Tibial Eminence Avulsion in a Tibial Plateau Fracture - Our Approach: A Clinical Case

A middle-aged female patient with a tibial plateau fracture combined with an avulsion of the tibial eminence was treated with a combination of medial plate fixation for the plateau and an arthroscopic aided nonabsorbable suture of the eminence. Our technique for tibial eminence avulsion fractures has no interference with tibial plateau osteosynthesis materials and has proven, once again, to have good results in the treatment of combined and complex injuries of the knee.

Implant retention in a rabbit model of fracture-related infection

Aims

Fracture-related infection (FRI) is commonly classified based on the time of onset of symptoms. Early infections (< two weeks) are treated with debridement, antibiotics, and implant retention (DAIR). For late infections (> ten weeks), guidelines recommend implant removal due to tolerant biofilms. For delayed infections (two to ten weeks), recommendations are unclear. In this study we compared infection clearance and bone healing in early and delayed FRI treated with DAIR in a rabbit model.

Methods

Staphylococcus aureus was inoculated into a humeral osteotomy in 17 rabbits after plate osteosynthesis. Infection developed for one week (early group, n = 6) or four weeks (delayed group, n = 6) before DAIR (systemic antibiotics: two weeks, nafcillin + rifampin; four weeks, levofloxacin + rifampin). A control group (n = 5) received revision surgery after four weeks without antibiotics. Bacteriology of humerus, soft-tissue, and implants was performed seven weeks after revision surgery. Bone healing was assessed using a modified radiological union scale in tibial fractures (mRUST).

Results

Greater bacterial burden in the early group compared to the delayed and control groups at revision surgery indicates a retraction of the infection from one to four weeks. Infection was cleared in all animals in the early and delayed groups at euthanasia, but not in the control group. Osteotomies healed in the early group, but bone healing was significantly compromised in the delayed and control groups.

Conclusion

The duration of the infection from one to four weeks does not impact the success of infection clearance in this model. Bone healing, however, is impaired as the duration of the infection increases.

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

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

External Fixation as a Primary and Definitive Treatment for Complex Tibial Diaphyseal Fractures: An Underutilized and Efficacious Approach

Background

External fixation is one of the most often utilized treatment options for complicated tibial diaphyseal fractures (TDF). The purpose of this study was to assess the efficacy of unilateral external fixators as primary and definitive therapy for complex TDF in a resource-limited setting.

Materials and Methods

A retrospective study between June 2016 and March 2021 included 110 subjects with TDF who were treated with an external fixator as definitive fixation in hospitals affiliated with Ibb University. The patient's demographic characteristics, complications, and outcomes were gathered and analyzed. Factors associated with pin site infection were also investigated.

Results

The mean age was 42.1 ± 10.1 years, with 92.7% being male. Rural residents accounted for 22.7%. Smoking and diabetes mellitus were present in 27.3% and 30.0%, respectively. General complications occurred in 12.0%, with pulmonary embolism being the most common at 4.5%. Orthopedic complications included pin-track infections in 27.3% (30) and osteomyelitis in 1.8% (2). Pin site infections required medical treatment in 21 cases and external fixator changes in five. Two cases each needed several debridements for osteomyelitis and soft tissue. Full union occurred in 79.1% (87) over 23.1 ± 3.2 weeks and final alignment in 97.3% (107) over 34.8 ± 4.8 weeks. Malunions occurred in 1.8% (2), and one case had hypertrophic nonunion. Factors like rural residency, smoking, diabetes, open fractures, worst fracture grade (Gustilo and Anderson type C), and general complications occurrence significantly correlated with pin site infection (all p-values < 0.05).

Conclusion

A unilateral external fixator as a primary and definitive treatment is a viable, simple, and effective option for TDF with a high success rate even in a resource-limited setting. In this study, residents in rural areas, smoking, diabetes, open fracture, worst fracture grade, and general complication occurrence were associated with pin site infection occurrence.

Poller Screws and Post-Operative Pain Relief in Tibial Fractures

Introduction Poller screws optimise fracture alignment in those fractures managed with intramedullary (IM) nails. They enhance stability, control nail insertion, and prevent translation. Indications encompass acute fractures, delayed unions/non-unions, and deformity. Classified into four generations, they've shown positive outcomes: improved alignment, reduced complications, and shorter healing. However, their pain management impact is understudied. This retrospective cohort study aimed to compare opioid medication needs in tibial fractures managed with IM nails with and without poller screws. Methods Between January 2015 and December 2022, a retrospective analysis was conducted on tibial fractures treated at a major trauma centre. Patients primarily treated with IM nails were included. Patient and operation notes as well as radiographs, were reviewed to identify poller screw utilisation. Opioid medication data was collected and converted to "coverage" (days) and "strength" (morphine milligrams equivalent or MME). Two-tailed independent samples T-tests were performed to determine differences between patients treated with (n=205) and without poller screws (n=540). Results Patients with poller screws had fewer days with opioid prescriptions in the second post-operative month (6.8 vs. 8.9 days, p=0.038) and significantly lower opioid strength requirements across the first post-operative year (688.4 vs. 1295.4 MME, p=0.001), except the first month. Conclusion There is limited research on the connection between poller screws and pain. This study discusses their potential to reduce post-operative pain in tibial fractures. The results highlight the importance of using poller screws alongside IM. This combination appears to be effective in improving post-operative pain management and enhancing overall patient outcomes.

Illicit drug abuse and complexity of tibial shaft fracture based on AO/OTA classification: Is there any connection?

Purpose

Illicit drug abuse is a global epidemic afflicting millions worldwide. Several studies have investigated the contribution of this dependence as a risk factor for fracture, but its impacts on fracture severity have been rarely studied. The present study primarily aims to determine the relationship between illicit drug abuse and the severity of tibial shaft fractures.

Methods

This retrospective study consecutively included patients aged ≥18 years with tibial shaft fracture who attended Sina Tertiary Hospital, Tehran, Iran, between 2016 and 2021. The fracture patterns were assessed according to the Arbeitsgemeinschaft für Osteosynthesefragen Foundation/Orthopaedic Trauma Association classification. Participants were divided into three individual specialists into groups: simple (A), wedge (B) and multifragmentary (C) fractures. The association of illicit drug abuse and other recorded variables, including age, sex, body mass index (BMI), comorbidities, physical activity, smoking habits and mechanism of injury, was also examined and assessed in multivariate logistic regression.

Results

Of 219 patients, 26 were drug abusers, and 193 had no history of use. A total of 20 out of 26 drug abusers experienced a complex fracture, yielding a rate of 76.9%, while this rate for nonusers was 50.3% (97 out of 193), indicating a statistically significant difference between the two subgroups (p = 0.011). The smoking history also influenced the fracture pattern (p = 0.027) based on univariate analysis; however, using adjusted multivariate analysis yielded only illicit drug abuse (odds ratio = 3.495; confidence interval = 1.144-10.680) as a risk factor for more complex fractures.

Conclusion

The evidence from this study suggests that complexity and fracture patterns can depend on illicit drug abuse history.

Level of Evidence

Level III.

Olink proteomics analysis uncovers the landscape of inflammation-related proteins in patients with acute compartment syndrome

Purpose

Our primary purpose was to explore the landscape of inflammation-related proteins, and our second goal was to investigate these proteins as potential biomarkers of acute compartment syndrome (ACS), which is a serious complication of tibial fractures.

Methods

We collected sera from 15 healthy subjects (control group, CG) and 30 patients with tibial fractures on admission day, comprising 15 patients with ACS (ACS group, AG) and 15 patients without ACS (fracture group, FG). Ten samples in each group were analyzed by the inflammation panel of Olink Proteomics Analysis, and all samples were verified by an ELISA. Receiver-operating characteristic (ROC) curve analysis was performed to identify the diagnostic ability and cutoff values of potential biomarkers.

Results

Our findings showed that the levels of IL6, CSF-1, and HGF in the FG were significantly higher than those in the CG. Similar results were found between the AG and CG, and their cutoff values for predicting ACS compared with the CG were 9.225 pg/ml, 81.04 pg/ml, and 0.3301 ng/ml, respectively. Furthermore, their combination had the highest diagnostic accuracy. Notably, compared with FG, we only found a higher expression of CCL23 in the AG. Additionally, we identified 35.75 pg/ml as the cutoff value of CCL23 for predicting ACS in patients with tibial fractures.

Conclusion

We identified CCL23 as a potential biomarker of ACS in comparison with tibial fracture patients and the significance of the combined diagnosis of IL6, CSF-1, and HGF for predicting ACS compared with healthy individuals. Furthermore, we also found their cutoff values, providing clinicians with a new method for rapidly diagnosing ACS. However, we need larger samples to verify our results.

Successful Total Knee Arthroplasty for Hoffa and Proximal Tibial Fractures: Report of Three Complex Cases After Failed Osteosynthesis Procedures

BACKGROUND Distal femoral and proximal tibial fractures often lead to nonunion and post-traumatic osteoarthritis, and total knee arthroplasty (TKA) has emerged as an effective alternative for older patients. This report includes 3 cases of successful TKA treatment. The cases involve a 42-year-old man and a 62-year-old man with Hoffa coronal fractures of the distal femur, and a 50-year-old man with a proximal tibial fracture. These patients underwent multiple osteosynthesis procedures before receiving TKA. CASE REPORT Case 1: A 42-year-old man with a displaced Hoffa's fracture had persistent knee pain. Nonunion post-initial fixation led to reoperation with iliac bone grafting and plate fixation. TKA using a Posterior Stabilized (PS)-type implant resulted in improved motion and function after 3 years. Case 2: A 62-year-old man suffered lateral condyle and ligament injuries from a displaced Hoffa's fracture. Despite plate fixation, dislocation occurred, requiring conversion. TKA with long-stem hinge-type implant, using augmentation block, led to enhanced stability and outcomes at 2 years. Case 3: A 50-year-old man's tibial nonunion, treated with plate fixation, resulted in infection and bone fusion. TKA using a constrained PS-type implant insert addressed the lateral tibial adhesions via iliotibial band (ITB) release and treated severe tibial plateau damage. Positive results were seen at 1 year. CONCLUSIONS The challenges of pseudarthrosis, like bone defects and compromised tissue, highlight the need for precise implant selection based on evaluations of bone quality, defects, knee stability, and hyperextension, rather than resorting to overly-constrained implants.

Factors associated with compartment syndrome after a tibial fracture in children

Objectives

Compartment syndrome (CS) after a tibial fracture in children is one of the orthopedic emergencies. Identifying high-risk patients in a timely fashion minimizes morbidities. This study aimed to find the risk factors of CS after a tibial fracture.

Methods

The study data was retrieved from the Trauma Quality Improvement Program database of the calendar year 2017-2019. All patients aged <18 years old who were admitted to the hospital with tibial fractures were included in the study. Patients' characteristics, including demography, injury, injury severity, and associated crushed and vascular injuries were analyzed between the groups who developed CS versus those who did not develop CS after a tibial fracture. Multiple logistic regression analyses were performed to find the association of CS. All p values are two-sided and a p value<0.05 is considered statistically significant.

Results

Of 4492 patients who qualified for the study, 49 (1.1%) patients developed CS. The patients who developed CS sustained more crush injuries and were associated with a higher rate of vascular injury (2% vs 0.1%, p=0.043% & 10.2% vs 2.2%, p=0.005). Multivariable analysis showed that for every increase in 1 year of age, the odds of occurrence of CS increased by 15.7% (adjusted OR (AOR)=1.157, 95% CI: 1.032 to 1.297, p=0.013). Non-African American race was associated with more than double the risk of developing CS when compared with the African American race, AOR was 2.238, (95% CI: (1.08 to 4.638)). The associated crush injury had an approximately 19-fold higher risk of CS when compared with patients presented with no crush injury, AOR was 18.812, (95% CI: (1.513 to 233.931)). Associated vascular injury was found to have significantly higher AOR, 3.509, 95% CI: (1.287 to 9.563) of CS.

Conclusion

Increased age, non-African American race, vascular injury, and crushed injury were associated with a risk of developing CS after a tibial fracture.

Level of evidence IV

Study type: Observational cohort study.

Comparison of Nanocrystalline Hydroxyapatite Bone Graft with Empty Defects in Long Bone Fractures: A Retrospective Case-Control Study

BACKGROUND The regeneration of bone defects is indicated to restore lost tissue mass and functionality. Ostim®, an absorbable nanocrystalline hydroxyapatite (NCHA) paste, is indicated to enhance bone regeneration in bone defects due to trauma or surgery. This retrospective study of 110 patients with long-bone fracture defects presenting at a single trauma center between 2010 and 2012 aimed to compare outcomes with and without the use of Ostim® absorbable nanocrystalline hydroxyapatite paste. MATERIAL AND METHODS The study encompassed fractures in 110 patients - 55 patients received any defect augmentation (ED) and 55 patients were treated with NCHA augmentation. Fractures were located at the distal radius (66.4%, n=73), proximal humerus (5.5%, n=6), and proximal tibia (28.2%, n=31). Evaluating the clinical follow-up, the study encompassed post-surgery complications (eg, non-unions, infection). Bone healing was evaluated by conventional radiographs. RESULTS Postoperative complications occurred in 45.5% of patients regardless of the treatment (P=1.0). The non-union rate in both groups was 5.5% (n=8, P=1.0), and the risk for infection was lower in the NCHA group (3.6%, ED: n=3, NCHA: n=1, p=0.62). Patients suffered open fractures were treated in the NCHA group (100%, n=7, P=0.003). Radiological assessment demonstrated comparable healing of the fracture border, fracture gap, and articular surface (P>0.05). CONCLUSIONS The findings from this retrospective study support previous studies that have shown Ostim® absorbable nanocrystalline hydroxyapatite paste enhances outcomes and reduces the risk of complications when used to repair bone defects in long-bone fractures in trauma patients. NCHA paste augmentation is suitable for use in traumatic long-bone fractures.

Comparative Study of Minimally Invasive Plate Osteosynthesis (MIPO) and Intramedullary Nailing (IMN) for Treating Extraarticular Distal Tibial Fractures: Clinical and Radiological Outcomes

BACKGROUND Treatment of extra-articular distal tibial fractures is problematic owing to limited soft tissue cover, poor vascularity of the location, and adjacency to the ankle, and thus continues to be controversial. This study aimed to compare clinical and radiological outcomes in 69 patients with extra-articular distal tibia fractures treated with minimally invasive plate osteosynthesis (MIPO) and an interlocking intramedullary nail (IMN). MATERIAL AND METHODS Sixty-nine patients, with mean of age 39.8±18.3 years, were retrospectively evaluated. Thirty-five patients were treated with IMN, and 34 patients were treated with MIPO. Clinical and radiological outcomes were evaluated. RESULTS The average follow-up was 13.3±6 months and union time was 16.2±5.4 weeks. Nonunion was observed in only 4.3% of patients treated with MIPO (P=0.114). Non-acceptable malalignment of extremity was observed in 4.3% of patients with IMN and 7.2% of patients with MIPO. There were no significant differences in union time, nonunion, surgical timing, operating time, malalignment, and complications between groups (P>0.05). The mean American Orthopaedic Foot and Ankle Society (AOFAS) surgery score was 95.8±5 in IMN and 91.9±14.3 in MIPO. AOFAS, Tenny-Wiss radiological, and Ovadia-Beals clinical scores were better in IMN than MIPO (P=0.019, P=0.03, P=0.02, respectively). Mean time of full weight-bearing and of return to daily life with IMN was significantly shorter than with MIPO (P.

Avulsion Fracture of the Tibial Tuberosity in an Adolescent: Case Report

The present study reports a rare case of avulsion fracture of the tibial tuberosity in an adolescent. A 14-year-old male patient sprained his left knee during a soccer match. At the first emergency-room visit, he presented pain in his left knee, 2 +/4+ edema, and inability to walk and flex the affected knee, but no neurovascular changes or signs of compartment syndrome. Radiographs revealed a physeal fracture at the left proximal tibia, classified by Ogden, Tross and Murphy, and modified by Ryu and Debenham, as type IV, and complemented by Aerts et al. as type IV-B. Immobilization was performed with a plaster cast from the inguinal to malleolar regions, followed by analgesia. The patient was operated on the next day, when open reduction and internal fixation using 4.5-mm cannulated screws were performed. The patient was discharged one day after surgery, with plaster cast immobilization and load restraint for four weeks, and bone consolidation was radiologically confirmed three months after the procedure. The patient evolved with a range of motion similar to that of the contralateral limb, no length discrepancy in the lower limbs, and no complaints after one year of follow-up.

Energy intake restriction significantly improves POCD after internal fixation of tibial fractures in mice

OBJECTIVE

To investigate the effect of energy intake restriction on postoperative cognitive dysfunction (POCD) after internal fixation of tibial fractures in mice.

METHODS

Thirty mice were divided into model groups of internal fixation of tibial fractures with 0%, 20%, 30% and 40% energy intake restriction and sham operation group (n = 6). Novel object recognition task and elevated plus maze test were used to assess the ability of recognition memory and anxiety-related behavior before and one week after surgery. The blood samples were collected from mice on days 1, 3 and 7 after surgery, and the mice were euthanized on the 8th day after surgery. RT-PCR and Western blot were employed to detect the expression of AMPK-SIRT1 pathway-related genes and proteins in the hippocampus. ELISA was used to detect the levels of inflammatory factors in the peripheral blood of mice. Hematoxylin-eosin (H&E) staining and immunofluorescence (IF) staining were used to detect the proliferation, differentiation and injury of hippocampal cells.

RESULTS

The results showed that 20% and 30% energy intake restriction significantly improved the POCD after internal fixation of tibial fractures in mice. Significantly, 30% energy intake restriction reduced the expression of AP-1, NF-κB, CD45, IBA-1, and inflammatory factors IL-1β, IL-6, IL-8 and TNF-α, and increased the expression of AMPK and SIRT1 after the operation. H&E and IF staining showed that 30% energy intake restriction reduced postoperative hippocampal neuronal damage.

CONCLUSION

Energy intake restriction can significantly improve POCD after internal fixation of tibial fractures in mice and may provide a new treatment paradigm for POCD patients.

Varus placement of the tibial component of Oxford unicompartmental knee arthroplasty decreases the risk of postoperative tibial fracture

AIMS

A fracture of the medial tibial plateau is a serious complication of Oxford mobile-bearing unicompartmental knee arthroplasty (OUKA). The risk of these fractures is reportedly lower when using components with a longer keel-cortex distance (KCDs). The aim of this study was to examine how slight varus placement of the tibial component might affect the KCDs, and the rate of tibial plateau fracture, in a clinical setting.

METHODS

This retrospective study included 255 patients who underwent 305 OUKAs with cementless tibial components. There were 52 males and 203 females. Their mean age was 73.1 years (47 to 91), and the mean follow-up was 1.9 years (1.0 to 2.0). In 217 knees in 187 patients in the conventional group, tibial cuts were made orthogonally to the tibial axis. The varus group included 88 knees in 68 patients, and tibial cuts were made slightly varus using a new osteotomy guide. Anterior and posterior KCDs and the origins of fracture lines were assessed using 3D CT scans one week postoperatively. The KCDs and rate of fracture were compared between the two groups.

RESULTS

Medial tibial fractures occurred after surgery in 15 patients (15 OUKAs) in the conventional group, but only one patient (one OUKA) had a tibial fracture after surgery in the varus group. This difference was significant (6.9% vs 1.1%; p = 0.029). The mean posterior KCD was significantly shorter in the conventional group (5.0 mm (SD 1.7)) than in the varus group (6.1 mm (SD 2.1); p = 0.002).

CONCLUSION

In OUKA, the distance between the keel and posterior tibial cortex was longer in our patients with slight varus alignment of the tibial component, which seems to decrease the risk of postoperative tibial fracture.Cite this article: Bone Joint J 2022;104-B(10):1118-1125.

Use of a Minimally Invasive Traction Repositor versus Conventional Manual Traction for the Treatment of Tibial Fractures: A Comparative Study from a Tertiary Hospital in China

Background

Closed reduction and intramedullary nail fixation of tibial fractures may not utilize a fracture table or reduction aids like a femoral distractor, and only manual traction will help aid the reduction process. This study aimed to describe and further investigate the effectiveness of an originally designed minimally invasive traction repositor (MITR) for the treatment of tibial fractures.

Methods

From January 2018 to April 2021, a total of 119 eligible patients with tibial shaft fractures were included and retrospectively assigned to two groups according to different reduction methods: MITR group vs conventional manual traction (CMT) group. The baseline characteristics between the two groups were comparable, including age, gender, BMI, residence, smoking history, drinking history, injury mechanism, fracture type, ASA, method of anesthesia, and surgical delay (all P > 0.05). The operation time, fracture reduction duration, intraoperative blood loss, fluoroscopy time, number of intraoperative fluoroscopies, VAS, HSS, fracture healing time, and complications were compared.

Results

All patients completed the follow-ups with an average of 18.5 months (range 12-42 months). The operation time, fracture reduction duration, intraoperative blood loss, fluoroscopy time, and number of fluoroscopies were significantly decreased in the MITR group (all P < 0.05). At one month postoperatively, the VAS score was statistically lower in the MITR group (1.8±0.8) than in the CMT group (2.6±1.5). At 6 months postoperatively, the HHS score was statistically higher in the MITR group (90.8±2.3) than in the CMT group (86.4±3.8). We observed no statistical difference in the mean fracture healing time, bone nonunion, implant failure, and infection between the two groups (all P > 0.05).

Conclusion

Compared with CMT, MITR facilitates the minimally invasive treatment of tibial fractures and has the advantages of operation time, fracture reduction duration, intraoperative blood loss, fluoroscopy time, number of fluoroscopies, and satisfactory VAS and HSS scores.

Correlation Between the Fracture Line Plane and Perioperative Deep Vein Thrombosis in Patients with Tibial Fracture

Objective

To explore the correlation between the fracture line inferior plane and perioperative deep venous thrombosis (DVT) in patients with tibial fractures.

Methods

Data was collected from the medical records of 536 consecutive patients with tibial fractures at Xi’an Honghui Hospital. The patients were divided into distal, shaft, and proximal segment groups according to the fracture line inferior plane on radiographs. Multivariate logistic regression models were used to identify the role of the inferior plane of the fracture line in perioperative DVT.

Results

A total of 431 patients were included in the study and 226 patients had perioperative DVT in the lower extremities, including 11 proximal and 215 distal DVTs. Univariate regression analysis showed a significant correlation between the proximal segment and perioperative DVT; however, no correlation was found in the shaft segment group. Additionally, age, coronary heart disease, associated injuries, and time to operation ≥6 days were risk factors for perioperative DVT. However, fixation with intramedullary nails may be a protective factor for perioperative DVT compared with plates. After adjusting for potential confounding factors, the proximal segment group had an increased incidence of perioperative DVT compared to the distal segment group.

Conclusions

The proximal segment may be correlated with an increased incidence of perioperative DVT by 7.30-fold in patients with tibial fractures compared to that in the distal segment. In clinical practice, surgeons should be vigilant for DVT formation in these patients.

The Role of the Ilizarov Ring External Fixator in the Management of Tibial Fractures with Impending/Incomplete Compartment Syndrome

Objective  The management of tibia fractures complicated by compartment syndrome affects the treatment and functional outcome of patients due to the complications associated with fasciotomy. The purpose of the present study is to differentiate impending/incomplete compartment syndrome (ICS) from established acute compartment syndrome (ACS) in tibial fractures, and to assess the outcome of the fixation of the Ilizarov apparatus in patients with these fractures presenting with ICS, who were not submitted to fasciotomy.

Methods  After the establishment of the inclusion and exclusion criteria, 19 patients were included in the study from January 2007 to December 2017. All patients were male, with an average age of 42.3 ± 11.38 years. All of these patients were managed with Ilizarov ring fixation as per the medical and surgical protocol established in the present study.

Results  The average follow-up obtained for our 18 patients was of 47 ± 41.5 months, with one patient being lost to follow-up. The average time for ring application was of 3.7 ± 1.7 days. In total, 3 (16.7%) of these patients had nonunion. There were no soft-tissue or neurovascular complications in the immediate postoperative period. All of the patients eventually united and were independently mobile without any sequelae of compartment syndrome.

Conclusion  The Ilizarov ring external fixator can be used in the management of tibial fractures with ICS, avoiding fasciotomy with its various complications of infection and nonunion, resulting in fewer surgeries and faster rehabilitation. Surgeons should carefully differentiate ACS and ICS in these patients, as the clinical and functional results vary significantly. Unnecessary fasciotomies should be avoided.

Sensitivity and specificity of modified RUST score using clinical and radiographic findings as a gold standard

Aims

The modified Radiological Union Scale for Tibia (mRUST) fractures score was developed in order to assess progress to union and define a numerical assessment of fracture healing of metadiaphyseal fractures. This score has been shown to be valuable in predicting radiological union; however, there is no information on the sensitivity, specificity, and accuracy of this index for various cut-off scores. The aim of this study is to evaluate sensitivity, specificity, accuracy, and cut-off points of the mRUST score for the diagnosis of metadiaphyseal fractures healing.

Methods

A cohort of 146 distal femur fractures were retrospectively identified at our institution. After excluding AO/OTA type B fractures, nonunions, follow-up less than 12 weeks, and patients aged less than 16 years, 104 sets of radiographs were included for analysis. Anteroposterior and lateral femur radiographs at six weeks, 12 weeks, 24 weeks, and final follow-up were separately scored by three surgeons using the mRUST score. The sensitivity and specificity of mean mRUST score were calculated using clinical and further radiological findings as a gold standard for ultimate fracture healing. A receiver operating characteristic curve was also performed to determine the cut-off points at each time point.

Results

The mean mRUST score of ten at 24 weeks revealed a 91.9% sensitivity, 100% specificity, and 92.6% accuracy of predicting ultimate fracture healing. A cut-off point of 13 points revealed 41.9% sensitivity, 100% specificity, and 46.9% accuracy at the same time point.

Conclusion

The mRUST score of ten points at 24 weeks can be used as a viable screening method with the highest sensitivity, specificity, and accuracy for healing of metadiaphyseal femur fractures. However, the cut-off point of 13 increases the specificity to 100%, but decreases sensitivity. Furthermore, the mRUST score should not be used at six weeks, as results show an inability to accurately predict eventual fracture healing at this time point.

Cite this article: Bone Jt Open 2021;2(10):796–805.

Osteochondral Segond Fracture Associated with Fibular Head Avulsion Fracture - "Arcuate Sign"

A deviated osteochondral fracture of the anterolateral tibia associated with fibular head avulsion in a 50-year-old patient is reported. In general, avulsion fracture of the iliotibial tract is associated with injuries in the cruciate ligament, in the meniscus and in lateral knee structures, as in the case herein reported.

Does the shoe-lace technique aid direct closure of fasciotomy wounds after acute compartment syndrome of the lower leg? a retrospective case-control study

Background and objective:

Tibia fractures are relatively common injuries that are accompanied with acute compartment syndrome in approximately 2% to 20% of cases. Although the shoe-lace technique, where vessel loops are threaded in a crisscross fashion and tightened daily, has been widely used, no studies have compared the shoe-lace technique with the conventional one. The aim of this study was to compare the shoe-lace technique with the conventional technique.

Methods:

We identified 359 consecutive patients with intramedullary nailed tibia fracture and complete medical records including outpatient data between April 2007 and April 2015 from electronic patient database of our institute. The use of the shoe-lace technique was compared to conventional one (in which wounds were first left open with moist dressings). Main outcome measurement is direct closure of fasciotomy wounds.

Results:

From 359 consecutive patients with intramedullary nailed tibia fracture, fasciotomy was performed on 68 (19%) patients. Of these, the shoe-lace technique was used in 47 (69%) patients while in 21 (31%) patients, the shoe-lace technique was not applied. Side-to-side approximation was successful in 36 patients (77%) in the shoe-lace+ group and 7 patients (33%) in the shoe-lace– group (p = 0.002).

Conclusions:

The main finding of our comparative study was that the shoe-lace technique seems to ease direct closure of lower leg fasciotomy wounds, and thus reduces the frequency of free skin grafts. Our finding needs to be confirmed in a high-quality randomized controlled trial.

The Cambridge Experience With Tibial Plateau Fractures in Older Adults: A Case Series

Complex tibial plateau fractures (TPFs) represent a significant treatment challenge for any Orthopaedic surgeon. Current literature suggests that significantly displaced TPFs in the elderly require operative fixation, an operation that is associated with serious complications including septic and post-operative arthritis. As a result, these patients are five times more likely to require a total knee replacement (TKR). We present a case series of five elderly patients with complex TPFs who made serendipitous recoveries while awaiting operations. Their fractures were deemed so severe that they were being considered for TKR instead of fixation. We discovered their surprising functional improvements while they were being reviewed pre-operatively and decided to delay operating. We are currently unaware of any cases in the literature that have reported such findings. In total, five patients presented in 2019 with closed, varus/valgus stable fractures. They were managed non-operatively in hinged-knee braces, progressively weight-bearing with a minimum follow-up of 10 months. Oxford Knee Scores (OKS) were recorded at zero and four months after their injury. All patients were female with an average age of 69 years. Average fracture depression - 8.48mm, average fracture split - 8.66mm, average OKS reduction - 19%. All patients were able to mobilise independently at four months follow-up. Our results suggest that non-operative management can be considered as primary management in elderly patients with significantly displaced TPFs. Should this fail, or they develop arthritis, a TKR can be performed. This carries two benefits: the patient avoids the significant complications associated with fixation and should a TKR be required, it can more easily be performed in a patient without metalwork in-situ. We feel that the results from this case series might offer insight into a new treatment strategy and continue to closely follow these patients.

Weight Discharge in Postoperative of Plateau Fracture Tibialis: Systematic Review of Literature

Tibial plateau fractures are a risk to the functional integrity of the knee, affecting the axial alignment and capable of leading to pain and disability of the individual. Early weight bearing and joint mobilization can prevent these functional deficits. the goal of the present study was to conduct a systematic review of the literature about studies that quote the beginning, evolution, and progression criteria for weight-bearing in postoperative period of tibial plateau fractures. We selected articles published in the last 12 years, in Portuguese and English, that described the time of onset and progression of weight-bearing, considering the severity of the fracture. Thirty-six articles were selected. There is no consensus in the literature as to the beginning and evolution of weight-bearing in the postoperative period of tibial plateau fractures; however, a relationship between the severity of the fracture and the fixation method has been observed.

Hematoma as a cause of a febrile and inflammatory response after tibial fractures

After incurring bilateral tibial fractures and developing sizable hematomas at the trauma sites, a child experienced 4 days of fever with an elevated C-reactive protein level and sedimentation rate. As thrombotic and infectious etiologies were ruled out, the patient's febrile and inflammatory response was likely attributable to hematoma formation. Hematomas are a recognized cause of noninfectious fever. Local release of pyrogenic cytokines within the hematoma may be the source for elevation in temperature and inflammatory markers.

Fracture of the anterior tibial tuberosity in children

Fractures of the anterior tibial tuberosity during childhood are an infrequent pathology (around 3% of all proximal tibial fractures), but the incidence of this injury has risen over recent years, likely due to the increased involvement of this age group in sports activities.

This fracture is more commonly seen in children 12–14 years old.

It is vital to identify the anatomical structures associated with this type of fracture, along with the pathophysiological mechanisms involved.

Treatment includes non-operative and operative options, with the goal of achieving articular congruency, restoring the extensor mechanism function, and avoiding damage to the proximal tibial physis.

Understanding the management of this fracture, and the complications that might arise, is critical. The provision of an appropriate clinical management plan and the avoidance of complications are vital in the prevention of disability.

Cite this article: EFORT Open Rev 2020;5:260-267. DOI: 10.1302/2058-5241.5.190026

Comparative Study of Function and Quality of Life in Patients with Fracture of the Tibial Plateau Operated with Locked or Conventional Plates

Objective

To compare clinical, functional, and quality of life outcomes between patients with tibial plateau fractures operated with locked or conventional plates, and to compare the costs of these implants.

Methods

This was a comparative cross-sectional study of a consecutive series of patients with tibial plateau fractures treated surgically from August 2015 to June 2016. Patients < 18 years old, those unable to answer the questionnaires or to attend the outpatient reassessment, polytrauma patients, those with associated injuries on the ipsilateral limb, and patients who had not undergone treatment with bone plates were excluded. The present study compared the costs of the implants for the hospital, quality of life (with the 12-Item Short Form Health Survey [SF-12]), Lysholm score, pain scale, and clinical and radiological parameters.

Results

A total of 45 patients with tibial plateau fractures were admitted, and 11 cases were excluded. Two cases were lost to follow-up; therefore, 32 remained for the analysis (94%). The mean follow-up time was of 15.1 months (standard deviation [SD] = 4.8 months). In group A (locked plates), there were 22 patients (69%), at an average hospital cost of BRL 4,125.39/patient (SD = 1,634.79/patient) for the implants. In group B (conventional plates) there were 10 patients (31%), at an average cost of BRL 438.53 (SD = 161.8/patient) ( p  < 0.00001). For the other parameters, no differences were observed, except for a greater articular depression in group A (2.7 mm ± 3.3 mm versus 0.5 mm ± 1.6 mm; p  = 0.02; TE = 0.90).

Conclusion

The costs of locked implants for the treatment of tibial plateau fractures are significantly higher than those of conventional implants, without any clinical, quality of life, radiological, or functional advantages of the locked implants demonstrated in the present series.

"Floating knee," an Uncommon Injury: Analysis of 12 Cases

Objective

Floating knee injuries are complex injuries and are usually caused by high-velocity trauma. These injuries are often associated with life treating injuries, which should take precedent over extremity injuries. The authors reviewed the outcomes of floating knee injuries managed in this institute from 2003 to 2015.

Method

A retrospective study was conducted of all patients with floating knee injuries from2003 to 2015. Twelve patients were included in the study. Data related to fracture type, associated injuries, treatment modalities, and complications were noted. Functional assessment was performed using the modified Karlstrom and Olerud criteria after complete bony union.

Result

The mechanism of injury was motor vehicle accident in all patients. The mean follow up was four years. The mean age of patients was 34.75 year. The mean union time was 6.5 months in femurs and 6.7 month in tibias. The complications were knee stiffness, delayed union, and infection. According to modified Karlstrom criteria, there were three - excellent, five - good, three - fair, and one poor result.

Conclusion

Floating knee injuries are severe injuries and are usually associated with multi-organ injuries. Early detection and appropriate management of associated injuries, early fixation of fractures, and postoperative rehabilitation are needed for good outcome. Complications are frequent, in the form of delayed union, knee stiffness, and infection.

Tibial stress injuries - location, severity, and classification in magnetic resonance imaging examination

Purpose

To describe and illustrate the spectrum of magnetic resonance imaging (MRI) findings of tibial stress injuries (TSI) and propose a simplified classification system.

Material and methods

Retrospective analysis of MRI exams of 44 patients with clinical suspicion of unilateral or bilateral TSI, using a modified classification system to evaluate the intensity and location of soft-tissue changes and bone changes.

Results

Most of the patients were young athletic men diagnosed in late stage of TSI. Changes were predominantly found in the middle and distal parts of tibias along medial and posterior borders.

Conclusions

TSI may be suspected in young, healthy patients with exertional lower leg pain. MRI is the only diagnostic method to visualise early oedematic signs of TSI. Knowledge of typical locations of TSI can be helpful in proper diagnosis before its evolution to stress fracture.

Patient coping and expectations about recovery predict the development of chronic post-surgical pain after traumatic tibial fracture repair

BACKGROUND

The association of patient expectations about recovery with the development of chronic post-surgical pain (CPSP) is uncertain.

METHODS

Three hundred and fifty-nine patients enrolled in the SPRINT trial completed the Somatic Preoccupation and Coping (SPOC) questionnaire six weeks after a traumatic tibial fracture repair. The SPOC questionnaire measures patients' somatic complaints, coping, and optimism for recovery. Using adjusted models, we explored the association of SPOC scores with ≥ mild CPSP and ≥ moderate pain interference with activity at one yr after surgery.

RESULTS

Of 267 tibial fracture patients with data available for analysis, 147 (55.1%) reported CPSP at one yr. The incidence of CPSP was 37.6% among those with low (≤40) SPOC scores, 54.1% among those with intermediate (41-80) scores, and 81.7% among those with high (>80) scores. Addition of SPOC scores to an adjusted regression model to predict CPSP improved the c-statistic from 0.61 (95% CI 0.55-0.68) to 0.70 (95% CI 0.64-0.76, P=0.005 for the difference) and found the greatest risk was associated with high SPOC scores (OR 6.56, 95% CI 2.90-14.81). Similarly, an adjusted regression model to predict pain interference with function at one yr (c-statistic 0.77, 95% CI 0.71-0.83) found the greatest risk for those with high SPOC scores (OR 10.10, 95% CI 4.26-23.96).

CONCLUSIONS

Patient's coping and expectations of recovery, as measured by the SPOC questionnaire, is an independent predictor of CPSP and pain interference one yr after traumatic tibial fracture. Future studies should explore whether these beliefs can be modified, and if doing so improves prognosis.

CLINICAL TRIAL REGISTRATION

NCT 00038129.

Combined Ipsilateral Fracture of the Tibial Pilon, Talar Body, and Calcaneus: Outcome at 4 Years

Combined fractures of the talar body and the adjacent bones are rare. We present a case of a 35-year-old male with a complex foot and ankle trauma resulting in an unusual combined ipsilateral fracture of the anterolateral tibial plafond, talar body, and sustentaculum tali of the calcaneus. To the best of our knowledge, this particular combination of fractures has not yet been reported in the literature. The combination of talar body fracture with fractures of the adjacent bones was treated by a bilateral open reduction with anatomic reconstruction of the joint surfaces resulting in an excellent clinical outcome at 4-year followup.

An approach to floating knee injury in Indian Population: An analysis of 52 patients

BACKGROUND

Floating knee is a condition resulting from high energy trauma usually associated with minor to life threatening injuries making it challanging to treat There are no studies available in literature describing cross leg sitting and squatting after surgical management of floating knee. This study analyzes prognostic factors, plan of management, functional outcomes (special attention to squatting and cross legged sitting), complications.

MATERIALS AND METHODS

52 patients with floating knee injuries treated over a period of 3 years were included in this study. The study followed an algorithmic approach for the management. Femur fractures were fixed before fixing the tibia according to fracture type that was classified by Fraser classification after the stabilization of patient. The mean followup duration was 21 ± 6 months. The outcome was assessed using Karlstrom criteria after bony union.

RESULTS

The study consists of majority (46) of male. Thirty three patients had some types of significantly associated injury. The mean postoperative range of motion of the knee was observed to be 97° ± 27°. Twenty one patients showed excellent results, whereas 17, 8, and 6 patients had good, fair, and poor results, respectively, as per Karlstrom criteria. Knee pain, stiffness, infection, nerve palsy, delayed union, and nonunion were some of the complications observed. Cross legged sitting was possible in 40 patients and squatting in 31.

CONCLUSION

The prognosis of floating knee injury is dependent on factors such as type of fracture, soft tissue condition, and management. Excellent outcomes following these injuries can be achieved with individualized plan of management by multidisciplinary team.

Pediatric Tibial Shaft Fractures

Tibial shaft fractures are one of the most common pediatric fractures. They require appropriate diagnosis and treatment to minimize complications and optimize outcomes. Diagnosis is clinical and radiological, which can be difficult in a young child or with minimal clinical findings. In addition to acute fracture, Toddler's and stress fractures are important entities. Child abuse must always be considered in a nonambulatory child presenting with an inconsistent history or suspicious concomitant injuries. Treatment is predominantly nonoperative with closed reduction and casting, requiring close clinical and radiological followup until union. Although there is potential for remodeling, this may not be adequate with more significant deformities, thus requiring remanipulation or rarely, operative intervention. This includes flexible intramedullary nailing, Kirschner wire fixation, external fixation, locked intramedullary nailing, and plating. Complications are uncommon but include deformity, growth arrest, nonunion, and compartment syndrome.

Biomechanical assessment and 3D finite element analysis of the treatment of tibial fractures using minimally invasive percutaneous plates

The aim of the present study was to investigate the biomechanical effects of varying the length of a limited contact-dynamic compression plate (LC-DCP) and the number and position of screws on middle tibial fractures, and to provide biomechanical evidence regarding minimally invasive plate osteosynthesis (MIPO). For biomechanical testing, 60 tibias from cadavers (age at mortality, 20-40 years) were used to create middle and diagonal fracture models without defects. Tibias were randomly grouped and analyzed by biomechanic and three-dimensional (3D) finite element analysis. The differences among LC-DCPs of different lengths (6-, 10- and 14-hole) with 6 screws, 14-hole LC-DCPs with different numbers of screws (6, 10 and 14), and 14-hole LC-DCPs with 6 screws at different positions with regard to mechanical characteristics, including compressing, torsion and bending, were examined. The 6-hole LC-DCP had greater vertical compression strain compared with the 10- and 14-hole LC-DCPs (P<0.01), and the 14-hole LC-DCP had greater lateral strain than the 6- and 10-hole LC-DCPs (P<0.01). Furthermore, significant differences in torque were observed among the LC-DPs of different lengths (P<0.01). For 14-hole LC-DCPs with different numbers of screws, no significant differences in vertical strain, lateral strain or torque were detected (P>0.05). However, plates with 14 screws had greater vertical strain compared with those fixed with 6 or 10 screws (P<0.01). For 4-hole LC-DCPs with screws at different positions, vertical compression strain values were lowest for plates with screws at positions 1, 4, 7, 8, 11 and 14 (P<0.01). The lateral strain values and vertical strain values for plates with screws at positions 1, 3, 6, 9, 12 and 14 were significantly lower compared with those at the other positions (P<0.01), and torque values were also low. Thus, the 14-hole LC-DCP was the most stable against vertical compression, torsion and bending, and the 6-hole LC-DCP was the least stable. However, the use of 14 screws with a 14-hole LC-DCP provided less stability against bending than did 6 or 10 screws. Furthermore, fixation with distributed screws, in which some screws were close to the fracture line, provided good stability against compression and torsion, while fixation with screws at the ends of the LC-DCP provided poor stability against bending, compressing and torsion.

A comparative study of intramedullary interlocking nailing and minimally invasive plate osteosynthesis in extra articular distal tibial fractures

BACKGROUND

Extraarticular distal tibial fractures are among the most challenging fractures encountered by an orthopedician for treatment because of its subcutaneous location, poor blood supply and decreased muscular cover anteriorly, complications such as delayed union, nonunion, wound infection, and wound dehiscence are often seen as a great challenge to the surgeon. Minimally invasive plate osteosynthesis (MIPO) and intramedullary interlocking nail (IMLN) are two well-accepted and effective methods, but each has been historically related to complications. This study compares clinical and radiological outcome in extraarticular distal tibia fractures treated by intramedullary interlocking nail (IMLN) and minimally invasive plate osteosynthesis (MIPO).

MATERIALS AND METHODS

42 patients included in this study, 21 underwent IMLN and 21 were treated with MIPO who met the inclusion criteria and operated between June 2014 and May 2015. Patients were followed up for clinical and radiological evaluation.

RESULTS

In IMLN group, average union time was 18.26 weeks compared to 21.70 weeks in plating group which was significant (P < 0.0001). Average time required for partial and full weight bearing in the nailing group was 4.95 weeks and 10.09 weeks respectively which was significantly less (P < 0.0001) as compared to 6.90 weeks and 13.38 weeks in the plating group. Lesser complications in terms of implant irritation, ankle stiffness, and infection, were seen in interlocking group as compared to plating group. Average functional outcome according to American Orthopedic Foot and Ankle Society score was measured which came out to be 96.67.

CONCLUSION

IMLN group was associated with lesser duration of surgery, earlier weight bearing and union rate, lesser incidence of infection and implant irritation which makes it a preferable choice for fixation of extra-articular distal tibial fractures. However, larger randomized controlled trials are required for confirming the results.

Acute limb compartment syndrome in the lower leg following trauma: assessment in the intensive care unit

Acute limb compartment syndrome (ALCS) is a serious complication of traumatic injury. Although ALCS can occur in any limb, it most commonly occurs following injury to the lower leg, particularly in fractures of the tibia. Practitioners should recognise and treat ALCS as early as possible to prevent the development of further, potentially serious, complications. Most of the literature recommends that patients at risk of ALCS should be carefully monitored, with a focus on pain as the main symptom. However, patients in the intensive care unit (ICU) who are unconscious or sedated may be unable to report pain or are unreliable in doing so, therefore it is necessary to consider alternative assessments for ALCS. This article provides an overview of the evidence and guidelines in relation to ALCS in the lower leg and how to undertake an effective assessment for the condition in patients in the ICU. This will enable practitioners to make evidence-based clinical decisions to improve practice and patient safety.

Virtual stress testing of fracture stability in soldiers with severely comminuted tibial fractures

Virtual stress testing (VST) provides a non-invasive estimate of the strength of a healing bone through a biomechanical analysis of a patient's computed tomography (CT) scan. We asked whether VST could improve management of patients who had a tibia fracture treated with external fixation. In a retrospective case-control study of 65 soldier-patients who had tibia fractures treated with an external fixator, we performed VST utilizing CT scans acquired prior to fixator removal. The strength of the healing bone and the amount of tissue damage after application of an overload were computed for various virtual loading cases. Logistic regression identified computed outcomes with the strongest association to clinical events related to nonunion within 2 months after fixator removal. Clinical events (n = 9) were associated with a low tibial strength for compression loading (p < 0.05, AUC = 0.74) or a low proportion of failed cortical bone tissue for torsional loading (p < 0.005, AUC = 0.84). Using post-hoc thresholds of a compressive strength of four times body-weight and a proportional of failed cortical bone tissue of 5%, the test identified all nine patients who failed clinically (100% sensitivity; 40.9% positive predictive value) and over three fourths of those (43 of 56) who progressed to successful healing (76.8% specificity; 100% negative predictive value). In this study, VST identified all patients who progressed to full, uneventful union after fixator removal; thus, we conclude that this new test has the potential to provide a quantitative, objective means of identifying tibia-fracture patients who can safely resume weight bearing. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:805-811, 2017.

Management of diaphyseal tibial fractures by plate fixation with absolute or relative stability: a retrospective study of 45 patients

Background

Fixation of diaphyseal tibial fractures by plates is not considered the best option due to complications that may eventually arise; however, if principles of stability and proper surgical techniques are used, it is possible to obtain fracture consolidation without major risks.

Methods

We conducted a cross-sectional observational descriptive study by retrospectively analyzing medical records of patients with diaphyseal tibial fractures that were treated with plates from the period between June 2011 and June 2014 at San José and Susana López Hospitals in the city of Popayan, Colombia. 3 treatment groups were created and analyzed according to the type of fracture (Association Osteosynthesis/Osteosynthesis Trauma Association AO/OTA): group I: simple fractures 42A/B, absolute stability; group II: simple fractures 42A/B, Minimally Invasive Plate Osteosynthesis (MIPO) technique, relative stability; group III: multifragmentary fractures 42C, MIPO technique, relative stability. A descriptive analysis of patients, fracture consolidation time, and complications in each group were performed.

Results

45 patients with tibial fractures treated with osteosynthesis plates were analyzed. Group I: 14 patients, 42A (n=13) and 42B (n=1), had an average consolidation time of 16.38 (SD=1.98) and 14 weeks, respectively. In group II: 19 patients, out of which 18 achieved fracture consolidation (42A n=15 and 42B n=3) with an average time of 17.4 (SD=3.33) and 17.3 weeks (SD=6.11), respectively. Finally, in group III: 12 patients all with 42C fractures with a consolidation time of 16.86 (SD=2.93) weeks. The average fracture consolidation time for all 44 patients was 16.86 weeks (SD 2.93).

Conclusions

Osteosynthesis plates are an alternative to intramedullary nailing for diaphyseal tibial fractures and their outcomes can be favorable as long as the management of soft tissues and the proper principle of stability are taken into account.

Level of evidence

IV.

Management of Gustilo Anderson III B open tibial fractures by primary fascio-septo-cutaneous local flap and primary fixation: The 'fix and shift' technique

BACKGROUND

Open fractures of tibia have posed great difficulty in managing both the soft tissue and the skeletal components of the injured limb. Gustilo Anderson III B open tibial fractures are more difficult to manage than I, II, and III A fractures. Stable skeletal fixation with immediate soft tissue cover has been the key to the successful outcome in treating open tibial fractures, in particular, Gustilo Anderson III B types. If the length of the open wound is larger and if the exposed surface of tibial fracture and tibial shaft is greater, then the management becomes still more difficult.

MATERIALS AND METHODS

Thirty six Gustilo Anderson III B open tibial fractures managed between June 2002 and December 2013 with "fix and shift" technique were retrospectively reviewed. All the 36 patients managed by this technique had open wounds measuring >5 cm (post debridement). Under fix and shift technique, stable fixation involved primary external fixator application or primary intramedullary nailing of the tibial fracture and immediate soft tissue cover involved septocutaneous shift, i.e., shifting of fasciocutaneous segments based on septocutaneous perforators.

RESULTS

Primary fracture union rate was 50% and reoperation rate (bone stimulating procedures) was 50%. Overall fracture union rate was 100%. The rate of malunion was 14% and deep infection was 16%. Failure of septocutaneous shift was 2.7%. There was no incidence of amputation.

CONCLUSION

Management of Gustilo Anderson III B open tibial fractures with "fix and shift" technique has resulted in better outcome in terms of skeletal factors (primary fracture union, overall union, and time for union and malunion) and soft tissue factors (wound healing, flap failure, access to secondary procedures, and esthetic appearance) when compared to standard methods adopted earlier. Hence, "fix and shift" could be recommended as one of the treatment modalities for open III B tibial fractures.

Computed tomography angiography and magnetic resonance imaging performance of acute segmental single compartment syndrome following an Achilles tendon repair: A case report and literature review

Acute compartment syndrome of the lower extremity is a serious postinjury complication that requires emergency treatment. Early diagnosis is of paramount importance for a good outcome. Four muscle compartments in the calf (anterior, lateral, deep posterior, and superficial posterior) may be individually or collectively affected. Acute segmental single-compartment syndrome is an extremely rare condition characterized by high pressure in a single compartment space with threatening of the segmental tissue viability. In this case report, we describe a young man with Achilles tendon rupture who complained of postoperative pain in the anterior tibial region. Emergent computed tomography angiography and magnetic resonance imaging revealed local muscle edema. Segmental anterior compartment syndrome was diagnosed and fasciotomy was performed.

Surgical stabilization for open tibial fractures in children: External fixation or elastic stable intramedullary nail - which method is optimal?

BACKGROUND

Management of open tibial fractures is well documented in adults, with existing protocols outlining detailed treatment strategies. No clear guidelines exist for children. Surgical stabilization of tibial fractures in the pediatric population requires implants that do not disrupt the open epiphyses (growth plate). Both elastic stable intramedullary nails and external fixation can be used. The objective of this study was to identify the optimal method of surgical stabilization in the treatment of open tibial fractures in children.

MATERIALS AND METHODS

MEDLINE and Embase were searched from their inception to March 2014 using the following advanced search terms (Key words): "open tibia fracture," "fracture fixation," "external fixation," "intramedullary," and "bone nail." Only studies in English and pertaining to children with open fractures treated with elastic stable intramedullary nails or external fixation between 1994 and 2014 were included. Twelve clinical studies were critically appraised.

RESULTS

Due to a paucity in the literature coupled with a nonsystematic presentation of results, it proved to be very difficult in extracting relevant results from the studies. This was further added by a variation in outcome measures. Consequently, the results we obtained were difficult to draw conclusions from.

CONCLUSION

There is no conclusive evidence or best practice guidelines for their management. Thus, as is highlighted in this study, more research is needed to determine the optimum treatment strategy for this common pediatric injury. The existing literature is of poor quality; consisting mainly of retrospective reviews of patients' medical records, charts, and radiographs. Carefully designed, high-quality prospective cohort studies utilizing a nationalized multi-hospital approach are needed to improve understanding before protocols and guidelines can be developed and implemented.

Preoperative determination of tibial nail length: An anthropometric study

OBJECTIVE

To assess the correlation between five anthropometric parameters and the distance from tibial tuberosity to medial malleolus in 100 volunteers.

METHODS

Six anthropometric parameters were measured in 50 male and 50 female medical students using a metallic scale: medial knee joint line to ankle joint line (K-A), medial knee joint line to medial malleolus (K-MM), tibial tuberosity to ankle joint (TT-A), tibial tuberosity to medial malleolus (TT- MM), olecranon to 5th metacarpal head (O-MH) and body height (BH). Nail size predicted based upon TT-MM measurement was chosen as ideal nail size. A constant was derived for each of the six anthropometric parameters which was either added or subtracted to each measurement to derive nail size. A regression equation was applied to BH measurements. Nail sizes calculated were compared with that obtained from TT-MM measurement and accuracy was evaluated. Accuracy of O-MH and BH regression equations recommended by other authors were calculated in our data.

RESULTS

Adding 11 mm to TT-A distance had highest accuracy (81%) and correlation (0.966) in predicting nails correctly. Subtracting 33 mm from K-MM measurement and 25 mm from K-A distance derived accurate sizes in 69% and 76% respectively. Adding 6 mm to O-MH distance had a poor accuracy of 51%. Nail size prediction based upon body height regression equation derived correct nail sizes in only 34% of the cases. Regression equation analysis by other authors based on O-MH and BH distances yielded correct sizes in 11% and 5% of the cases respectively.

CONCLUSION

TT-A, K-A and K-MM measurements can be used simultaneously to increase accuracy of nail size prediction. This method would be helpful in determining nail size preoperatively especially when one anatomic landmark is difficult to palpate.

The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre

Objectives

The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison.

Methods

A total of 15 radiographs of tibial shaft fractures treated by intramedullary nailing (IM) were scored by three observers using the RUST system. Following discussion on how the criteria of the RUST system should be implemented, 45 sets (i.e. AP and lateral) of radiographs of IM nailed tibial fractures were scored by five observers. Finally, these 45 sets of radiographs were rescored with the baseline post-operative radiograph available for comparison.

Results

The initial intraclass correlation (ICC) on the first 15 sets of radiographs was 0.67 (95% CI 0.63 to 0.71). However, the original description was being interpreted in different ways. After agreeing on the interpretation, the ICC on the second cohort improved to 0.75. The ICC improved even further to 0.79, when the baseline post-operative radiographs were available for comparison.

Conclusion

This study demonstrates that the RUST scoring system is a reliable and repeatable outcome measure for assessing tibial fracture healing. Further improvement in the reliability of the scoring system can be obtained if the radiographs are compared with the baseline post-operative radiographs.

Cite this article: Mr J.M. Leow. The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre. Bone Joint Res 2016;5:116–121. DOI: 10.1302/2046-3758.54.2000628.

Effectiveness of Serial Measurement of Differential Pressure in Closed Tibial Diaphyseal Fractures in Diagnosing Acute Compartment Syndrome using Whiteside's Technique

Acute Compartment Syndrome is a limb-threatening emergency and it occurs most commonly after fractures. The aim of our study is to find out the effectiveness of serial measurement of differential pressure in closed tibial diaphyseal fractures, in diagnosing acute compartment syndrome, using Whiteside’s technique. A total of 52 cases in the age group of 15 to 55 years admitted with closed fractures were studied for serial compartment pressure as well as serial differential pressure. Eight patients had persistent compartment pressure > 40mmHg, out of which only two patients had persistent differential pressure < 30mmHg and these two patients underwent fasciotomy. Thus, by measuring the compartment pressure serially and calculating differential pressure serially, acute compartment syndrome can be diagnosed or ruled out with higher precision, so that unnecessary fasciotomies can be avoided.

Minimally invasive osteosynthesis of distal tibial fractures using anterolateral locking plate: Evaluation of results and complications

PURPOSE

Soft tissue healing is of paramount importance in distal tibial fractures for a successful outcome. There is an increasing trend of using anterolateral plate due to an adequate soft tissue cover on ante- rolateral distal tibia. The aim of this study was to evaluate the results and complications of minimally invasive anterolateral locking plate in distal tibial fractures.

METHODS

This is a retrospective study of 42 patients with distal tibial fractures treated with minimally invasive anterolateral tibial plating. This study evaluates the bone and soft tissue healing along with emphasis on complications related to bone and soft tissue healing.

RESULTS

Full weight bearing was allowed in mean time period of 4.95 months (3-12 months). A major local complication of a wound which required revision surgery was seen in one case. Minor complications were identified in 9 cases which comprised 4 cases of marginal necrosis of the surgical wound, 1 case of superficial infection, 1 case of sensory disturbance over the anterolateral foot, 1 case of muscle hernia and 2 cases of delayed union. Mean distance between the posterolateral and anterolateral incision was 5.7 cm (4.5-8 cm).

CONCLUSION

The minimally invasive distal tibial fixation with anterolateral plating is a safe method of stabilization. Distance between anterolateral and posterolateral incision can be placed less than 7 cm apart depending on fracture pattern with proper surgical timing and technique.

Comparison of intramedullary nail and plating in treatment of diaphyseal tibial fractures with intact fibulae: A randomized controlled trial

BACKGROUND

Tibial fracture without concomitant fibular fracture is an injury that has long attracted notice for the fact that it sometimes heals cleanly, other times causes various problems when the bone does not heal, or misaligns. In this randomized clinical trial, we assessed two treatment modalities plating and intramedullary nailing for treatment of closed, noncomminuted tibial fractures with intact fibulae.

MATERIALS AND METHODS

During the three year period, 1470 patients with leg fractures were treated and out of which, 114 were eligible to enter the study. Of the eligible patients, 73 were recruited to enter the trial, and ultimately 69 of these were followed for at least one year. The patients were randomized into two groups, one of which was treated by plating of the fracture, the other group by intramedullary nailing, both of which are standard surgical procedures. The primary variables that influenced the outcome of the procedures in both treatments were the duration of surgery, the amount of bleeding, the time to union, the need to repeat surgery to achieve union, the need to remove a device, and patients' complaints about pain or discomfort in the limb.

RESULTS

One case of nonunion occurred in the group treated with intramedullary nailing and one of the patients in this group developed late, deep infection in the screws location, which was resolved by screw removal (P = 0.285 and P = 0.478, respectively). In both groups the tibial fractures achieved union in about 4 months, though the intramedullary group underwent more operations to achieve union (dynamization was performed in 4 patients, representing 12.1% of the patients in this group, P = 0.047). During the followup period, the incidence of implant removal (after union) was not statistically significant between the two groups: two patients (6.1%) in the intramedullary group and four patients (11.1%) in the plate group (P = 0.675) had implants removed. Of the other studied variables, the difference between the two groups was statistically significant only with regard to patients' complaints of pain in the limb and the number of individuals with knee pain (in both cases, P = 0.001). In the intramedullary group, 18 patients had no complaints (54.4%) and 13 complained of knee pain (39.4%), while in the plate group 29 had no complaints (80.6%).

CONCLUSION

Based upon the findings of the present study, both the methods studied are suitable treatments for closed noncomminuted isolated tibial fractures, but the patients in whom intramedullary nails are used are more likely to require additional surgeries to achieve union, and probably will have more complaints of pain in their limbs or knees.

Clinical and functional outcomes of acute lower extremity compartment syndrome at a Major Trauma Hospital

Background:

Acute lower extremity compartment syndrome (CS) is a condition that untreated causes irreversible nerve and muscle ischemia. Treatment by decompression fasciotomy without delay prevents permanent disability. The use of intracompartmental pressure (iCP) measurement in uncertain situations aids in diagnosis of severe leg pain. As an infrequent complication of lower extremity trauma, consequences of CS include chronic pain, nerve injury, and contractures. The purpose of this study was to observe the clinical and functional outcomes for patients with lower extremity CS after fasciotomy.

Methods:

Retrospective chart analysis for patients with a discharge diagnosis of CS was performed. Physical demographics, employment status, activity at time of injury, injury severity score, fracture types, pain scores, hours to fasciotomy, iCP, serum creatine kinase levels, wound treatment regimen, length of hospital stay, and discharge facility were collected. Lower extremity neurologic examination, pain scores, orthopedic complications, and employment status at 30 days and 12 months after discharge were noted.

Results:

One hundred twenty-four patients were enrolled in this study. One hundred and eight patients were assessed at 12 months. Eighty-one percent were male. Motorized vehicles caused 51% of injuries in males. Forty-one percent of injuries were tibia fractures. Acute kidney injury occurred in 2.4%. Mean peak serum creatine kinase levels were 58,600 units/ml. Gauze dressing was used in 78.9% of nonfracture patients and negative pressure wound vacuum therapy in 78.2% of fracture patients. About 21.6% of patients with CS had prior surgery. Nearly 12.9% of patients required leg amputation. Around 81.8% of amputees were male. Sixty-seven percent of amputees had associated vascular injuries. Foot numbness occurred in 20.5% of patients and drop foot palsy in 18.2%. Osteomyelitis developed in 10.2% of patients and fracture nonunion in 6.8%. About 14.7% of patients underwent further orthopedic surgery. At long-term follow-up, 10.2% of patients reported moderate lower extremity pain and 69.2% had returned to work.

Conclusion:

Escalation in leg pain and changes in sensation are the cardinal signs for CS rather than reliance on assessing for firm compartments and pressures. The severity of nerve injury worsens with the delay in performing fasciotomy. Standardized diagnostic protocols and wound treatment strategies will result in improved outcomes from this complication.

Use of a raft construct through a locking plate without bone grafting for split-depression tibial plateau fractures

PURPOSE

To review the outcome after open reduction and internal fixation using a periarticular raft construct through a locking plate without bone grafting for split-depression tibial plateau fractures.

METHODS

Records of 38 knees in 31 men and 7 women aged 25 to 75 (mean, 42.7) years who underwent open reduction and internal fixation using a periarticular raft construct through a locking plate without use of a bone graft or bone substitute for split-depression (>5 mm) proximal tibial plateau fractures (Schatzker type II or AO/OTA type 4.1 B3) were reviewed. The integrity of the articular surface was assessed using radiographs. The Rasmussen radiological score and clinical score, the Lysholm knee score, and the Tegner activity score were also assessed.

RESULTS

The mean follow-up period was 22.8 (range, 6-36) months. All patients achieved bone union after a mean of 13.2 (range, 8-26) weeks. The mean range of motion was 118º (range, 100º-130º). The Rasmussen radiological score was excellent in 27 patients, good in 9, and fair in 2. The Rasmussen clinical score was excellent in 15 patients, good in 21, and fair in 2. The Lysholm knee score was excellent in 26 patients, good in 8, and fair in 4. 32 of the 38 patients recovered to their preoperative Tegner activity scores. Only one patient with severe comminution had loss of reduction after full weightbearing.

CONCLUSION

Fixation using a periarticular raft construct through a locking plate without use of a bone graft or bone substitute for split-depression proximal tibial plateau fractures is a viable option.

A useful surgical strategy for proximal tibial fractures (AO/OTA type 41-C) with diaphyseal involvement

Relatively few studies have addressed surgical strategy for complex proximal tibial fractures by now. The purpose of this study was to assess the results of a single lateral locking plate using minimally invasive plate osteosynthesis (MIPO) for proximal tibia fractures (AO/OTA type 41-C) with diaphyseal involvement. From Jun 2009 to Jun 2014, 20 patients (fifteen women and five men, mean age 35.8 years) were managed for proximal tibial fractures which extend into the diaphyseal region of the bone, including three 41-C1, eleven 41-C2, and six 41-C3. Twelve patients were open fractures. A single lateral locking plate characterized by percutaneous technology was used with or without additional lag screws. Mobilization was started immediately after the procedure, and non-weight-bearing was maintained for at least 6 weeks, then progressively weight bearing depends on both clinical and x-ray findings. Primary union was achieved by 16 of the 20 study subjects. Early bone grafting was performed in 4 cases with a massive initial bone defect and staged bone grafting was used in one to treat nonunion. The mean articular step off was 1.0 mm (range, 0-3 mm). No patient had misalignment greater than 10°. Acceptable range of knee motion of ≥120° was achieved in sixteen, and the mean knee Hass score was 87.4 at final follow-up visits. The complications included superficial infection in one patient. In conclusion, the surgical strategy can provide favorable results in the treatment of proximal tibial fractures (AO/OTA type 41-C) with diaphyseal involvement.

Arthroscopic management of proximal tibial fractures: technical note and case series presentation

Background and aims

The purpose of this article is to describe a new surgical method of arthroscopy assisted treatment of intraarticular proximal tibial fractures (ARIF – arthroscopic reduction and internal fixation), analyzing its efficiency and safety on a series of patients. Tibial plateau fractures affect the proximal tibial metaphyseal and articular surface, representing 1.2% of all fractures and up to 8% of all fractures in elderly.

Patients and method

Our case series consists of 6 patients with Schatzker types I-III tibial plateau fractures, treated in the Orthopedic and Traumatology Clinic of Cluj-Napoca from July 2012 to August 2014. Patients included in the study presented Schatzker type I-III tibial plateau fracture.

Results

The results obtained with the arthroscopic method were excellent in 5 cases (mean Rasmussen score 27.60 points) and good in 1 case (mean score 23.75). The radiological consolidation appeared after a mean of 12 weeks. No major complication was noted.

Conclusions

Diagnosis and treatment of associated lesions, shortening of hospitalization length and postoperative rehabilitation, but also the lower rate of complications, can make arthroscopic reduction and internal fixation the method of choice for the operative treatment of selected Schatzker I-III types of proximal tibial fractures.

Salvage of infected non-union of the tibia with an Ilizarov ring fixator

PURPOSE

To review outcomes of 24 patients who underwent Ilizarov ring fixation for infected nonunion of the tibia.

METHODS

Medical records of 21 men and 3 women aged 13 to 74 (mean, 38) years who underwent Ilizarov ring fixation for infected non-union of the tibia were reviewed. The mean bone defect was 3.3 (range, 2-5) cm. The mean time from injury to presentation was 11.9 (range, 1-36) months. The mean number of previous surgeries was 2 (range, 0-14). A local flap was used in 2 patients and a free flap was used in one patient. Nine of the patients underwent Ilizarov ring fixation without soft tissue and bony resection, as inadequate stability was the reason for non-union. Patients were assessed using the Association for the Study and Application of the Method of Ilizarov criteria.

RESULTS

Patients were followed up for a mean of 11 (range, 8-46) months. Functional outcome was excellent in 8 patients, good in 12, fair in 2, and failure in one, whereas bone union outcome was excellent in 6 patients, good in 14, fair in one, and poor in 2. The mean time to union was 8 (range, 3-31) months. The mean external fixation index was 4.2 (range, 1.5-15.7) cm/month. Complications encountered were pin tract infection (n=5), re-fracture (n=2), soft tissue impingement by Ilizarov rings (n=2), recurrence of wound infection (n=1), mal-union (n=1), and mortality (n=1).

CONCLUSION

Ilizarov ring fixation is a viable option for infected non-union of the tibia. Adequate assessment of bone union is crucial before removal of fixator to prevent re-fracture.

Minimally invasive percutaneous plate osteosynthesis does not increase complication rates in extra-articular distal tibial fractures

Background :

Selection of a treatment method in cases of unstable, nonarticular distal tibial fractures is still a matter of discussion. Intramedullary nailing, which is a “gold standard” for tibial shaft fractures, does not always work for this specific transition area between diaphysis and metaphysis. Instead, new minimally invasive techniques with special implants are popular.

Aims :

To determine the functional and radiological results of distal tibial fractures treated with minimally invasive percutaneous plate osteosynthesis (MIPPO) technique.

Study Design :

Retrospective cohort analysis.

Methods :

Thirty distal tibial fractures treated with MIPPO method, between January 2006 and December 2010, were evaluated retrospectively. All patients were classified according to AO/OTA classification. Period of hospital stay, time of fracture union, time to allow full weight bearing, early and late complications were inquired. Functional outcomes were assessed by AOFAS scores.

Results :

There were 13 male and 17 female patients with an average age of 44.26 (range, 22-77 years). One superficial infection and one malunion were observed. Two patients were revised for the loss of reduction and healed uneventfully. According to the AO/OTA classification, 23 patients were 43-A1 (76.6%), 3 were 43-A2 (10%) and 4 were 43-A3 (13.3%). Post-operative mean stay of patients at the hospital was 2.6 ± 1.42 days (range, 1-7 days). Mean full weight-bearing period of the patients was found out as 13.16 ± 2.6 weeks (range, 10-22 weeks). The mean period of union of fracture for patients was found out as 19.8 ± 2.99 weeks (range, 16-34 weeks).

Conclusion :

Treatment of distal tibial fractures with MIPPO method provides a successful treatment strategy as long as used as per the technique, and it respects and does not harm soft tissues which allows early callus formation and rapid healing that enable the patient to walk as early as possible after the operation. The overall clinical and functional outcome is still good despite minor complications.