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Orellana KJ, Houlihan NV, Carter MV, Baghdadi S, Baldwin K, Stevens AC, Cruz AI, Ellis HB, Green DW, Kushare I, Johnson B, Kerrigan A, Kirby JC, MacDonald JP, McKay SD, Milbrandt TA, Justin Mistovich R, Parikh S, Patel N, Schmale G, Traver JL, Yen YM, Ganley TJ. Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis. Am J Sports Med 2024; 52:1357-1366. [PMID: 37326248 DOI: 10.1177/03635465231175674] [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] [Indexed: 06/17/2023]
Abstract
BACKGROUND Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified. PURPOSE To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications. STUDY DESIGN Meta-analysis; Level of evidence, 4. METHODS A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data. RESULTS A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures (P < .001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures (P = .008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture). CONCLUSION Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs.
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Affiliation(s)
- Kevin J Orellana
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nathan V Houlihan
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael V Carter
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Soroush Baghdadi
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Keith Baldwin
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Aristides I Cruz
- Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | | | | | | | | | | | | | | | | | - R Justin Mistovich
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Shital Parikh
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Neeraj Patel
- Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | | | - Jessica L Traver
- Jessica L. Traver, MD (University of Texas Health Houston, Houston, Texas, USA
| | - Yi-Meng Yen
- Boston Children's Hospital, Boston, Massachusetts, USA
| | - Theodore J Ganley
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Gouveia K, Hache P, Johal H. Plating as a reduction aid prior to intramedullary nailing of tibia fractures: a systematic review and meta-analysis. Eur J Orthop Surg Traumatol 2024; 34:1259-1267. [PMID: 38145978 DOI: 10.1007/s00590-023-03801-w] [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: 09/18/2023] [Accepted: 11/25/2023] [Indexed: 12/27/2023]
Abstract
PURPOSE The purpose of this meta-analysis is to analyse the literature on plate-assisted reduction during intramedullary nailing of tibial shaft fractures and to compare the rates of infection and nonunion. METHODS The databases Medline, Embase, and Web of Science were searched from inception to February 2022 for literature comparing plate-assisted reduction during intramedullary nailing of extra-articular tibia fractures to standard, closed means of reduction. Data were extracted and pooled in a random effects meta-analysis for the primary outcomes of nonunion and infection risk. RESULTS Five comparative studies were identified including 520 total patients, of which 151 underwent tibial nailing with the use of plate-assisted reduction with an average follow-up time of 17.9 months. Approximately two-thirds of patients retained the plate used to assist reduction during intramedullary nailing (102 of 151). Pooled analysis of the infection rates found no significant difference with plate-assisted intramedullary nailing (Risk Ratio [RR] 0.90, 95% CI 0.49-1.65, p = 0.72), and for nonunion rates, there was also no significant difference with plate-assisted intramedullary nailing (Risk Ratio [RR] 0.80, 95% CI 0.40-1.60, p = 0.53). CONCLUSIONS Plate-assisted reduction during intramedullary nailing of tibia shaft fractures was not associated with an increased risk for nonunion or infection, and can be safely applied as an adjunct for reduction in challenging fracture patterns, without the need for later removal. However, evidence is quite limited and further investigation into the use of provisional plating as a technique is needed as its use in intramedullary nailing continues to expand.
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Affiliation(s)
- Kyle Gouveia
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
| | - Philip Hache
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Herman Johal
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
- Centre for Evidence-Based Orthopaedics, Hamilton, ON, Canada
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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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Watrinet J, Blum P, Maier M, Klingbeil S, Regenbogen S, Augat P, Schipp R, Reng W. Undersizing of the tibial component in Oxford unicompartmental knee arthroplasty (UKA) increases the risk of periprosthetic fractures. Arch Orthop Trauma Surg 2024; 144:1353-1359. [PMID: 38214714 DOI: 10.1007/s00402-023-05142-z] [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: 03/30/2023] [Accepted: 11/11/2023] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Tibial periprosthetic fractures (TPF) after unicompartmental knee arthroplasty (UKA) are a rare condition that affects about 1% of cases. Known risk factors include age, sex, body mass index (BMI), and bone density, as well as surgical technique and prosthesis design. The purpose of the study was to determine if undersizing of the tibial component in relation to the femoral component increases the risk of tibial periprosthetic fractures. MATERIAL AND METHODS Over a 6-year-period 1542 patients with cemented (n = 363) and uncemented (n = 1179) medial UKA were retrospectively evaluated. Tibial periprosthetic fractures were identified and classified, and epidemiologic data were documented at follow-up. Undersizing was defined as a smaller tibial component compared to the femoral implant. The association of potential risk factors for TPF with the incidence of TPF was investigated with binominal logistic regression. RESULTS Fourteen patients (0.9%) suffered from TPF at a median of 1 month after surgery. The mean follow-up period was 5.9 ± 1.7 years. Fractures were more common in cases with undersized tibial components [odds ratio (OR) 3.2, p < 0.05]. Furthermore, older age (OR 1.1, p < 0.05) and female sex (OR 6.5, p < 0.05) were identified as significant risk factors, while BMI (p = 0.8) and cemented implantation (p = 0.2) had no effect on fracture rate. Revision surgery included open reduction and internal fixation or conversion to total knee arthroplasty. CONCLUSIONS Undersizing of implant sizes in UKA increases the risk for TPF especially in patients with small tibial implants. Therefore, mismatched implants should be avoided for UKA particularly when risk factors like obesity, older age, or female gender are present. Tibial periprosthetic fractures were successfully treated by open reduction and internal fixation or conversion to total knee arthroplasty.
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Affiliation(s)
- Julius Watrinet
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany.
- Department Trauma Surgery, BG Unfallklinik Murnau, Prof. Küntscher Str. 8, 82418, Murnau, Germany.
| | - Philipp Blum
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany
- Department Trauma Surgery, BG Unfallklinik Murnau, Prof. Küntscher Str. 8, 82418, Murnau, Germany
| | - Michael Maier
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany
| | - Steffen Klingbeil
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany
| | - Stephan Regenbogen
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany
- Department Trauma Surgery, BG Unfallklinik Murnau, Prof. Küntscher Str. 8, 82418, Murnau, Germany
| | - Peter Augat
- Institute Institute for Biomechanics, BG Unfallklinik Murnau, Prof. Küntscher Str. 8, 82418, Murnau, Germany
- Institute for Biomechanics, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - Rolf Schipp
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany
| | - Wolfgang Reng
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany
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Li W, Zhao Y, Liu L, Yu H, Xie Z, Zhuang Q. Limb Fractures Treated With the Novel Plate Osteosynthesis Application Technique: Second to Minimally Invasive Plates osteosynthesis. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202403000-00012. [PMID: 38466989 PMCID: PMC10927324 DOI: 10.5435/jaaosglobal-d-24-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/16/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND The main aim of this article was to propose a new concept of minimally invasive surgery for treating limb fractures, named as second to minimally invasive plates osteosynthesis (STMIPO). METHODS We have described the STMIPO technique in a step-wise and standardized manner based on our findings from a study involving six patients treated at our institution. All patients with fracture achieved satisfactory outcomes. RESULTS Ours clinical trials have shown that the STMIPO technique can be successfully applied in various limb fractures, including fibula fractures, tibial fractures, femur fractures, humerus fractures, ulna fractures, and radius fractures. All fracture patients achieved satisfactory outcomes. CONCLUSION As a new minimally invasive technology, the STMIPO technique can serve as an alternative solution for fractures that are difficult to reduce with minimally invasive plates osteosynthesis (MIPO).
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Affiliation(s)
- Wei Li
- From the Department of orthopedic, No.2 people's hospital of Fuyang city, Fuyang city, Anhui province, China (Dr. Li, Dr. Zhao, and Dr. Zhuang); the Department of Pre hospital emergency, Chongqing Emergency Medical Center, Chongqing, China (Dr. Liu); the Department of orthopedic, People's hospital of Fuyang city, Fuyang city, Anhui province, China (Dr. Yu); and the Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, The People's Republic of China (Dr. Xie)
| | - Yaowei Zhao
- From the Department of orthopedic, No.2 people's hospital of Fuyang city, Fuyang city, Anhui province, China (Dr. Li, Dr. Zhao, and Dr. Zhuang); the Department of Pre hospital emergency, Chongqing Emergency Medical Center, Chongqing, China (Dr. Liu); the Department of orthopedic, People's hospital of Fuyang city, Fuyang city, Anhui province, China (Dr. Yu); and the Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, The People's Republic of China (Dr. Xie)
| | - Lian Liu
- From the Department of orthopedic, No.2 people's hospital of Fuyang city, Fuyang city, Anhui province, China (Dr. Li, Dr. Zhao, and Dr. Zhuang); the Department of Pre hospital emergency, Chongqing Emergency Medical Center, Chongqing, China (Dr. Liu); the Department of orthopedic, People's hospital of Fuyang city, Fuyang city, Anhui province, China (Dr. Yu); and the Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, The People's Republic of China (Dr. Xie)
| | - Haiyang Yu
- From the Department of orthopedic, No.2 people's hospital of Fuyang city, Fuyang city, Anhui province, China (Dr. Li, Dr. Zhao, and Dr. Zhuang); the Department of Pre hospital emergency, Chongqing Emergency Medical Center, Chongqing, China (Dr. Liu); the Department of orthopedic, People's hospital of Fuyang city, Fuyang city, Anhui province, China (Dr. Yu); and the Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, The People's Republic of China (Dr. Xie)
| | - Zhao Xie
- From the Department of orthopedic, No.2 people's hospital of Fuyang city, Fuyang city, Anhui province, China (Dr. Li, Dr. Zhao, and Dr. Zhuang); the Department of Pre hospital emergency, Chongqing Emergency Medical Center, Chongqing, China (Dr. Liu); the Department of orthopedic, People's hospital of Fuyang city, Fuyang city, Anhui province, China (Dr. Yu); and the Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, The People's Republic of China (Dr. Xie)
| | - Quankui Zhuang
- From the Department of orthopedic, No.2 people's hospital of Fuyang city, Fuyang city, Anhui province, China (Dr. Li, Dr. Zhao, and Dr. Zhuang); the Department of Pre hospital emergency, Chongqing Emergency Medical Center, Chongqing, China (Dr. Liu); the Department of orthopedic, People's hospital of Fuyang city, Fuyang city, Anhui province, China (Dr. Yu); and the Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, The People's Republic of China (Dr. Xie)
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Jones CA, Seilern und Aspang J, Holmes JS, Zamanzadeh RS, Phen HM, Baker JL, Hernandez-Irizarry RC, Moore TJ. Incidence and Risk Factors of Heterotopic Ossification in the Knee After Reamed Tibial Nailing. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202402000-00002. [PMID: 38324456 PMCID: PMC10846776 DOI: 10.5435/jaaosglobal-d-23-00258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/26/2023] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Heterotopic ossification (HO) in the knee after tibial intramedullary nailing (IMN) has yet to be thoroughly investigated. Our aim was to assess frequency and associated factors for HO in the knee after tibial IMN. METHODS This is a retrospective review at a single level 1 urban trauma center of 213 patients who underwent reamed tibial IMN. Plain radiographs were reviewed postoperatively and on final follow-up (≥6 weeks). Chart review was performed for surgical approach (suprapatellar versus infrapatellar), demographics, injury characteristics, and clinical follow-up. The primary outcome was frequency of HO. RESULTS HO on final follow-up (mean: 41.43 weeks) was recorded in 15% cases. Postsurgical retroinfrapatellar reaming debris (odds ratio [OR], 4.73), Injury Severity Score (OR, 1.05), intensive care unit admission (OR, 2.89), chest injury (OR, 3.4), and ipsilateral retrograde femoral IMN (OR, 5.08) showed a notable association with HO development. No association was observed in HO formation between surgical approach, knee pain, or range-of-motion deficits. DISCUSSION Radiographic evidence of HO in the knee after reamed tibial IMN is not uncommon and is associated with retained reaming debris, Injury Severity Score, chest injury, intensive care unit admission, and ipsilateral retrograde femoral nailing. No differences were noted in HO formation between approaches. HO was not associated with knee pain or range-of-motion deficits.
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Affiliation(s)
- Corey A. Jones
- From the Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
| | | | - Jeffrey S. Holmes
- From the Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
| | - Ryan S. Zamanzadeh
- From the Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
| | - Huai M. Phen
- From the Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
| | - J.'Lynn L. Baker
- From the Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
| | | | - Thomas J. Moore
- From the Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
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Makaram NS, Param A, Clement ND, Scott CEH. Primary Versus Secondary Total Knee Arthroplasty for Tibial Plateau Fractures in Patients Aged 55 or Over-A Systematic Review and Meta-Analysis. J Arthroplasty 2024; 39:559-567. [PMID: 37572727 DOI: 10.1016/j.arth.2023.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 03/20/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND Total knee arthroplasty allows immediate postoperative weight-bearing and is increasingly recognized as a suitable treatment option for older patients who have tibial plateau fractures (TPFs). This systematic review evaluated the clinical and functional outcomes associated with primary versus secondary TKA for the treatment of TPFs in patients aged ≥55 years. METHODS Various databases were searched from inception to December 2021. Studies investigating outcomes of primary TKA (pTKA) as the initial treatment for TPFs in patients of mean age ≥55 years or those investigating outcomes of secondary TKA (sTKA) following any other primary treatment for TPFs were included. Quality of included studies was assessed using a methodological scale. Of 767 potentially relevant studies, 12 studies comprising 341 patients were included: 121 patients underwent (pTKA) and 220 patients underwent sTKA. There were 3 high-quality studies. Patients in the sTKA cohort were significantly younger at the time of TKA compared with those undergoing pTKA (mean 61.3 versus 72.2 years, P < .001, 95% confidence interval (CI) 8.2 to 13.6). RESULTS Intraoperative and postoperative complication rates were lower with pTKA; in particular, sTKA was associated with a significantly increased rate of stiffness requiring reintervention and patella tendon rupture. Functional outcome was greater after pTKA, but this did not reach statistical significance (85.2 versus 79.9%, P = .359, 95% CI -16.7 to 6.1). CONCLUSION Primary TKA was associated with lower complication rates than secondary TKA after TPF. In appropriate cases of TPF in older adults, it may be preferable to proceed with TKA as primary treatment rather than delaying until after fracture union or malunion.
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Affiliation(s)
- Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; The University of Edinburgh, Edinburgh, United Kingdom
| | - Aava Param
- The University of Edinburgh, Edinburgh, United Kingdom
| | - Nicholas D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Chloe E H Scott
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Johnson TR, Oquendo YA, Seltzer R, Van Rysselberghe NL, Bishop JA, Gardner MJ. Incisional negative pressure wound therapy may not protect against post-operative surgical site complications in bicondylar tibial plateau fractures. Eur J Orthop Surg Traumatol 2024; 34:1173-1181. [PMID: 37989870 DOI: 10.1007/s00590-023-03782-w] [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: 09/04/2023] [Accepted: 11/01/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE To determine if incisional negative pressure wound therapy is protective against post-operative surgical site complications following definitive fixation of bicondylar tibial plateau fractures. METHODS A retrospective analysis of patients diagnosed with an acute bicondylar tibial plateau fracture (AO/OTA 41-C) undergoing ORIF from 2010 to 2020 was performed. Patients received either a standard sterile dressing (SD) or incisional negative pressure wound therapy (iNPWT). Primary outcomes included surgical site infection, osteomyelitis, and wound dehiscence. Secondary outcomes included non-union and return to the operating room. Multivariate logistic regression analyses were performed. RESULTS 180 patients were included and 22% received iNPWT (n = 40) and 78% received standard dressings (n = 140). iNPWT was more common in active smokers (24.7% vs. 19.3%, p = 0.002) and the SD group was more likely to be lost to follow up (3.6% vs. 0%, p = 0.025). iNPWT was not protective against infection or surgical site complications, and in fact, was associated with higher odds of post-operative infection (OR: 8.96, p = 0.005) and surgical site complications (OR:4.874, p = 0.009) overall. Alcohol abuse (OR: 19, p = 0.005), tobacco use (OR: 4.67, p = 0.009), and time to definitive surgery (OR = 1.21, p = 0.033) were all independent risk factors for post-operative infection. CONCLUSION In this series of operatively treated bicondylar tibial plateau fractures, iNPWT did not protect against post-operative surgical site complications compared to conventional dressings. Tobacco use, alcohol abuse, and time to definitive surgery, were independent risk factors for post-operative infection. Further studies are needed to determine if iNPWT offers a protective benefit in exclusively high-risk patients with relevant medical and social history.
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Affiliation(s)
- Taylor R Johnson
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA.
| | - Yousi A Oquendo
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA
| | - Ryan Seltzer
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA
| | | | - Julius A Bishop
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA
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Kamenaga T, Hiranaka T, Suda Y, Fujishiro T, Okamoto K, Kuroda R, Matsumoto T. Varus placement of the tibial component reduces the potential risk of fracture with adequate bony coverage in the Oxford unicompartmental knee arthroplasty. Sci Rep 2024; 14:1274. [PMID: 38218913 PMCID: PMC10787735 DOI: 10.1038/s41598-023-48659-4] [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] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 11/29/2023] [Indexed: 01/15/2024] Open
Abstract
A short keel-cortex distance (KCD), especially to the posterior cortex, is a potential risk factor for tibial plateau fracture after Oxford mobile-bearing unicompartmental knee arthroplasty (OUKA). This study aimed to evaluate the effect of tibial component alignment in the coronal plane and tibial proximal morphology on the KCD. Included in this study were 51 patients scheduled for primary Oxford medial unicompartmental knee arthroplasty (UKA). The anterior and posterior KCD were preoperatively assessed using 3D simulation software with the component set perpendicular to the tibial mechanical axis (neutral), 3° valgus, 3° varus, and 6° varus, relative to neutral alignment. We evaluated the existence of overhanging medial tibial condyle where the medial eminence line, the line including the medial tibial eminence parallel to the tibial axis, passes outside of the tibial shaft. In all component alignments, patients with a medial overhanging condyle had significantly shorter posterior KCD than those without. In patients with a medial overhanging condyle, the posterior KCD significantly increased when the tibial component was placed in 3° varus (4.6 ± 1.5 mm, P = 0.003 vs neutral, P < 0.001 vs 3° valgus) and 6° varus (5.0 ± 1.4 mm, P < 0.001 vs neutral, P < 0.001 vs 3° valgus) compared with in neutral (3.5 ± 1.9 mm) or 3° valgus (2.8 ± 1.8 mm). In OUKA, varus implantation increased the KCD. This could potentially decrease the risk of fracture, even in knees with the overhanging medial condyle. Conversely, valgus implantation of the tibial component shortened the KCD, and should therefore be avoided.
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Affiliation(s)
- Tomoyuki Kamenaga
- Department of Orthopedic Surgery and Joint Surgery Center, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki, Osaka, 569-1192, Japan
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo, 650-0017, Japan
| | - Takafumi Hiranaka
- Department of Orthopedic Surgery and Joint Surgery Center, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki, Osaka, 569-1192, Japan.
| | - Yoshihito Suda
- Department of Orthopedic Surgery and Joint Surgery Center, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki, Osaka, 569-1192, Japan
| | - Takaaki Fujishiro
- Department of Orthopedic Surgery and Joint Surgery Center, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki, Osaka, 569-1192, Japan
| | - Koji Okamoto
- Department of Orthopedic Surgery and Joint Surgery Center, Takatsuki General Hospital, 1-3-13, Kosobe-Cho, Takatsuki, Osaka, 569-1192, Japan
| | - Ryosuke Kuroda
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo, 650-0017, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo, 650-0017, Japan
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Daas S, Jlidi M, Baghdadi N, Bouaicha W, Mallek K, Lamouchi M, Khorbi A. Risk factors for malunion of distal tibia fractures treated by intramedullary nailing. J Orthop Surg Res 2024; 19:5. [PMID: 38169392 PMCID: PMC10762967 DOI: 10.1186/s13018-023-04472-3] [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: 10/12/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The treatment of distal tibia fractures (DTF) has historically been a difficult challenge for orthopedic surgeons because of the particular characteristics of this anatomical region. Intra medullary nailing (IMN) remains the best treatment option. However, achieving and maintaining perfect reduction and stable fixation with IMN can be technically challenging due to the large medullary cavity within a short distal fragment. The aim of our study is to determine the risk factors for malunion in DTF treated with IMN. METHODS It is a retrospective study including DTF treated surgically by IMN in the Orthopedics and Trauma Department at a tertiary hospital over a period of 7 years. The quality of reduction was evaluated by radiological assessment of the antero-posterior (AP) and lateral views of the tibia and ankle at the last follow-up. RESULTS Our series included 90 patients with an average age of 44.8 years. Sex-ratio was 2.6. Tobacco use was reported in 35.6% of the patients. Diabetes was present in 11.1% of the patients, and 12.2% of them had open fractures. According to the OTA/AO classification, the majority of injuries were classified as type A1 (76.7%). Fibula fractures were present in 86.7% of cases. The mean follow-up was 48 months. Malunion occurred in 13 cases. Based on the univariate analysis, smoking and dynamic fixation were significantly associated with malunion. In the multiple logistic regression analysis, dynamic fixation was found to be a significant factor that increased the risk of malunion by 7.5 times. CONCLUSION Neither patient demographics nor fracture characteristics were risk factors for malunion. Nevertheless, it should be noted that dynamic nailing must be avoided as it is associated with a higher risk of malunion. Furthermore, one to two medial to lateral distal locking screws provide sufficient stability without the need for additional fibular fixation. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Selim Daas
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Mohamed Jlidi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia.
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Nahla Baghdadi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Walid Bouaicha
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Karim Mallek
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Mouldi Lamouchi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Adel Khorbi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Jang Y, Wilson N, Jones J, Alcaide D, Szatkowski J, Sorkin A, Slaven JE, Natoli R. Plating Versus Intramedullary Nailing of OTA/AO 43C1 and C2 Intra-articular Distal Tibia Fractures: A Propensity Score and Multivariate Analysis. J Orthop Trauma 2024; 38:e9-e14. [PMID: 37735766 DOI: 10.1097/bot.0000000000002697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To compare rates of reduction loss, nonunion, and infection in intra-articular distal tibia fractures (IADTF) treated with limited open reduction internal fixation and intramedullary nailing (IMN) as compared to open reduction internal fixation with plate and screws (plate fixation [PF]). METHODS DESIGN Retrospective review. SETTING Level-I academic trauma center. PATIENT SELECTION CRITERIA Patients age ≥ 18 with OTA/AO 43C1 and C2 IADTF treated with IMN or PF between 2013-2021. OUTCOME MEASURES AND COMPARISONS Loss of reduction, surgical site infection (SSI), nonunion, and patient-reported outcomes (PROs) were compared for IMN versus PF treatments. RESULTS One hundred ten patients met the inclusion criteria (IMN 33 and PF 77). There was no loss of reduction found. Seventeen nonunions (15% overall; IMN 4/33 and PF 13/77) and 13 SSIs (12% overall; IMN 2/33 and PF11/77) were identified. Despite several risk factors being identified for nonunion and SSI in bivariate analysis, only open fracture remained significant as a risk factor for both nonunion (odds ratio 0.09 for closed fracture, 95% confidence interval, 0.02-0.56, P = 0.009) and SSI (odds ratio 0.07 for closed fracture, 95% confidence interval, 0.06-0.26, P = 0.012) in the multivariate model. Propensity scoring based on presurgical variables was significantly different between patients who received IMN versus PF ( P = 0.03); however, logistic regression incorporating the propensity score revealed no significant association with nonunion and SSI. Adjusting for the propensity score, there remained no association comparing IMN versus PF with nonunion and SSI ( P = 0.54 and P = 0.17, respectively). There was also no difference in PROs between IMN and PF (physical function: P = 0.25 and pain interference: P = 0.21). CONCLUSIONS Overall nonunion and SSI prevalence was 15% and 12%, respectively, in operatively treated OTA/AO 43C1 and C2 IADTF. An open fracture was a significant risk factor for nonunion and SSI. Metaphyseal fixation through IMN or PF did not affect loss of reduction, nonunion, SSI, or PROs. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Yohan Jang
- Division of Orthopedic, Trauma, Indiana University, Methodist Hospital, Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN; and
| | | | - Jenna Jones
- Indiana University School of Medicine, Indianapolis, IN; and
| | - Doriann Alcaide
- Indiana University School of Medicine, Indianapolis, IN; and
| | - Jan Szatkowski
- Division of Orthopedic, Trauma, Indiana University, Methodist Hospital, Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN; and
| | - Anthony Sorkin
- Division of Orthopedic, Trauma, Indiana University, Methodist Hospital, Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN; and
| | - James E Slaven
- Indiana University School of Medicine, Indianapolis, IN; and
| | - Roman Natoli
- Division of Orthopedic, Trauma, Indiana University, Methodist Hospital, Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN; and
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Tapper V, Reito A, Pamilo K, Ylitalo A, Toom A, Paloneva J. Complications and secondary operations after non-operative and operative treatment of tibial plateau fractures: a population-based study of 562 patients with mean follow-up of 7 years. Arch Orthop Trauma Surg 2024; 144:269-280. [PMID: 37921992 DOI: 10.1007/s00402-023-05102-7] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/10/2023] [Indexed: 11/05/2023]
Abstract
INTRODUCTION The incidence of tibial plateau fractures (TPF) is 1% of all fractures and increases with age. Whether non-operatively or operatively treated, complications (infection, malalignment, loss of reduction and delayed union or nonunion) and post-traumatic osteoarthritis are not uncommon, and the risk for complications has generally been assumed to rise with age. This study investigated all post-TPF complications and secondary surgery after non-operative and operative treatment. Secondary aims were to determine the incidence and epidemiology of TPF in the population of the Central Finland region. MATERIALS AND METHODS All patients over age 18 years with a TPF, including incidence, etiology, fracture type, and possible complications and reoperations, sustained during the period 1998-2019 were retrospectively identified from hospital records. RESULTS The annual mean incidence of TPF was 14.4/100,000, with older women at highest risk. The proportions of non-operative and operatively treated patients who had undergone at least one additional surgical operation were 6% and 26%, respectively. Age and female gender were identified as risk factors for complications and secondary operations. The risk peaked in patients aged 60-65 years, decreasing thereafter. Non-operative treatment showed low risk for both non-union and loss of reduction. CONCLUSIONS Older women were at the highest risk for TPF and for subsequent complications and secondary operations after TPF. Secondary operations after operatively treated TPF were not uncommon and patients aged 60-65 years were at highest risk. Given the low rates of complications and re-operations, non-operative treatment may be a safe option in cases of all minimally displaced TPF.
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Affiliation(s)
- Valtteri Tapper
- Department of Surgery, Hospital Nova, Wellbeing Services County of Central Finland, Keskussairaalantie 19, 40620, Jyvaskyla, Finland.
| | - Aleksi Reito
- Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - Konsta Pamilo
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | - Antti Ylitalo
- Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - Alar Toom
- Department of Surgery, Hospital Nova, Wellbeing Services County of Central Finland, Keskussairaalantie 19, 40620, Jyvaskyla, Finland
| | - Juha Paloneva
- Department of Surgery, Hospital Nova, Wellbeing Services County of Central Finland, Keskussairaalantie 19, 40620, Jyvaskyla, Finland
- University of Eastern Finland, Kuopio, Finland
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Landau AJ, Oladeji AK, Cummings JL, Goldstein R, Lin A, Hosseinzadeh P. Outcomes of Elastic Stable Intramedullary Nailing for Surgical Treatment of Pediatric Tibial Shaft Fractures. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202312000-00004. [PMID: 38038594 PMCID: PMC10686583 DOI: 10.5435/jaaosglobal-d-23-00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND This retrospective study aimed to assess radiographic and clinical outcomes, characterize demographic, injury, and fracture characteristics, and elucidate the rate of postoperative complications and associated factors in a large cohort of children treated with elastic stable intramedullary nail for diaphyseal tibial fractures at two large pediatric referral centers. METHODS Medical records were reviewed for demographic clinical and radiographic parameters at injury, surgery, and all subsequent clinical visits until radiographic healing was observed and/or for a minimum of 6 months postoperatively. RESULTS A total of 146 patients (79.5% male) were included. The mean (SD) age was 11.8 (63.0) years. Radiographic union occurred by 3 months in 56.6% of patients. Nine patients had delayed union, and four had nonunion. By 3 months postoperatively, 97.2% of patients had progressed to full weight bearing and 92.5% had full range of motion of the knee and ankle. Subgroup analyses revealed that patients with open fractures were found to be more than eight times at increased risk of developing delayed union (.6 months, odds ratio = 8.71). CONCLUSION Elastic stable intramedullary nail remains a safe and effective treatment of open and closed pediatric diaphyseal tibial fractures. A small yet notable risk of residual angular deformity, delayed union, and nonunion remains, although rates may be better than previously reported.
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Affiliation(s)
- Andrew J. Landau
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Afolayan K. Oladeji
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Jason L. Cummings
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Rachel Goldstein
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Adrian Lin
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Pooya Hosseinzadeh
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
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14
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Feng D, Zhang Y, Wu W, Jia H, Ma C. Docking site complications analysis of Ilizarov bone transport technique in the treatment of tibial bone defects. J Orthop Surg Res 2023; 18:889. [PMID: 37993906 PMCID: PMC10666420 DOI: 10.1186/s13018-023-04356-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 09/17/2023] [Accepted: 11/07/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Treating long bone defects of the extremities caused by trauma, infection, tumours, and nonunion has been challenging for clinical orthopaedic surgeons. Bone transport techniques have the potential to treat bone defects. However, inevitable docking site complications related to bone transport techniques have been reported in many studies. The purpose of this study was to investigate the risk factors associated with docking site complications in patients who underwent the Ilizarov bone transport technique for the treatment of tibial bone defects. METHODS This retrospective study included 103 patients who underwent bone transport for the treatment of large bone defects in the tibia from October 2012 to October 2019. Patient demographic data, complications and clinical outcomes after a minimum of 2 years of follow-up were collected and retrospectively analysed. Additionally, univariate analysis and logistic regression analysis were used to analyse the factors that may affect the development of docking site complications in patients with tibial bone defects treated with the Ilizarov bone transport technique. The clinical outcomes were evaluated using the Association for the Study and Application of the Ilizarov criteria (ASAMI) at the last clinical follow-up. RESULTS All 103 patients with an average follow-up of 27.5 months. The docking site complications rate per patient was 0.53, and delayed union occurred in 22 cases (21.4%), axial deviation occurred in 19 cases (18.4%) and soft tissue incarceration occurred in 10 cases (9.7%). According to the results of the logistic regression analysis, the bone defect length (P = 0.001, OR = 1.976), and bone defect of distal 1/3 (P = 0.01, OR = 1.976) were significantly correlated with delayed union. Bone defect length (P < 0.001, OR = 1.981) and external fixation time (P = 0.012, OR = 1.017) were significantly correlated with axial deviation. Soft tissue defects (P = 0.047, OR = 6.766) and the number of previous operations (P = 0.001, OR = 2.920) were significantly correlated with soft tissue incarceration. The ASAMI bone score at the last follow-up showed a rate of excellent and good bone results of 95.1% and a rate of excellent functional results of 90.3%. CONCLUSION The Ilizarov bone transport technique is a practical and effective method for the treatment of tibial bone defects. However, the incidence of complications at the docking site is high, of which bone defect length, external fixation time, the number of previous operations, soft tissue defects and the bone defect of distal 1/3 are statistically significantly associated with the occurrence of docking site complications.
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Affiliation(s)
- Dongwei Feng
- Department of Pain, The First Affiliated Hospital of Hebei North University, Zhang Jiakou, Hebei, China
| | - Yaxin Zhang
- International Medical Services, The First Affiliated Hospital of Hebei North University, Zhang Jiakou, Hebei, China
| | - Weize Wu
- Department of Joint Surgery, The First Affiliated Hospital of Hebei North University, Zhang Jiakou, Hebei, China
| | - Heping Jia
- Department of Pain, The First Affiliated Hospital of Hebei North University, Zhang Jiakou, Hebei, China.
| | - Chuang Ma
- Department of Orthopaedic, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China.
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Siddiqi A, Tozzi D, Springer BD, Rosen A. Diagnosis and Management of Intraoperative Periprosthetic Fractures in Primary Total Knee Arthroplasty. J Am Acad Orthop Surg 2023; 31:e760-e768. [PMID: 37585395 DOI: 10.5435/jaaos-d-23-00153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/03/2023] [Indexed: 08/18/2023] Open
Abstract
Intraoperative periprosthetic fracture is an uncommon but notable complication that can occur during primary total knee arthroplasty. These fractures may occur at various stages during the procedure, including surgical exposure, implant preparation, implant trialing, and final implantation. Management of femoral and tibial fractures necessitates intraoperative recognition, including attentiveness of preoperative patient and surgical risk factors. This comprehensive review article focuses on the patient and surgical risk factors, diagnosis, management, and outcomes related to intraoperative fractures during primary total knee arthroplasty.
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Affiliation(s)
- Ahmed Siddiqi
- From the Department of Orthopaedic Surgery, Orthopaedic Institute Brielle Orthopedics, Hackensack Meridian Health, Manasquan, NJ (Siddiqi), SUNY Downstate, Brooklyn, NY (Tozzi), OrthoCarolina Hip and Knee Center, Charlotte, NC (Springer), and the Department of Orthopedic Surgery, Scripps Clinic, San Diego, CA (Rosen)
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Larsen P, Elsoe R. Gait recovery is not associated with meniscus and/or knee ligament injuries following lateral tibial plateau fractures. A prospective 3-year cohort study of 56 patients. Orthop Traumatol Surg Res 2023; 109:103569. [PMID: 36736456 DOI: 10.1016/j.otsr.2023.103569] [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: 08/24/2022] [Revised: 12/06/2022] [Accepted: 01/10/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Though associated meniscus and/or knee ligament injuries following lateral tibial plateau fractures (TPF) are common, the importance of development in gait recovery is unknown. This study aim to report the 12- and 36-month gait recovery in patients with lateral TPF divided into two groups presenting with and without associated meniscus and/or knee ligament injuries. (Associated meniscus and/or knee ligament injuries were grouped as: 1) missing, 2) lateral or medial menisci, 2) posterior and anterior cruciate ligament (PCL/ACL), and 4) lateral or medial collateral ligament.) HYPOTHESIS: Comparable results at the 12- and 36-month follow-up between groups presenting with and without soft tissue injuries. PATIENTS AND METHODS Study design: cohort study. Included were patients admitted following a lateral TPF (AO-type 41 B) between December 1, 2013 and November 30, 2016. The primary outcome score was gait sample. RESULTS Fifty-six patients were included. The mean age of the patients at the time of fracture was 56 years (range from 22 to 86). Female gender represents 75%. MRI-verified associated meniscus and/or knee ligament injuries were observed in 28 patients (50%). The average gait speed at the 12- and 36-month follow-up were 125.7 (SD31.3) and 127.7 (SD16.6) cm/sec. for patients with associated meniscus and/or knee ligament injuries and 125.2 (SD31.1) and 130.1 (SD15.6) cm/sec. for patients without associated meniscus and/or knee ligament injuries (p=0.96, p=0.17). Regardless of soft tissue injuries, the development in percent of gait asymmetry for step-length and single-support decrease significantly between the 12- and the 36-month follow-up. (p>0.002) DISCUSSION: This study indicates that gait recovery following lateral TPFs were not associated with associated meniscus and/or knee ligament injuries at the 12- and 36-month follow-up. Between the 12- and 36-month follow-up asymmetry of the gait function decline significantly indicating a prolonged recovery period of gait function following TPFs. LEVEL OF EVIDENCE II; prospective cohort study.
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Affiliation(s)
- Peter Larsen
- Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg, Denmark; Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Rasmus Elsoe
- Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark.
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Yeramosu T, Young P, Cinats DJ, Toney CB, Satpathy J, Patel TT, Kates SL, Perdue PW. Safety of Prepping the External Fixator In Situ During Staged Internal Fixation of Pilon Fractures: A Retrospective Comparative Cohort Study. J Orthop Trauma 2023; 37:469-474. [PMID: 37053112 PMCID: PMC10524202 DOI: 10.1097/bot.0000000000002617] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2023] [Indexed: 04/14/2023]
Abstract
OBJECTIVE (1) To assess the rate of fracture-related infection (FRI) and unplanned reoperation of disinfecting and prepping in the external fixator (Ex-Fix) instrument during definitive open reduction and internal fixation (ORIF) of pilon fractures treated by a staged protocol and (2) to determine whether the amount of time from external fixation to ORIF influences the risk of FRI. DESIGN Retrospective cohort study. SETTING Level 1 academic trauma center. PATIENTS One hundred thirty-three patients who underwent operative treatment for pilon fracture between 2010 and 2020. INTERVENTION External fixation and ORIF with or without the Ex-Fix prepped in situ during definitive fixation. MAIN OUTCOME MEASUREMENTS FRI and unplanned reoperation rates. RESULTS 133 patients were enrolled, of which 47 (35.3%) had Ex-Fix elements prepped in situ. There was an overall infection rate of 23.3% and unplanned reoperation rate of 11.3%, and there was no significant difference in rates between the 2 cohorts. Patients with Ex-Fix elements prepped in situ who developed an FRI had a higher rate of MRSA and MSSA . Diabetes ( P = 0.0019), open fracture ( P = 0.0014), and longer (≥30 days) interval to ORIF ( P = 0.0001) were associated with postoperative FRI. CONCLUSIONS Prepping elements of the Ex-Fix in situ did not lead to an increase in rates of FRI or unplanned reoperation. Although diabetes and open fracture were associated with FRI risk, a stronger association was a longer interval of Ex-Fix utilization before definitive internal fixation, specifically 30 days or greater. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Teja Yeramosu
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Porter Young
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - David J. Cinats
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Clarence B. Toney
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Jibanananda Satpathy
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Tejas T. Patel
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen L. Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Paul W. Perdue
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
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Torre BB, Pavano C, Connors JP, Silver J, Bellas N, Shekhman M, Solovyova O. Early Tibial Baseplate Fracture After Medial Unicondylar Knee Arthroplasty: A Report of 2 Cases. JBJS Case Connect 2023; 13:01709767-202309000-00028. [PMID: 37535760 DOI: 10.2106/jbjs.cc.22.00733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
CASE Implant failure after unicondylar knee arthroplasty (UKA) is a rare but well-described complication in the arthroplasty literature. However, there is a paucity of literature regarding rapid catastrophic failure of modern implant designs. This is a case report of 2 patients with early catastrophic failure of the tibial baseplate after UKA with a Stryker Restoris MultiCompartmental Knee System implant using Mako robotic assistance, both requiring revision to total knee arthroplasty. CONCLUSION Improved awareness and understanding of early UKA tibial baseplate failure may help identify both patient and surgical risk factors that could help prevent further instances in the future.
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Affiliation(s)
- Barrett B Torre
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut
| | - Colin Pavano
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut
| | - John Patrick Connors
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut
| | - Jacob Silver
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut
| | - Nicholas Bellas
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut
| | - Mark Shekhman
- Department of Orthopedic Surgery, Bone and Joint Institute at Hartford Hospital, Hartford, Connecticut
| | - Olga Solovyova
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut
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Mortimer RB, Martirosian A. Tibial Plateau Fracture After Attack by an Escaped Goat. Wilderness Environ Med 2023; 34:103-105. [PMID: 36509670 DOI: 10.1016/j.wem.2022.10.004] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 09/21/2022] [Accepted: 10/10/2022] [Indexed: 12/14/2022]
Abstract
Humans come into contact with goats in wild settings. If a goat feels threatened, it may address the perceived threat violently. While out walking, a 55-y-old man was attacked by an escaped domestic goat. Much as goats interact with each other, this goat pushed him over with its horns and then rose up on 2 legs to come back down on him with its head. The man experienced a Schatzker VI bicondylar tibial plateau fracture that required external and then internal fixation. Besides his physical injuries, he experienced acute stress disorder, which is common after traumatic events. Acute stress reactions can progress into chronic posttraumatic stress disorder but also often resolve. Psychological first aid is appropriate after traumatic events, including animal attacks. It is appropriate to screen for posttraumatic stress disorder symptoms after such events and treat or refer if present. After 1 y, the man returned to full function and experienced no posttraumatic stress disorder.
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Affiliation(s)
- Roger B Mortimer
- Department of Family and Community Medicine, University of California San Francisco, Fresno Medical Education Program, Fresno, CA.
| | - Armen Martirosian
- Department of Orthopedic Surgery, University of California San Francisco, Fresno Medical Education Program, Fresno, CA
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Abstract
BACKGROUND Tibial tubercle avulsion fractures (TTAF) often require surgical reduction and stabilization. Traditional teachings recommend postoperative knee immobilization for 4 to 6 weeks; however, the necessity of these restrictions is unclear and the actual practice varies. This study's purpose was to: (1) retrospectively review operatively managed TTAFs at a single center to examine the spectrum of postoperative rehabilitation guidelines, and (2) compare the outcomes of patients based on the timing of initiation of postoperative knee range of motion (ROM). METHODS Operatively managed TTAFs treated at a single center from 2011-2020 were identified. Patients with polytrauma, associated lower extremity compartment syndrome, or treatment other than screw fixation were excluded. Patient demographics, mechanism of injury, Ogden Classification, associated injuries, operative technique, postoperative ROM progression, and time to release to unrestricted activities were collected. Patients were grouped based on the initiation of postoperative ROM as Early (<4 wk, EROM) or Late (≥4 wk, LROM). Bivariate analysis was used to compare characteristics between these 2 groups. RESULTS Study criteria identified 134 patients, 93.3% (n=125) of whom were male. The mean age of the cohort was 14.77 years [95% confidence interval (CI: 14.5 to 15.0]. Forty-nine patients were designated EROM; 85 patients were categorized as LROM. The groups did not differ significantly with regards to age, race, injury characteristics, or surgical technique. Both groups progressed similarly with regards to postoperative range of motion. Ultimate activity clearance was achieved at ~20 weeks postoperatively without differences between groups ( P >0.05). Four instances of postoperative complication were identified, all of which occurred in the LROM group. CONCLUSION A broad range of postoperative immobilization protocols exists following the screw fixation of TTAFs. Across otherwise similar cohorts of patients undergoing operative treatment, initiation of knee range of motion before 4 weeks was without complication and provided equivalent outcomes to traditional immobilization practices. Given the clear benefits to patients and caregivers provided by the permission of early knee motion and the avoidance of casting, providers should consider more progressive postoperative rehab protocols following operatively treated TTAFs. LEVEL OF EVIDENCE Level III, Retrospective Cohort.
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Affiliation(s)
- Kevin Huang
- Department of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA
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21
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Shimberg JL, Leska TM, Cruz AI, Patel NM, Ellis HB, Ganley TJ, Johnson B, Milbrandt TA, Yen YM, Mistovich RJ. A Multicenter Comparison of Open Versus Arthroscopic Fixation for Pediatric Tibial Spine Fractures. J Pediatr Orthop 2022; 42:195-200. [PMID: 35067605 DOI: 10.1097/bpo.0000000000002049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation (ARIF). The purpose of the study is to evaluate short-term treatment outcomes of tibial spine fractures in patients treated with both open and arthroscopic fracture reduction. METHODS We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into 2 cohorts based on treatment: ARIF and open reduction and internal fixation (ORIF). Short-term surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups. RESULTS There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Average follow-up was 1.12 years. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared with those treated with ORIF (24.6%, P=0.021). Most concomitant injuries (74.5%) were treated with intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, P=1.00) and subsequent anterior cruciate ligament injury (2.1% in ARIF patients and 3.5% in ORIF, P=0.86). The rate of short-term complications, return to the operating room, and failure to return to full range of motion were similar between treatment groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training. CONCLUSION This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF, with a significantly higher rate of concomitant injuries identified in patients treated with ARIF. The majority of identified concomitant injuries were treated with surgical intervention. Extensive surgical evaluation or pretreatment magnetic resonance imaging should be considered in the workup of tibial spine fractures to increase concomitant injury identification. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | - Aristides I Cruz
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Neeraj M Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | | | - Ben Johnson
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | | | | | - R Justin Mistovich
- Case Western Reserve University
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
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22
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Morita Y, Kuriyama S, Maeda T, Nakamura S, Nishitani K, Ito H, Matsuda S. Hinge fractures reaching the tibial plateau can be caused by forcible opening of insufficient posterior osteotomy during open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2022; 31:1533-1545. [PMID: 34981163 DOI: 10.1007/s00167-021-06816-0] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/20/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to use the finite element method (FEM) to reproduce fracture lines that reach the lateral tibial plateau during open-wedge high tibial osteotomy (OWHTO) in patients with Type III lateral hinge fracture (LHF). It was hypothesized that the FEM could clarify biomechanical causes of Type III LHF, enabling prevention of adverse complications. METHODS This study used the nonlinear FEM to analyze the data of eight knees in eight patients (two males and six females) with Type III LHF among 82 patients who underwent OWHTO, as well as the data of eight individuals with no LHF. To predict the onset of Type III LHF, simulation models were also developed in which posterior osteotomy sufficiency varied from 50% to perfect, the latter defined as osteotomy reaching the hinge point. RESULTS Real-life instances of Type III LHF caused by insufficient posterior osteotomy were reproduced in all patient-specific FEM models, and these models accurately predicted fracture types and locations. During opening of the osteotomy gap, the fracture line reached the lateral tibial plateau, and extended vertically from the end of the insufficient posterior osteotomy, avoiding the rigid proximal tibiofibular joint. In contrast, sufficient posterior osteotomy resulted in a lack of LHF. Posterior osteotomy extension ≥ 70% of the width of the osteotomy plane was the cut-off value to prevent Type III LHF. CONCLUSION Forced opening of insufficient posterior osteotomy was found to be a biomechanical cause of Type III LHF that extended perpendicularly to the lateral tibial plateau, avoiding the proximal tibiofibular joint. The clinical significance of this study is that sufficient posterior osteotomy during OWHTO, defined as at least 70% of the width of the osteotomy plane, can prevent Type III LHF.
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Affiliation(s)
- Yugo Morita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shinichi Kuriyama
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Takahiro Maeda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shinichiro Nakamura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kohei Nishitani
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hiromu Ito
- Department of Orthopaedic Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
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Kumbaracı M, Hancıoğlu S, Turgut A. Analysis of risk factors for re-displacement of pediatric tibia fractures: A retrospective study of 196 cases. Acta Orthop Traumatol Turc 2022; 56:36-41. [PMID: 35234127 DOI: 10.5152/j.aott.2021.21219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aims of this study were (1) to analyze the factors that may cause loss of reduction (LOR) in pediatric tibia diaphysis and distal third fractures treated with closed reduction and casting (CRC) and (2) to determine the effectiveness of cast index (CI), gap index (GI), and three-point index (TPI) in prediction of LOR. METHODS The patients aged 0-16 years who were admitted to the emergency department between January 2014 and January 2018, with tibia diaphysis or distal third fractures and treated with CRC were included the study. A total of 196 pediatric patients (41 females, 155 males) were retrospectively evaluated. The radiographs on admission were analyzed in terms of fracture type, location of the fracture, presence/location of the fibula fracture as well as initial angulation in both planes, translation, and the time of definitive cast. On radiographs taken after closed reduction and final casting, angulation in the coronal and sagittal planes, amount of translation (%), CI, GI, and TPI were measured. Logistic regression analysis was used to evaluate the risk factors of re-displacement. RESULTS Of 196 patients, 46 developed re-displacement (23%). Age (P : 0.029), initial translation (P : 0.006), post-reduction translation (P : 0.001), and post-reduction AP angulation (P : 0.002) were found statistically significant. Mean CI and GI were higher in re-displacement group (P : 0.033, 0.036, respectively). According to multivariate logistic regression analysis postreduction AP angulation, post-reduction translation, and cast index were found independent risk factors. CONCLUSION One should carefully evaluate patients who underwent CRC due to tibia fracture with CI > 1.02, post-reduction AP angulation > 3.4°, and post-reduction translation > 24.3° in terms of occurrence of re-displacement. LEVEL OF EVIDENCE Level IV, Therapeutic Study.
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Affiliation(s)
- Mert Kumbaracı
- Department of Orthopaedics and Traumatology, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Sertan Hancıoğlu
- Department of Orthopaedics and Traumatology, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Ali Turgut
- Department of Orthopaedics and Traumatology, Tepecik Training and Research Hospital, İzmir, Turkey
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24
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Lee C, Brodke DJ, Engel J, Schloss MG, Zaidi SMR, O’Toole RV, Gulbrandsen T, Hogue M, Badon J, Bergin PF, Lirette ST, Morellato J. Low-energy Gunshot-induced Tibia Fractures: What Proportion Develop Complications? Clin Orthop Relat Res 2021; 479:1793-1801. [PMID: 33760776 PMCID: PMC8277282 DOI: 10.1097/corr.0000000000001736] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 02/23/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gunshot injuries of the extremities are common in the United States, especially among people with nonfatal gunshot wounds. Controversy persists regarding the proper management for low-energy gunshot-induced fractures, likely stemming from varying reports on the likelihood of complications. There has yet to be published a study on a large cohort of patients with gunshot-induced tibia fractures on which to base our understanding of complications after this injury. QUESTIONS/PURPOSES (1) What percentage of patients with low-energy gunshot-induced tibia fractures developed complications? (2) Was there an association between deep infection and fracture location, injury characteristics, debridement practices, or antibiotic use? METHODS This was a multicenter retrospective study. Between January 2009 and December 2018, we saw 201 patients aged 16 years or older with a gunshot-induced fracture who underwent operative treatment; 2% (4 of 201) of those screened had inadequate clinical records, and 38% (76 of 201) of those screened had inadequate follow-up for inclusion. In all, 121 patients with more than 90 days of follow-up were included in the study. Nonunion was defined as a painful fracture with inadequate healing (fewer than three cortices of bridging bone) at 6 months after injury, resulting in revision surgery to achieve union. Deep infection was defined according to the confirmatory criteria of the Fracture-Related Infection Consensus Group. These results were assessed by a fellowship-trained orthopaedic trauma surgeon involved with the study. Complication proportions were tabulated. A Kaplan-Meier chart demonstrated presentations of deep infection by fracture location (proximal, shaft, or distal). Univariate statistics and multivariate Cox regression were used to examine the association between deep infection and fracture location, entry wound size, vascular injury, intravenous (IV) antibiotics in the emergency department (ED), deep and superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics, while adjusting for age, race/ethnicity, smoking status, and BMI. A power analysis for the result of deep infection demonstrated that we would have had to observe a hazard ratio of 4.28 or greater for shaft versus proximal locations to detect statistically significant results at 80% power and alpha = 0.05. RESULTS The overall complication proportion was 49% (59 of 121), with proportions of 14% (17 of 121) for infection, 27% (33 of 121) for wound complications, 20% (24 of 121) for nonunion, 9% (11 of 121) for hardware breakage, and 26% (31 of 121) for revision surgery. A positive association was present between deep infection and deep debridement (HR 5.51 [95% confidence interval 1.12 to 27.9]; p = 0.04). With the numbers available, we found no association between deep infection and fracture location, entry wound size, vascular injury, IV antibiotics in the ED, superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics. CONCLUSION In this multicenter study, we found a higher risk of complications in operative gunshot-induced tibia fractures than prior studies have reported. Infection, in particular, was much more common than expected based on prior studies. Consequently, surgeons might consider adopting the general management principles for nongunshot-induced open tibia fractures with gunshot-induced fractures, such as the use of IV antibiotics both initially and after surgery. Further research is needed to test and validate these approaches. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Christopher Lee
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Dane J. Brodke
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Jamie Engel
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Michael G. Schloss
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Syed Muhammad R. Zaidi
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Robert V. O’Toole
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Trevor Gulbrandsen
- Department of Orthopaedic Surgery, University of Iowa, Iowa City, IA, USA
| | - Matthew Hogue
- Department of Orthopaedic Surgery, University of Iowa, Iowa City, IA, USA
| | - Justin Badon
- Department of Orthopaedic Surgery, University of Mississippi, Jackson, MS, USA
| | - Patrick F. Bergin
- Department of Orthopaedic Surgery, University of Mississippi, Jackson, MS, USA
| | - Seth T. Lirette
- Department of Data Science, University of Mississippi, Jackson, MS, USA
| | - John Morellato
- Department of Orthopaedic Surgery, University of Mississippi, Jackson, MS, USA
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25
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Mellick LB, Gonzalez JC. Childhood Accidental Spiral Tibial Fractures and Toddler's Fractures: Where are We 30 Years Later? Pediatr Emerg Care 2021; 37:e496-e498. [PMID: 34009884 DOI: 10.1097/pec.0000000000002435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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26
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Lin S. CORR Insights®: Low-energy Gunshot-induced Tibia Fractures: What Proportion Develop Complications? Clin Orthop Relat Res 2021; 479:1802-1804. [PMID: 33950876 PMCID: PMC8277247 DOI: 10.1097/corr.0000000000001802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 04/13/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Sheldon Lin
- Department of Orthopaedics, Rutgers-The New Jersey Medical School, Newark, NJ, USA
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27
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Schoeb M, Winter EM, Sleddering MA, Lips MA, Schepers A, Snel M, Appelman-Dijkstra NM. Bone Material Strength Index as Measured by Impact Microindentation is Low in Patients with Primary Hyperparathyroidism. J Clin Endocrinol Metab 2021; 106:e2527-e2534. [PMID: 33780545 PMCID: PMC8266436 DOI: 10.1210/clinem/dgab207] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Indexed: 12/26/2022]
Abstract
CONTEXT In primary hyperparathyroidism (PHPT) bone mineral density (BMD) is typically decreased in cortical bone and relatively preserved in trabecular bone. An increased fracture rate is observed however not only at peripheral sites but also at the spine, and fractures occur at higher BMD values than expected. We hypothesized that components of bone quality other than BMD are affected in PHPT as well. OBJECTIVE To evaluate bone material properties using impact microindentation (IMI) in PHPT patients. METHODS In this cross-sectional study, the Bone Material Strength index (BMSi) was measured by IMI at the midshaft of the tibia in 37 patients with PHPT (28 women), 11 of whom had prevalent fragility fractures, and 37 euparathyroid controls (28 women) matched for age, gender, and fragility fracture status. RESULTS Mean age of PHPT patients and controls was 61.8 ± 13.3 and 61.0 ± 11.8 years, respectively, P = .77. Calcium and PTH levels were significantly higher in PHPT patients but BMD at the lumbar spine (0.92 ± 0.15 vs 0.89 ± 0.11, P = .37) and the femoral neck (0.70 ± 0.11 vs 0.67 ± 0.07, P = .15) were comparable between groups. BMSi however was significantly lower in PHPT patients than in controls (78.2 ± 5.7 vs 82.8 ± 4.5, P < .001). In addition, BMSi was significantly lower in 11 PHPT patients with fragility fractures than in the 26 PHPT patients without fragility fractures (74.7 ± 6.0 vs 79.6 ± 5.0, P = .015). CONCLUSION Our data indicate that bone material properties are altered in PHPT patients and most affected in those with prevalent fractures. IMI might be a valuable additional tool in the evaluation of bone fragility in patients with PHPT.
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Affiliation(s)
- Manuela Schoeb
- Center for Bone Quality, Department of Internal Medicine and division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth M Winter
- Center for Bone Quality, Department of Internal Medicine and division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maria A Sleddering
- Center for Bone Quality, Department of Internal Medicine and division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mirjam A Lips
- Center for Bone Quality, Department of Internal Medicine and division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Abbey Schepers
- Center for Bone Quality and Center for Endocrine Tumors, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Snel
- Center for Bone Quality, Department of Internal Medicine and division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Natasha M Appelman-Dijkstra
- Center for Bone Quality, Department of Internal Medicine and division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
- Correspondence: Natasha M. Appelman-Dijkstra, LUMC Center for Bone Quality, Department of Internal Medicine, Division Endocrinology, Albinusdreef 2, 2300 RC Leiden, The Netherlands.
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28
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MacNeille R, Gockley A, Hennrikus W. Outcomes of Short Versus Long Leg Casts for Childhood Accidental Spiral Tibial CAST Fractures. Pediatr Emerg Care 2021; 37:e252-e254. [PMID: 32796348 DOI: 10.1097/pec.0000000000002212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of the current study was to analyze the outcomes of short versus long leg casts in the treatment of childhood accidental spiral tibial (CAST) fractures. METHODS A retrospective review was performed of medical records at a single tertiary children's hospital from 2009 to 2014 of children with distal, spiral tibial fractures (CAST fractures). The following points were documented for each patient: sex, laterality of fracture, age at presentation, type of cast, length of time in cast, use of a controlled ankle motion boot after cast removal, suspicion for abuse, and complications including skin irritation, skin breakdown, infection, compartment syndrome, fracture displacement, and gait disturbances. RESULTS A total of 21 patients with an age range of 12 to 62 months were found to have CAST fractures as confirmed by x-ray. Fourteen were treated with short leg casts, whereas 7 were treated with long leg casts. Both groups healed with equal outcomes, and there was no documented suspicion for abuse in any case. CONCLUSIONS A short leg walking cast seems to be an effective and safe method of treatment for CAST fractures and could be considered as potentially preferable to long leg casts because of the added benefits of increased mobility and function. Follow-up to this preliminary study is warranted to better elucidate any differences in benefit between these treatment options, and clinical judgment should be used when considering immobilization options.
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Affiliation(s)
- Rhett MacNeille
- From the Department of Orthopaedics, Penn State Milton S. Hershey Medical Center, Hershey, PA
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29
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Shen JJ, Qian JS, Zhang J, Huang JF. Anterior horizontal rafting plate to treat complex osteoporotic tibial plateau fractures: a technical note. Acta Orthop Traumatol Turc 2021; 55:271-276. [PMID: 34100370 PMCID: PMC10566359 DOI: 10.5152/j.aott.2021.20291] [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] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/13/2020] [Accepted: 11/10/2020] [Indexed: 02/05/2023]
Abstract
Complex tibial plateau fractures in elderly patients exhibiting severe osteoporosis and articular surface collapse are challenging. Decision-making is difficult when the posterior column is involved. Open reduction and internal fixation of complex tibial plateau fractures in patients with severe osteoporosis are prone to failure. In this paper, we describe a new method for the maintenance of the articular surface of complex tibial plateau fractures in elderly patients. An anterior horizontal rafting plate (3.5-mm-thick reconstruction and locking plate [Zimmer Inc., Warsaw, IN, USA]) is placed via conventional posteromedial and anterolateral incisions. The plate is inserted between the anterior bony surface of the proximal tibia and the subpatellar fat pad; plate positioning is checked under direct vision. The patient is encouraged to begin functional recovery soon after operation. Progressive weight-bearing begins at 10 weeks postoperatively and is gradually increased during fracture healing. Clinical follow-up was performed at 4, 8, and 12 weeks, 6 and 12 months, and yearly thereafter. No articular collapse or fragment displacement was evident on three-dimensional computed tomography performed 6 months after surgery. The knee range of motion was 5-130º at the last follow-up (4 years after surgery). This technique may be a good option for treating complex tibial plateau fractures, especially in elderly patients with severe osteoporosis.
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Affiliation(s)
- Jian-Jian Shen
- Department of Orthopaedics, Cixi People’s Hospital, Cixi, Zhejiang,
China
| | - Jian-Sheng Qian
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang,
China
| | - Jun Zhang
- Department of Orthopaedics, Zhejiang Provincial People’s Hospital, Hangzhou, Zhejiang,
China
| | - Jie-Feng Huang
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang
China
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Dornacher D, Leitz F, Kappe T, Reichel H, Faschingbauer M. The degree of correction in open-wedge high tibial osteotomy compromises bone healing: A consecutive review of 101 cases. Knee 2021; 29:478-485. [PMID: 33743262 DOI: 10.1016/j.knee.2021.02.025] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/21/2021] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The bone healing in open-wedge high tibial osteotomy (OWHTO) proceeds gradually by a filling of the osteotomy gap. This can comprise several risk factors. METHODS A retrospective study analysed the clinical and radiological course of 101 consecutive OWHTOs in 96 patients. The following risk factors were considered: age, body mass index, tobacco consumption, amount of tobacco consumption, severity of comorbidities, infection of the surgical area, occurrence of a lateral hinge fracture and the degree of correction. The bone healing was evaluated by using the modified Radiographic Union Score for Tibial fractures (RUST). RESULTS A disturbance in bone healing was observed in 16 of the 101 osteotomies. Binary logistic regression analysis showed a correlation between the angle of the opening wedge and the development of a disturbance in bone healing (P = 0.002). The odds ratio indicated an increase in the risk of a disturbance in bone healing of 56% with each additional degree of correction. For the risk factor 'age' a statistical trend was recognizable (P = 0.077) with the risk of a disturbance in bone healing in higher age. CONCLUSION Lateral hinge fractures seem not to have a detrimental effect on the filling of the osteotomy gap. An increase in the opening wedge bears the risk of a disturbance in bone healing.
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Affiliation(s)
| | - Franziska Leitz
- Karl-Olga Hospital Stuttgart, Department of Orthopedics, Hackstraße 61, 70190 Stuttgart, Germany
| | - Thomas Kappe
- Department of Orthopedics, University of Ulm, Ulm, Germany
| | - Heiko Reichel
- Department of Orthopedics, University of Ulm, Ulm, Germany
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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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Vemulapalli KC, Davis SL, Mathews V, Goytia RN, Stocks GW, Dunn WR, Laughlin MS, Brinker MR. Treatment of Periprosthetic Nonunions of the Lower Extremity. Orthopedics 2020; 43:209-214. [PMID: 32379335 DOI: 10.3928/01477447-20200428-04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/05/2020] [Indexed: 02/03/2023]
Abstract
Multiple studies have reported nonunion rates of 3% to 17% following peri-prosthetic fractures. Determining management strategies based on the available literature is difficult because existing studies are small and involve heterogeneous treatments and multiple surgeons. The purpose of this study was to describe a consecutive series of patients who presented to the authors' clinic with a periprosthetic nonunion of the lower extremity and to report the methods used to achieve limb salvage and the associated complications. Patients were included if they were indicated for surgery for a nonunion of a periprosthetic fracture of the lower extremity that had previously undergone either closed or open intervention. A total of 26 patients were included in this study. Average follow-up was 58 months. Average age was 69 years, and 77% of the patients were female. Twenty-three patients had periprosthetic nonunions of the femur, with 6 being associated with total hip arthroplasty, 15 with total knee arthroplasty, and 2 with both a total hip arthroplasty and a total knee arthroplasty. Three patients had a periprosthetic nonunion of the tibia associated with a total knee arthroplasty. Limb salvage was successful in 25 of 26 cases. This was achieved by either healing of the nonunion using exuberant fixation with prosthesis revision when necessary (n=20) or resection of the nonunion with placement of a tumor prosthesis (n=5). Four of the 26 patients (15%) incurred at least 1 complication during treatment. Exuberant fixation of the nonunion (with prosthesis revision when necessary) or nonunion resection with placement of a tumor prosthesis was successful in 96% of cases. [Orthopedics. 2020;43(4):209-214.].
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Elghazy MA, Hagemeijer NC, Waryasz GR, Guss D, O'Donnell S, Blankenhorn B, DiGiovanni CW. Tibial Stress Fracture Following Ankle Arthrodesis. Foot Ankle Int 2020; 41:556-561. [PMID: 32064929 DOI: 10.1177/1071100720907595] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND End-stage ankle arthritis is frequently treated with either tibiotalar or tibiotalocalcaneal (TTC) arthrodesis, but the inherent loss of accommodative motion increases mechanical load across the distal tibia. Rarely, patients can go on to develop a stress fracture of the distal tibia without any antecedent traumatic event. The purpose of this study was to determine the incidence of tibial stress fracture after ankle arthrodesis, highlight any related risk factors, and identify the effectiveness of treatment strategies and their healing potential. METHODS A retrospective chart review was performed at 2 large academic medical centers to identify patients who had undergone ankle arthrodesis and subsequently developed a stress fracture of the tibia. Any patient with a tibial stress fracture before ankle arthrodesis, or with a nontibial stress fracture, was excluded from the study. RESULTS A total of 15 out of 1046 ankle fusion patients (1.4%) developed a tibial stress fracture at a mean time of 42 ± 82 months (range, 3-300 months) following the index procedure. The index procedure for these 15 patients who went on to subsequently develop stress fractures included isolated ankle arthrodesis (n = 8), ankle arthrodesis after successful subtalar fusion (n = 2), primary TTC arthrodesis (n = 2), and ankle arthrodesis subsequent to successful subtalar fusion with resultant ankle nonunion requiring revision TTC nailing (n = 3). Four patients had undergone fibular osteotomy with subsequent onlay strut fusion, and 5 had undergone complete resection of the lateral malleolus. Stress fracture location was found to be at the level of the fibular osteotomy in 2 patients and at the proximal end of an existing or removed implant in 9. Fourteen of the 15 patients had a nondisplaced stress fracture and were initially treated with immobilization and activity modification. Of these, 3 failed to improve with nonoperative treatment and subsequently underwent operative fixation (intramedullary nail in 2; plate fixation in 1). Only 1 of the 15 patients presented with a displaced fracture and underwent immediate plate fixation. All patients reported pain improvement and were ultimately healed at final follow-up. CONCLUSION In this case series review, we found a 1.4% incidence of tibial stress fracture after ankle arthrodesis, and both hardware transition points and a fibular resection or osteotomy appear to be risk factors. Operative intervention was required in approximately 25% of this population, but the majority of tibial stress fractures following ankle fusion were successfully treated nonoperatively, and ultimately all healed. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Mohamed Abdelaziz Elghazy
- Department of Orthopedic Surgery, Faculty of Medicine, Mansoura University, Mansoura, Dakahliya, Egypt
- Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Noortje C Hagemeijer
- Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Gregory R Waryasz
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA
| | - Daniel Guss
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA
| | - Seth O'Donnell
- Department of Orthopaedic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Brad Blankenhorn
- Department of Orthopaedic Surgery, The Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA
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Pegg EC, Walter J, D'Lima DD, Fregly BJ, Gill HS, Murray DW. Minimising tibial fracture after unicompartmental knee replacement: A probabilistic finite element study. Clin Biomech (Bristol, Avon) 2020; 73:46-54. [PMID: 31935599 PMCID: PMC10135372 DOI: 10.1016/j.clinbiomech.2019.12.014] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/11/2019] [Accepted: 12/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Periprosthetic tibial fracture after unicompartmental knee replacement is a challenging post-operative complication. Patients have an increased risk of mortality after fracture, the majority undergo further surgery, and the revision operations are less successful. Inappropriate surgical technique increases the risk of fracture, but it is unclear which technical aspects of the surgery are most problematic and no research has been performed on how surgical factors interact. METHODS Firstly, this study quantified the typical variance in surgical cuts made during unicompartmental knee replacement (determined from bones prepared by surgeons during an instructional course). Secondly, these measured distributions were used to create a probabilistic finite element model of the tibia after replacement. A thousand finite element models were created using the Monte Carlo method, representing 1000 virtual operations, and the risk of tibial fracture was assessed. FINDINGS Multivariate linear regression of the results showed that excessive resection depth and making the vertical cut too deep posteriorly increased the risk of fracture. These two parameters also had high variability in the prepared synthetic bones. The regression equation calculated the risk of fracture from three cut parameters (resection depth, vertical and horizonal posterior cuts) and fit the model results with 90% correlation. INTERPRETATION This study introduces for the first time the application of a probabilistic approach to predict the aetiology of fracture after unicompartmental knee replacement, providing unique insight into the relative importance of surgical saw cut variations. Targeted changes to operative technique can now be considered to seek to reduce the risk of periprosthetic fracture.
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Affiliation(s)
- Elise C Pegg
- Centre for Orthopaedic Biomechanics, Department of Mechanical Engineering, University of Bath, UK.
| | | | - Darryl D D'Lima
- Shiley Center for Orthopaedic Research & Education, Scripps Clinic, La Jolla, CA, USA
| | - Benjamin J Fregly
- Department of Mechanical Engineering, Rice University, Houston, TX, USA
| | - Harinderjit S Gill
- Centre for Orthopaedic Biomechanics, Department of Mechanical Engineering, University of Bath, UK; Centre for Therapeutic Innovation, Department of Mechanical Engineering, University of Bath, UK
| | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Franzone JM, Finkelstein MS, Rogers KJ, Kruse RW. Evaluation of Fracture and Osteotomy Union in the Setting of Osteogenesis Imperfecta: Reliability of the Modified Radiographic Union Score for Tibial Fractures (RUST). J Pediatr Orthop 2020; 40:48-52. [PMID: 31815862 DOI: 10.1097/bpo.0000000000001068] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Evaluation of the union of osteotomies and fractures in patients with osteogenesis imperfecta (OI) is a critical component of patient care. Studies of the OI patient population have so far used varied criteria to evaluate bony union. The radiographic union score for tibial fractures (RUST), which was subsequently revised to the modified RUST, is an objective standardized method of evaluating fracture healing. We sought to evaluate the reliability of the modified RUST in the setting of the tibias of patients with OI. METHODS Tibial radiographs of 30 patients with OI fractures, or osteotomies were scored by 3 observers on 2 separate occasions. Each of the 4 cortices was given a score (1=no callus, 2=callus present, 3=bridging callus, and 4=remodeled, fracture not visible) and the modified RUST is the sum of these scores (range, 4 to 16). The interobserver and intraobserver reliabilities were evaluated using intraclass coefficients (ICC) with 95% confidence intervals. RESULTS The ICC representing the interobserver reliability for the first iteration of scores was 0.926 (0.864 to 0.962) and for the second series was 0.915 (0.845 to 0.957). The ICCs representing the intraobserver reliability for each of the 3 reviewers for the measurements in series 1 and 2 were 0.860 (0.707 to 0.934), 0.994 (0.986 to 0.997), and 0.974 (0.946 to 0.988). CONCLUSIONS The modified RUST has excellent interobserver and intraobserver reliability in the setting of OI despite challenges related to the poor quality of the bone and its dysplastic nature. The application and routine use of the modified RUST in the OI population will help standardize our evaluation of osteotomy and fracture healing. LEVEL OF EVIDENCE Level III-retrospective study of nonconsecutive patients.
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Affiliation(s)
| | - Mark S Finkelstein
- Department of Medical Imaging, Division of Pediatric Radiology, Alfred I. duPont Hospital for Children, Wilmington, DE
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van Herpen FHM, van Dijsseldonk RB, Rijken H, Keijsers NLW, Louwerens JWK, van Nes IJW. Case Report: Description of two fractures during the use of a powered exoskeleton. Spinal Cord Ser Cases 2019; 5:99. [PMID: 31839991 PMCID: PMC6906330 DOI: 10.1038/s41394-019-0244-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 09/23/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 11/08/2022] Open
Abstract
Introduction Powered robotic exoskeletons are a promising solution to enable standing and walking in patients with spinal cord injury (SCI). Although training and walking with an exoskeleton in motor complete SCI patients is considered safe, the risks of unexpected (technical) adverse events and the risk of fractures are not fully understood. This article reports the occurrence of two different cases of bone fracture during exoskeleton usage. Furthermore, advice is given for extra safety training and instructions. Case presentation The first case concerns a 47-year-old woman with T12 AIS A SCI. Her exoskeleton shut down unexpectedly probably causing a misalignment of the joints of her lower extremities relative to the joints of the exoskeleton, which resulted in a fracture of her left tibia. The second case involves a 39-year-old man with L1 AIS B SCI. An unexpected fracture of the right distal tibia occurred without a specific prior (traumatic) incident. Discussion Exoskeleton training instructors, SCI patients and their buddies should be instructed how to handle emergency situations. Furthermore, they should be aware of the risk of stress fractures of the lower extremities. Proper alignment of the exoskeleton relative to the body is of utmost importance to reduce fracture risk. In the case of swelling and discoloring of the skin, radiographic examination should be performed in order to exclude any fracture.
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Affiliation(s)
- F. H. M. van Herpen
- Department of Rehabilitation, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - R. B. van Dijsseldonk
- Department of Research, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - H. Rijken
- Department of Rehabilitation, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - N. L. W. Keijsers
- Department of Research, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J. W. K. Louwerens
- Department of Orthopaedics, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - I. J. W. van Nes
- Department of Rehabilitation, Sint Maartenskliniek, Nijmegen, The Netherlands
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Abstract
RATIONALE Unicompartmental knee arthroplasty (UKA) is an effective method to treat single compartment disease of the knee joint. Report about the complications of UKA, especially tibial plateau fractures, is rare. Given its rarity, its pathogenesis is not well described, and a standard of treatment is still not established. Therefore, relevant studies and analysis of this complication have a significant effect on helping physicians avoid risks and guide clinical diagnosis and treatment. PATIENT CONCERNS The 1st case corresponds to a 70-year-old male patient who complained of knee pain, difficulty walking, nocturnal rest pain, and elevated skin temperature at 3 weeks after the left knee arthroplasty. The second case is a 72-year-old female patient who complained of left knee pain and swelling during movement at 2 weeks after the left knee arthroplasty. DIAGNOSIS The 1st case showed a fracture of the medial malleolus of the left knee and a secondary depression of the medial tibial plateau in X-rays and the second case showed a fracture of the medial malleolus of the left knee in computed tomography (CT) and X-rays. INTERVENTIONS The 1st case was treated with plate and screw fixation and the second case was treated conservatively and immobilized using brace and remained nonweight bearing for 6 weeks. OUTCOMES After 1 year, both patients have good joint activity, and there was no pain or loosening of the prosthesis and fragment displacement. LESSONS The incidence of tibial plateau fractures (TPF) related to UKA might be low, but fatal and difficult to treat. Its pathogenesis determines procedure-related factors; when fracture develops, treatment should be based on the degree of displacement, stability of implant fixation, etc.
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Affiliation(s)
- Chao Lu
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital
| | - Guozhu Ye
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Wengang Liu
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital
| | - Huai Wu
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital
| | - Gaoyi Wu
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital
| | - Jin Chen
- Orthopedics Department, Guangdong Second Traditional Chinese Medicine Hospital
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
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Liu H, Wang H, Shao B, Lu H, Zhang S, Ou L, Chen Y, Xiang L. Epidemiological evaluation of traumatic lower limb fractures in children: Variation with age, gender, time, and etiology. Medicine (Baltimore) 2019; 98:e17123. [PMID: 31567950 PMCID: PMC6756687 DOI: 10.1097/md.0000000000017123] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
To investigate the age, gender, time, and etiology differences of traumatic lower limb fractures (TLLFs) in a population of children (≤18 years old), we retrospectively reviewed 936 children who had TLLFs and who came to our university-affiliated hospitals from 2001 to 2010. This study enrolled 657 males (70.2%) and 279 females (29.8%) aged (11.6 ± 4.9) years old. The most common etiologies and fracture sites were motor vehicle collisions (MVCs, 440, 47.0%) and tibias (376, 40.2%). A total of 126 (13.5%) patients suffered neurological deficits (NDs), 127 (13.6%) patients sustained associated injuries (ASOIs), and 78 (8.3%) patients sustained complications. During all periods the occurrence increased with increasing age group and a male preponderance was observed in all age groups. With increasing age, the proportion of injuries due to different etiologies increased and the proportion of femur fracture decreased from 65.2% to 34.5%. With increasing year of admission, the proportion of injuries due to MVCs decreased. The most common fracture sites were tibias in MVCs, femurs in low fall, high fall, and struck by object, feet in sprain. Male patients presented with significantly higher proportions of injuries due to struck by object and sprain, significantly lower proportions of pelvis fracture than the female patients. MVCs and tibias were the most common etiologies and fracture sites. Prevention and treatment should be taken according to the pattern of TLLFs which have specific annual, gender, and age characteristics.
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Affiliation(s)
- Huan Liu
- Department of Orthopedics, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou
| | - Hongwei Wang
- Department of Orthopedics, General Hospital of Northern Theater Command of Chinese PLA, Shenyang, Liaoning
- State Key Laboratory of Robotics, Shenyang Institute of Automation, Chinese Academy of Science, Shenyang, Liaoning,
- State Key Laboratory of Materials Processing and Die and Mould Technology, Huazhong University of Science and Technology, Wuhan, Hubei
- State Key Laboratory of Trauma, Burn and Combined Injury, Third Military Medical University, Chongqing
| | - Bing Shao
- Department of Anesthesia, General Hospital of Northern Theater Command of Chinese PLA, Shenyang, Liaoning
| | - Han Lu
- Department of Orthopedics, General Hospital of Northern Theater Command of Chinese PLA, Shenyang, Liaoning
| | - Song Zhang
- Department of Nuclear Medicine, Xinqiao Hospital, the Third Military Medical University, Chongqing
| | - Lan Ou
- Department of Radiology, Southwest Hospital, the Third Military Medical University, Chongqing, China
| | - Yu Chen
- Department of Orthopedics, General Hospital of Northern Theater Command of Chinese PLA, Shenyang, Liaoning
| | - Liangbi Xiang
- Department of Orthopedics, General Hospital of Northern Theater Command of Chinese PLA, Shenyang, Liaoning
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Boylan MR, Suchman KI, Bosco JA, Tejwani NC. Tibial Shaft Fractures in Workers Compensation and No-Fault Insurance Is There a Difference in Resource Utilization? Bull Hosp Jt Dis (2013) 2019; 77:200-205. [PMID: 31487486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Workers Compensation claims have been previously associated with inferior clinical outcomes. However, variation in inpatient stays for orthopedic trauma injuries according to insurance type has not been previously examined. METHODS We investigated the differences according to insurance for tibial shaft fractures in regard to length of stay and disposition. Using the New York SPARCS database, we identified 1,856 adult non-elderly patients with an isolated tibial shaft fracture who underwent surgery. Patients were stratified by insurance type, including private, Medicaid, Workers Compensation, and no-fault, which covers medical expenses related to automobile or pedestrian accidents. RESULTS Compared to private insurance (mean: 2.7 days), length of stay was longer for no-fault (mean: 3.9 days; adjusted difference +33%, p < 0.001) and Medicaid (mean: 3.5 days; adjusted difference +22%, p < 0.001), but not significantly different for Workers Compensation (mean: 3.5 days; adjusted difference +4%, p = 0.474). Compared to private insurance (rate: 3.5%), disposition to a facility was significantly higher for no-fault (rate: 10.1%; adjusted odds ratio [OR] = 3.3, p < 0.001) and Medicaid (rate: 7.6%; OR = 2.2, p = 0.003), but was not significantly different for Workers Compensation (rate: 6.3%; OR = 1.8, p = 0.129). CONCLUSIONS Patients with no-fault insurance, but not Workers Compensation, are subject to longer hospital stays and are more likely to be discharged to a facility following operative fixation of an isolated tibial shaft fracture. These findings suggest that financial, social, and legal factors influence medical care for patients involved in automobile accidents with no-fault insurance.
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Checa Betegón P, Arvinius C, Cabadas González MI, Martínez García A, Del Pozo Martín R, Marco Martínez F. Management of pediatric tibial tubercle fractures: Is surgical treatment really necessary? Eur J Orthop Surg Traumatol 2019; 29:1073-1079. [PMID: 30729308 DOI: 10.1007/s00590-019-02390-x] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 01/29/2019] [Indexed: 11/26/2022]
Abstract
Fractures of the anterior tibial tubercle are infrequent lesions. They often occur in male adolescent athletes, usually in relation with sports involving powerful jumps. We present a retrospective study of 10 patients, with an average age of 15.1 years, all of them males, and a total of 11 acute avulsions of the anterior tibial tubercle. We analyzed the etiology of the lesion, the type of treatment used as well as non-weight bearing period, protected immobilization period, and time until sports reincorporation. We obtained 11 acute avulsions: one case of type I; three cases of type II; four cases of type III; and three cases of type IV. Five cases were treated conservatively, including the three cases of type IV, and surgery was only performed in six cases since an anatomical reduction was not obtained with closed reduction. The results were satisfactory in all cases, with 100% percentage of sport reincorporation in less de 25 weeks. We registered only one complication, intolerance of material, which did not require additional surgeries. These fractures, although rare, have an excellent prognosis. Even if they are often treated surgically, we have obtained good results with the conservative treatment in patterns previously reported as surgical.
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Affiliation(s)
- P Checa Betegón
- Department of Traumatology and Orthopaedic Surgery, Hospital Clínico Universitario San Carlos, Madrid, Madrid, Spain.
| | - C Arvinius
- Department of Traumatology and Orthopaedic Surgery, Hospital Clínico Universitario San Carlos, Madrid, Madrid, Spain
| | - M I Cabadas González
- Department of Traumatology and Orthopaedic Surgery, Hospital Clínico Universitario San Carlos, Madrid, Madrid, Spain
| | - A Martínez García
- Department of Traumatology and Orthopaedic Surgery, Hospital Clínico Universitario San Carlos, Madrid, Madrid, Spain
| | - R Del Pozo Martín
- Department of Traumatology and Orthopaedic Surgery, Hospital Clínico Universitario San Carlos, Madrid, Madrid, Spain
| | - F Marco Martínez
- Department of Traumatology and Orthopaedic Surgery, Hospital Clínico Universitario San Carlos, Madrid, Madrid, Spain
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Ahmad T, Muhammad ZA, Noordin S, Humayun A. Analysing outcomes through orthopaedic trauma registry - A prospective cohort study. J PAK MED ASSOC 2019; 69(Suppl 1):S7-S11. [PMID: 30697010] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To develop a registry for recording injury-specific data to identify gaps and improve care. Methods The prospective cohort study was conducted at Aga Khan University Hospital, Karachi, from June 2015 to July 2018 though enrollment of patients with limb trauma is continuing to date. Data on injuries and management related to Tibia shaft fractures was collected from medical records, and outcomes were assessed on follow-up visits. Internationally validated injury-specific scores were utilised for assessing functional, clinical and radiological outcomes. SPSS version 19 was used for data analysis. Results There were 763 patients with 825 limb injuries. Of the injuries, 310(37.6%) related to upper limbs and 515(62.4%) to the lower limbs. Management was surgical for 741(89.9%) and conservative for 84(10.1%) injuries. Overall, 12(1.57%) patients died, and in 7(0.91%) cases mortality was unrelated to trauma and its management. There were 105 patients with tibia shaft fractures. Of them, 88(83.8%) were males and 17(16.2%) were females. At one-year follow-up excellent-to-good results were 12(92%) for intramedullary nailing followed by 7(78%) for open reduction and internal fixation. Conclusion Registry data can be used to develop preventive strategies and to improve management protocols.
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MESH Headings
- Accidental Falls
- Accidents, Traffic
- Blast Injuries
- Cohort Studies
- Extremities/injuries
- Female
- Fracture Fixation, Internal/methods
- Fracture Fixation, Intramedullary/methods
- Fractures, Closed/epidemiology
- Fractures, Closed/etiology
- Fractures, Closed/surgery
- Fractures, Open/epidemiology
- Fractures, Open/etiology
- Fractures, Open/surgery
- Humans
- Male
- Mortality
- Open Fracture Reduction/methods
- Orthopedic Procedures
- Outcome Assessment, Health Care
- Pakistan/epidemiology
- Prospective Studies
- Registries
- Tibial Fractures/epidemiology
- Tibial Fractures/etiology
- Tibial Fractures/surgery
- Violence
- Wounds and Injuries/epidemiology
- Wounds and Injuries/etiology
- Wounds and Injuries/surgery
- Wounds, Nonpenetrating
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42
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Chung TL, Chen NC, Chen CL. Severe hypophosphatemia induced by denosumab in a patient with osteomalacia and tenofovir disoproxil fumarate-related acquired Fanconi syndrome. Osteoporos Int 2019; 30:519-523. [PMID: 30171299 DOI: 10.1007/s00198-018-4679-2] [Citation(s) in RCA: 5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 08/19/2018] [Indexed: 12/17/2022]
Abstract
Denosumab, a novel agent that inhibits osteoclasts, reduces the risk of fracture in patients with osteoporosis. However, worsening of hypophosphatemia and other symptoms may be induced by denosumab in patients with pre-existing hypophosphatemic osteomalacia. A 58-year-old man with hepatitis B presented with diffuse bone pain and muscle weakness. Denosumab was prescribed by the orthopedist according to documented low bone mass and spine compression fracture. After administering denosumab, the patient's bone pain worsened, and he later developed a right tibia stress fracture. His condition was diagnosed as adult-onset hypophosphatemic osteomalacia complicated by multiple bone fractures, which resulted from Fanconi syndrome with proximal tubulopathy due to tenofovir disoproxil fumarate (TDF) treatment for his hepatitis B. Denosumab use leads to aggressive hypophosphatemic osteomalacia and the complication of stress fractures, because of its effects on bone resorption. Physicians should be aware that in patients with chronic hepatitis B monoinfection who are administered TDF therapy, bone pain or fracture is possible but preventable by timely monitoring of serum phosphate levels. Denosumab should not be used in patients with untreated osteomalacia or vitamin D deficiency, as it may lead not only to hypocalcemia but also to hypophosphatemia in these patients.
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Affiliation(s)
- T-L Chung
- Division of Nephrology, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Rd., Kaohsiung, 813, Taiwan
- National Yang-Ming University, School of Medicine, Taipei, Taiwan
| | - N-C Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - C-L Chen
- Division of Nephrology, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Rd., Kaohsiung, 813, Taiwan.
- National Yang-Ming University, School of Medicine, Taipei, Taiwan.
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43
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Mirasoglu B, Egeren E, Karakaya H, Aktas S. Hyperbaric oxygen therapy for severe blast injury of lower extremity after terrorist attack: case report. Undersea Hyperb Med 2019; 46:75-79. [PMID: 31154688] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
More blast injuries are encountered in the civilian setting in recent years as terrorist attacks have increased globally. A 17-year-old male patient with severe blast injury of the right lower extremity was admitted to our department on the fifth day after a terrorist bombing attack. Initially he had been admitted to an emergency department with segmental tibia fracture and arterial injury (Gustilo IIIC). An amputation had been foreseen due to ischemia that persisted even after orthopedic fixation and revascularization interventions, followed by fasciotomy incisions. After consultation with our department hyperbaric oxygen (HBO2) therapy was administered twice daily for the first week. Ischemia improved prominently after 10 HBO2 sessions. HBO2 therapy was continued together with antibiotherapy and wound care. The patient underwent a total of 40 HBO2 sessions and two reconstructive operations and healed without amputation. Vascular injuries with concomitant orthopedic trauma cause most of the delayed amputations in bombing attacks since ischemia can persist at the microvascular level even though adequate treatments are applied. HBO2 corrects hypoxia at tissue level and so provides oxygen for the critically ischemic cells in the injured area. HBO2 also enhances host defense and decreases the ischemia reperfusion injury. In this case, HBO2 was effective in survival and functional recovery (salvage) of the extremity together with regular wound care, antibiotherapy and surgical repair.
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Affiliation(s)
- Bengusu Mirasoglu
- Department of Underwater and Hyperbaric Medicine, Istanbul University, Istanbul Faculty of Medicine, Istanbul, 34093 Fatih, Istanbul, Turkey
| | - Engin Egeren
- Department of Underwater and Hyperbaric Medicine, Istanbul University, Istanbul Faculty of Medicine, Istanbul, 34093 Fatih, Istanbul, Turkey
| | - Huseyin Karakaya
- Department of Underwater and Hyperbaric Medicine, Istanbul University, Istanbul Faculty of Medicine, Istanbul, 34093 Fatih, Istanbul, Turkey
| | - Samil Aktas
- Department of Underwater and Hyperbaric Medicine, Istanbul University, Istanbul Faculty of Medicine, Istanbul, 34093 Fatih, Istanbul, Turkey
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Stevenson DA, Hanson H, Stevens A, Carey J, Viskochil D, Sheng X, Wheeler K, Slater H. Quantitative Ultrasound and Tibial Dysplasia in Neurofibromatosis Type 1. J Clin Densitom 2018; 21:179-184. [PMID: 28438404 DOI: 10.1016/j.jocd.2017.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 12/30/2016] [Accepted: 03/23/2017] [Indexed: 01/14/2023]
Abstract
Neurofibromatosis type 1 (NF1) is a common autosomal dominant disorder associated with unilateral anterolateral bowing with subsequent fracture and nonunion. In infancy, physiologic bowing of the lower leg can be confused with pathologic tibial dysplasia in NF1. Little is known about the bone physiology of the tibiae prior to fracture or predictors of fracture. The aim of this study was to characterize bone quality of bowed tibiae prior to fracture in NF1 using quantitative ultrasound (QUS). Bone quality was assessed on both tibiae (the non-bowed and bowed tibiae) using QUS to measure speed of sound (SOS) at the mid-shaft in 23 individuals with NF1. SOS (m/s) was determined and Z-scores generated using cross-sectional reference data of the same sex and age. The mean difference in SOS Z-scores when comparing the bowed tibia vs the individual's contralateral unaffected tibia was statistically significant with lower mean Z-scores in the bowed tibia (p = 0.001). Radiographs of all individuals with a clinical diagnosis of anterolateral bowing were reviewed, and in 2 individuals the radiographs showed minimal bowing with absence of characteristic cortical thickening and medullary canal narrowing in NF1-related tibial dysplasia, suggesting physiologic bowing. In both individuals, the Z-scores of the bowed leg were not lower than the unaffected leg supporting the suggestion of physiologic bowing rather than pathologic tibial dysplasia. These data show that dysplastic tibiae in NF1 prior to fracture and nonunion have abnormal bone quality with significant decreases in SOS even though radiographically the tibiae show a thickened cortex. These data also suggest that QUS can help distinguish dysplastic bowing vs physiologic bowing in infancy in NF1. QUS is an effective quantitative outcome measure for trials aimed at improving tibial bowing to prevent fracture, and it is a potential aid in diagnosis and clinical management in NF1.
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Affiliation(s)
- David A Stevenson
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA; Department of Pediatrics, Division of Medical Genetics, Stanford University, Stanford, CA, USA.
| | - Heather Hanson
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Austin Stevens
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - John Carey
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - David Viskochil
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Xiaoming Sheng
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Karen Wheeler
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Hillarie Slater
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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45
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Samuel AM, Diaz-Collado PJ, Szolomayer LK, Wiznia DH, Chan WW, Lukasiewicz AM, Basques BA, Bohl DD, Grauer JN. Incidence of and Risk Factors for Knee Collateral Ligament Injuries With Proximal Tibia Fractures: A Study of 32,441 Patients. Orthopedics 2018; 41:e268-e276. [PMID: 29451942 DOI: 10.3928/01477447-20180213-03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 12/15/2017] [Indexed: 02/03/2023]
Abstract
Proximal tibia fractures are associated with concurrent collateral ligament injuries. Failure to recognize these injuries may lead to chronic knee instability. The purpose of this study was to identify risk factors for concurrent collateral ligament injuries with proximal tibia fractures and their association with inpatient outcomes. A total of 32,441 patients with proximal tibia fractures were identified in the 2011-2012 National Trauma Data Bank. A total of 1445 (4.5%) had collateral ligament injuries, 794 (2.4%) had injuries to both collateral ligaments, 456 (1.4%) had a medial collateral ligament injury only, and 195 (0.6%) had a lateral collateral ligament injury only. On multivariate analysis, risk factors found to be associated with collateral ligament injuries included distal femur fracture (odds ratio, 2.1), pedestrian struck by motor vehicle (odds ratio, 2.0), obesity (odds ratio, 1.6), young age (odds ratio, 1.9 for 18 to 29 years vs 40 to 49 years), motorcycle accident (odds ratio, 1.5), and Injury Severity Score of 20 or higher (odds ratio, 1.4). In addition, patients with simultaneous injuries to both collateral ligaments had higher odds of inpatient adverse events (odds ratio, 1.51) and longer hospital stay (mean, 2.27 days longer). The risk factors reported by this study can be used to identify patients with proximal tibia fractures who may warrant more careful and thorough evaluation and imaging of their knee collateral ligaments. [Orthopedics. 2018; 41(2):e268-e276.].
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46
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Merali F, Leung M. Bilateral pathologic mid-tibial stress fractures: Initial presentation of mild primary hyperparathyroidism. Can Fam Physician 2017; 63:610-612. [PMID: 28807955 PMCID: PMC5555327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Fahim Merali
- Recently graduated general practitioner and sports and exercise medicine physician in Toronto, Ont.
| | - Mark Leung
- Lecturer in the Department of Family and Community Medicine at the University of Toronto and Director of the Sports and Exercise Medicine fellowship program at the University of Toronto
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47
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Caré W, Arnautou P, Segot A, de Charry F, Heyraud-Blanchet C, Livartowski J, Konopacki J, Malfuson JV. [Fracture of unusual cause]. Rev Med Interne 2017; 39:665-666. [PMID: 28579109 DOI: 10.1016/j.revmed.2017.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/09/2017] [Indexed: 11/18/2022]
Affiliation(s)
- W Caré
- Service de médecine interne, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France.
| | - P Arnautou
- Service d'hématologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - A Segot
- Service d'hématologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - F de Charry
- Service d'hématologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - C Heyraud-Blanchet
- Service de médecine interne, hôpital privé d'Antony, 1, rue Velpeau, 92160 Antony, France
| | - J Livartowski
- Service de médecine interne, hôpital privé d'Antony, 1, rue Velpeau, 92160 Antony, France
| | - J Konopacki
- Service d'hématologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - J-V Malfuson
- Service d'hématologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
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48
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Dexel J, Fritzsche H, Beyer F, Harman MK, Lützner J. Open-wedge high tibial osteotomy: incidence of lateral cortex fractures and influence of fixation device on osteotomy healing. Knee Surg Sports Traumatol Arthrosc 2017; 25:832-837. [PMID: 26254088 DOI: 10.1007/s00167-015-3730-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [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: 10/19/2014] [Accepted: 07/23/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE Open-wedge high tibial osteotomy (HTO) is an established treatment for young and middle-aged patients with medial compartment knee osteoarthritis and varus malalignment. Although not intended, a lateral cortex fracture might occur during this procedure. Different fixation devices are available to repair such fractures. This study was performed to evaluate osteotomy healing after fixation with two different locking plates. METHODS Sixty-nine medial open-wedge HTO without bone grafting were followed until osteotomy healing. RESULTS In patients with an intact lateral hinge, no problems were noted with either locking plate. A fracture of the lateral cortex occurred in 21 patients (30.4 %). In ten patients, the fracture was not recognized during surgery but was visible on the radiographs at the 6-week follow-up. Lateral cortex fracture resulted in non-union with the need for surgical treatment in three out of eight (37.5 %) patients using the newly introduced locking plate (Position HTO Maxi Plate), while this did not occur with a well-established locking plate (TomoFix) (0 out of 13, p = 0.023). CONCLUSION With regard to other adverse events, no differences between both implants were observed. In cases of lateral cortex fracture, fixation with a smaller locking plate resulted in a relevant number of non-unions. Therefore, it is recommended that bone grafting, another fixation system, or an additional lateral fixation should be used in cases with lateral cortex fracture. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Julian Dexel
- Department of Orthopaedic and Trauma Surgery, University Hospital Carl Gustav Carus, Medical Faculty of the Technical University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - Hagen Fritzsche
- Department of Orthopaedic and Trauma Surgery, University Hospital Carl Gustav Carus, Medical Faculty of the Technical University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Franziska Beyer
- Department of Orthopaedic and Trauma Surgery, University Hospital Carl Gustav Carus, Medical Faculty of the Technical University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Melinda K Harman
- Department of Bioengineering, Clemson University, Clemson, SC, USA
| | - Jörg Lützner
- Department of Orthopaedic and Trauma Surgery, University Hospital Carl Gustav Carus, Medical Faculty of the Technical University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany
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49
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Steele D, Morley W. Diagnosis and management of an acute knee injury. BMJ 2017; 356:i6783. [PMID: 28104685 DOI: 10.1136/bmj.i6783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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50
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Seewoonarain S, Servant C. A painful swollen knee after a fall. BMJ 2017; 356:i6772. [PMID: 28082271 DOI: 10.1136/bmj.i6772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Chris Servant
- The Ipswich Hospital NHS Trust, Heath Road, Ipswich, Suffolk, UK
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