a challenging operation which does not always receive the necessary preoperative planning or operative expertise. Iatrogenic fractures were most often caused by inadequate preoperative planning or assuming that a broken interlocking screw tilts during the extraction. We suggest the use of checklists in preoperative planning to avoid fractures caused by broken or undetected interlocking screws.
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Parkkinen M, Lindahl J, Mäkinen TJ, Koskinen SK, Mustonen A, Madanat R. Predictors of osteoarthritis following operative treatment of medial tibial plateau fractures. Injury 2018; 49:370-375. [PMID: 29157843 DOI: 10.1016/j.injury.2017.11.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/06/2017] [Accepted: 11/14/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine factors influencing the development of posttraumatic osteoarthritis (OA) following medial tibial plateau fractures and to evaluate concomitant injuries associated with these fractures. MATERIALS AND METHODS A chart review of patients with operatively treated medial tibial plateau fractures admitted to our Level I trauma centre from 2002 to 2008 was performed. Of 63 patients, 41 participated in a clinical and radiographic examination. The mean age was 47 years (range 16-78) and the mean follow-up time was 7.6 (range 4.7-11.7) years. All patients had preoperative computed tomography (CT) scans and postoperative radiographs. At the end of follow-up, standing radiographs, mechanical axis, and CT scans were evaluated. RESULTS Of the 41 patients, 24 had no or mild (Kellgren-Lawrence grade 0-2) OA and 17 had severe (grade 3-4) OA. Initial articular depression measured from preoperative CT scans was a significant predictor of OA (median 1.8mm vs 4.5mm, p=0.009). Fracture line extension to the lateral plateau (p=0.68) or fracture comminution (p=0.21) had no effect on the development of posttraumatic OA, nor did articular depression at the end of follow-up (p=0.68) measured from CT scans. Mechanical axis >4° of varus and ≥2mm articular depression or step-off were associated with worse WOMAC pain scores, but did not affect other functional outcome scores. Six patients (10%) had permanent peroneal nerve dysfunction. Ten patients (16%) required LCL reconstruction and nine (14%) ACL avulsions were treated at the time of fracture stabilisation. CONCLUSIONS The amount of articular depression measured from preoperative CT scans seems to predict the development of posttraumatic OA, probably reflecting the severity of chondral injury at the time of fracture. Restoration of mechanical axis and articular congruence are important in achieving a good clinical outcome.
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Affiliation(s)
- Markus Parkkinen
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland.
| | - Jan Lindahl
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland
| | - Tatu J Mäkinen
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland
| | - Seppo K Koskinen
- Trauma and Musculoskeletal Imaging, Karolinska University Hospital, Stockholm, Sweden
| | - Antti Mustonen
- Pohjola Sairaala, Department of Radiology, Puutarhurinkuja 2, 00300 Helsinki, Finland
| | - Rami Madanat
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland
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Ebrahimpour A, Okhovatpour MA, Sadighi M, Sarejloo AH, Sajjadi MRM. Comparative investigation of percutaneous plating and intramedullary nailing effects on IL-6 production in patients with tibia shaft fracture. Acta Orthop Traumatol Turc 2017; 51:478-481. [PMID: 29122411 PMCID: PMC6197449 DOI: 10.1016/j.aott.2017.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 09/13/2017] [Accepted: 09/19/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to analyze the effect of intramedullary nailing (IMN), open plating and percutaneous plating on the induction of IL-6 in patients with tibia fractures. METHODS A total of 30 patients with tibia shaft fracture underwent either intramedullary nailing (IMN, n = 15; 14 males and 1 female; mean age: 32.1 ± 15.6), ORIF plating (n = 8; 5 males and 3 females; mean age: 60.0 ± 17.8), or percutaneous plating (n = 7; 6 males and 1 female; mean age: 43.1 ± 21.4). Serum IL-6 cytokine levels were measured prior to, and 6 and 24 h after the surgery, using a special ELISA kit. RESULTS The IL-6 concentration increased to peak levels at 6 h in both IMN and percutaneous plating groups, and at 24 h in ORIF plating group (p < 0.001). The mean IL-6 concentration of percutaneous plating group was significantly lower than that of the IMN group at 6 h following the surgery (p = 0.022). In addition, the mean IL-6 concentration of ORIF plating group was significantly higher than that of the percutaneous plating group at 24 h post operation (p = 0.009). CONCLUSION Our results suggest that percutaneous plating compared to the IMN has lower effects on IL-6 production in patients with tibia fracture. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Adel Ebrahimpour
- Department of Orthopaedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad-Ali Okhovatpour
- Department of Orthopaedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Sadighi
- Department of Orthopaedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir-Hossein Sarejloo
- Department of Orthopaedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad-Reza Minator Sajjadi
- Department of Orthopaedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Bao T, Han F, Xu F, Yang Y, Shu X, Chen K, Qi B, Wei S, Yu A. Papineau technique combined with vacuum-assisted closure for open tibial fractures: clinical outcomes at five years. Int Orthop 2017; 41:2389-96. [PMID: 28849424 DOI: 10.1007/s00264-017-3620-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/14/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Treatment of open tibial fractures with soft tissue and segmental bone defects is difficult. This study reports our results for treating these injuries with a combination of Papineau open bone grafting and vacuum-assisted wound closure (VAC). METHODS The records of 19 patients with open tibial fractures with soft tissue and segmental bone defects treated with bone grafting and VAC from 2004 to 2010 were retrospectively reviewed. Outcomes included: time to complete granulation tissue coverage, wound healing, and bone union; length of hospitalization; frequency of debridement; number of deep tissue infections. RESULTS Initial surgery was performed within 48 hours of injury. Ten fractures were Orthopaedic Trauma Association classification 41-A3, one was 41-C3, seven were 43-A3, and one was 43-C3. No surgical complications occurred, and the mean length of hospitalization was 11.0 ± 3.0 weeks (range, 7-18 weeks). The mean follow-up time was 59.35 ± 8.76 months. The mean time for complete wound healing was 7.76 ± 1.52 weeks (range, 6-11 weeks). Bone union was achieved in all patients at a mean of 33.88 ± 8.37 weeks (range, 23-53 weeks). Only one patient developed a deep tissue infection, which was treated with antibiotics and debridements, and complete bone union wound healing was achieved. Based on Paley grade, five outcomes were excellent, eight were good, and four were fair. CONCLUSIONS The combination of VAC and open bone grafting results in good outcome for patients with open tibial fractures and severe bone and soft-tissue defects.
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