CASE REPORT: TREATMENT OF TIBIAL OBLIQUE DIAPHYSEAL FRACTURE IN DOMESTIC CAT

In skeletally immature dogs with simple non-displaced diaphyseal tibial and fibular fractures does internal fixation compared with external fixation result in less postoperative complications and improved fracture healing? Treatment. There were no publications that answered the PICO question. None. Both external skeletal fixation and internal fixation are reported as techniques for diaphyseal tibial and fibular fracture management in companion animals, though no study has been reported to compare these techniques directly, or to report fracture healing and postoperative complications in skeletally immature dogs with non-displaced diaphyseal tibial fractures. Given the absence of evidence answering the PICO, choice and recommendation on treatment for non-displaced diaphyseal tibial and fibular fractures in skeletally immature dogs should be decided on personal experience and stabilisation methods available to the veterinarian such as external fixation or internal fixation. Both surgical techniques have been reported in skeletally mature and immature dogs with diaphyseal tibial fractures, but not specifically in skeletally immature patients with non-displaced diaphyseal tibial and fibular fractures. They are both applicable methods of fixation for tibial fractures in companion animals, though there is lacking evidence for which has more favourable outcomes for non-displaced diaphyseal tibial and fibular fractures in skeletally immature dogs as no studies have directly compared these stabilisation techniques.

Introduction: This Privat Docent thesis collects the author's recent retrospective study results on potential clinical and radiological risk factors for the occurrence of acute compartment syndrome in the treatment of tibia fractures. Clinical evaluation of acute compartment syndrome and intra-compartmental pressure measurements are not completely reliable. This might lead to difficulties in diagnosing or ruling out acute compartment syndrome, especially in patients with equivocal clinical signs and those with loco-regional anesthesia, intubated, sedated or obtunded. Alternative predictors of acute compartment syndrome need to be determined. The objective of the author's research was therefore to analyze the relation between key demographic, injury-related, clinical and radiographic factors in patients with proximal tibia, diaphyseal tibia and distal tibia fractures and the subsequent development of acute compartment syndrome. Recent publications and current research: -Association between open tibia fractures and acute compartment syndrome (retrospective cohort study, 711 consecutive adult patients with 725 tibia fractures): this study highlighted an association between open Gustilo type 2 and 3 lesions and occurrence of acute compartment syndrome in proximal intra-articular fractures only; there was no association with closed or any type of open fractures in extra-articular fractures, and there were not enough acute compartment syndrome cases among distal intra-articular fractures to draw conclusions. -Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial plateau fractures (retrospective cohort study, 265 consecutive adult patients with 269 intra-articular tibial plateau fractures): two parameters related to the occurrence of acute compartment syndrome in tibial plateau fractures were pointed out, namely the presence of a non-contiguous tibia fracture or knee dislocation, and higher AO/OTA classification. -Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial shaft fractures (retrospective cohort study, 270 consecutive adult patients with 273 tibial shaft fractures): one radiological parameter related to the occurrence of acute compartment syndrome was pointed out: this parameter was a longer distance between the center of the fracture and the talar dome, in other words a fracture located more proximally within the tibia. Diaphyseal tibial fractures associated to other musculoskeletal, thoraco-abdominal or cranio-cerebral injuries were also at higher risk of acute compartment syndrome. Radiographic signs of higher fracture displacement were not associated with ACS occurrence. -Current research – Association between muscle mass surrounding the fracture site and occurrence of acute compartment syndrome in extra-articular fractures of the tibia: this research is aimed at refining the conclusion of the previous study, in which the most powerful acute compartment syndrome predictor in tibial shaft fractures was the distance between the talar dome and the center of the tibial shaft fracture, meaning that a more proximal fracture was more prone to be associated with the development of acute compartment syndrome. The explanation for this finding was that a fracture surrounded by a larger muscle mass (proximal diaphysis) may result in a higher amount of energy transferred to the soft tissues and potentially to acute compartment syndrome development. This ongoing research consists of analyzing acute compartment syndrome rate and muscle mass associated to each eight arbitrarily pre-defined isometric tibia segments in order to evaluate a potential correlation between both these factors. Conclusions and perspective for future research: Early recognition of injuries at risk of acute compartment syndrome is essential in the screening and treatment of tibia fractures, especially by intubated, sedated or obtunded patients. Author's recent publications were able to demonstrate different risk factors for the occurrence of acute compartment syndrome during the treatment of tibia fractures. When one or more risk factor is present, regular clinical examinations and/or repeated or continuous intra-compartmental pressure measurements should be performed before and after the surgery to monitor soft tissue condition, even if the initial assessments were unremarkable regarding the eventual presence of acute compartment syndrome. All the factors highlighted by the author in predicting the occurrence of acute compartment syndrome would need to be confirmed and refined by larger studies.

Most pediatric tibial shaft fractures (75%)1 can be treated nonoperatively; however, unstable and open fractures require surgical intervention. Titanium elastic nails have become a popular technique for fixation of pediatric tibial shaft fractures. They act as internal splints that impart relative stability to the fracture, promoting callus formation at the fracture site2. After the patient is placed in the supine position, the proximal tibial physis is marked using fluoroscopy. An anteromedial and anterolateral incision are made distal to the physis. Entry holes are created in the proximal part of the tibia, and appropriately sized titanium nails are introduced into the bone. Nail size should be 40% of the width of the canal, yielding 80% canal fill when 2 nails are used. The nails are prebent into a gentle C-shape to increase cortical contact at the apex so that 3-point fixation is achieved. The nails are passed to the fracture site, and the fracture is then reduced. The nails are then passed across the fracture site and stopped proximal to the distal tibial physis. The nails are then cut and tamped distally until there is just a short portion of nail left out of the proximal part of the tibia so that the nails can be removed once the fracture is healed. The wounds are then closed, and postoperative immobilization is applied. Many pediatric tibial shaft fractures can be treated with closed reduction and cast immobilization. Open fractures, or fractures that fail nonoperative management, can be treated with external fixation, open reduction and internal fixation (ORIF), or intramedullary stabilization3. Anatomic reduction and fracture compression can be achieved with ORIF; however, a drawback to this technique is the lack of soft-tissue coverage in the diaphyseal area of the tibia, which can lead to infection and wound-healing problems4. External fixation has traditionally been the technique of choice for open tibial fractures; however, with the ability to use flexible tibial nails in both open and closed tibial fractures, external fixation is now reserved for open fractures with large soft-tissue defects or in fractures with segmental bone loss. Intramedullary flexible nailing can be used in both open and closed tibial fractures, provides excellent fracture fixation, and utilizes incisions that are more cosmetically appealing to patients5,6. Outcomes following flexible nailing for pediatric tibial fractures are excellent. In a study of 19 patients undergoing flexible nailing for tibial shaft fractures, 18 had excellent or satisfactory results7. Compared with patients who had external fixation, those treated with flexible nails had less pain, shorter time to union, and better functional outcomes2. Compared with patients treated with ORIF, those who underwent flexible intramedullary nailing spent less time in the operating room and had lower rates of wound complications4. In the immediate postoperative period, clinicians should be aware of the risk of compartment syndrome, particularly in patients with high-energy injuries, older patients (>14 years old), and heavier patients (>50 kg)8. There is also an increased risk of soft-tissue irritation and fracture malunion in heavier patients treated with flexible nails9,10. Nail size should be 80% of the canal diameter (e.g., two 4.0-mm nails should be chosen for a canal that measures 10 mm).Nails should be properly contoured to avoid corticotomy of the far cortex during insertion; apex of the bend should be positioned at the level of the fracture.During insertion, leave room to advance nails further after they are cut proximally.Do not bury the proximal nail tips beneath the cortex as extraction will be difficult.Ensure that the ends of the nails are not lying up against the proximal tibial physis as this may cause premature growth arrest.

Background: Management of open diaphyseal tibial shaft fractures can be comminuted due to lack of soft tissue coverage and blood supply of the tibial shaft. Open reduction and internal fixation [ORIF] with plates and screws achieves stability, allows joint mobilization but does not allow early weight bearing which as a stimulus is a must for early union. Closed reduction and intramedullary fixation compromise the intramedullary blood supply and increases the risk of infection in open fractures. Ilizarov is considered safe in treating these open injuries, at the same time it has the advantages of easy application, minimal invasive, and convenient subsequent soft tissue repair. Objective: The aim of current study was to evaluate treatment of open comminuted diaphyseal tibial fracture by ilizarov external fixator; its effective, availability, outcomes and complications. Patients and Methods: This prospective study included a total of 10 patients with comminuted tibial diaphyseal fractures managed with early Ilizarov external fixator, attending at Alharam Hospital. This study was conducted between Feb 2018 and July 2019. General assessment indicators included pain, complete union, deformity in comparison to healthy limb, infection, leg limb discrepancy, stiffness and activity of the patients were analysed. Results: Follow-up of all participants for analysis was done. The follow-up time was 17 months. Three cases developed ankle stiffness. The average total range of knee motion in our cases was 130.5 (range 125-140). A significant limp occurred only in 3 cases. NO persistent limp persisted in our cases. Fifteen patients had minimal pain at the site of fracture. Signicant pain occurred in three cases. Pin site infection occurred in 7 patients. All the patients achieved full union and activity. Excellent results were obtained in 4 cases (40%). Good results were obtained in 3 cases (30%) with overall good to excellent results were about (70%). Fair results were obtained in 3 cases (30%). Conclusion: It could be concluded that the Ilizarov external fixator is a golden horse for orthopedic surgeons. It holds wonderful promise in the management of open diaphyseal tibial shaft fractures.

Background: Management of open diaphyseal tibial shaft fractures can be comminuted due to lack of soft tissue coverage and blood supply of the tibial shaft. Open reduction and internal fixation [ORIF] with plates and screws achieves stability, allows joint mobilization but does not allow early weight bearing which as a stimulus is a must for early union. Closed reduction and intramedullary fixation compromise the intramedullary blood supply and increases the risk of infection in open fractures. Ilizarov is considered safe in treating these open injuries, at the same time it has the advantages of easy application, minimal invasive, and convenient subsequent soft tissue repair. Objective: The aim of current study was to evaluate treatment of open comminuted diaphyseal tibial fracture by ilizarov external fixator; its effective, availability, outcomes and complications. Patients and Methods: This prospective study included a total of 10 patients with comminuted tibial diaphyseal fractures managed with early Ilizarov external fixator, attending at Alharam Hospital. This study was conducted between Feb 2018 and July 2019. General assessment indicators included pain, complete union, deformity in comparison to healthy limb, infection, leg limb discrepancy, stiffness and activity of the patients were analysed. Results: Follow-up of all participants for analysis was done. The follow-up time was 17 months. Three cases developed ankle stiffness. The average total range of knee motion in our cases was 130.5 (range 125-140). A significant limp occurred only in 3 cases. NO persistent limp persisted in our cases. Fifteen patients had minimal pain at the site of fracture. Signicant pain occurred in three cases. Pin site infection occurred in 7 patients. All the patients achieved full union and activity. Excellent results were obtained in 4 cases (40%). Good results were obtained in 3 cases (30%) with overall good to excellent results were about (70%). Fair results were obtained in 3 cases (30%). Conclusion: It could be concluded that the Ilizarov external fixator is a golden horse for orthopedic surgeons. It holds wonderful promise in the management of open diaphyseal tibial shaft fractures.

Objective To evaluate the biomechanism of three kinds of internal fixations in treatment of complex tibial plateau fractures. Methods Eighteen human antiseptic cadaver tibial plateau specimens were used to make models of complex tibial plateau fracture (type Ⅵ fractures of Schatzker classification). The models were fixated with a lateral Golf-buttress plate (GP), modified dual plate (a lateral Golf-buttress plate plus a medial five-hole one-third tubular antiglide plate) (DP) or a lateral locking compression plate (LCP) respectively to compare strength, rigidity and stability of different fixation methods. Results The biomechanical strength, rigidity and stability in DP group and LCP group were better than those in GP group (P 0.05). Conclusions Locking compression plate and modified dual plate are fairly ideal internal fixators for treatment of complex tibial plateau fractures. In the meantime, locking compression plate emphasizes conservation of soft tissues and blood supply, can better meet the requirement of the biological fixation of fracture and is the most ideal internal fixator at present. Key words: Tibial fractures; Fracture fixation; internal; Biomechanics

Tibial plateau fractures are intra-articular fractures of the knee. Restoring the articular surface, axis of lower extremities and function of knee is the main goal of treatment. Open reduction and internal fixation remains the gold standard for the treatment. However, it is more difficult to treat fractures in elderly patients with severe osteoarthritis, osteoporosis, and comminuted knee joints. Open reduction and internal fixation are sometimes difficult to achieve the treatment goal, and the patients are prone to bed-related complications. Total knee arthroplasty (TKA) is the main method for the treatment of traumatic arthritis after knee fracture, but the surgery is difficult with multiple complications. At present, some authors have applied primary TKA to the tibial plateau fractures and reported the advantages including immediate post-operative knee stability, early functional exercise and weight-bearing activities, and no need to consider the meniscus retention, cruciate ligament repair and articular anatomical reduction. This article reviews the surgical advantages, surgery-related issues and expenses to discuss the treatment of tibial plateau fractures in the elderly with TKA, providing reference for the treatment of tibial plateau fractures in the elderly. Key words: Tibial fractures; Arthroplasty, replacement, knee; Aged

What's New in Orthopaedic Trauma.

Objective To observe the therapeutic effect between less invasive stabilization system (LISS) plate and anatomical plate internal fixation for the treatment of tibial plateau fractures. Methods The clinical data of 58 patients with tibial plateau fractures were retrospectively analyzed. The patients were divided into LISS plate group and anatomical plate group according to the internal fixation method with 29 cases each. The operative time, blood loss, incision length, fracture healing time, postoperative weight-bearing time, postoperative complications and therapeutic effect (according to Rasmussen knee joint function score scale) were compared between 2 groups. Results The operative time, incision length, blood loss and incidence of postoperative complications in LISS plate group were significantly lower than those in anatomical plate group: (68.5 ± 7.1) min vs. (92.3 ± 9.4) min, (5.8 ± 1.4) cm vs. (8.6 ± 2.1) cm, (208.5 ± 27.8) ml vs. (329.7 ± 25.2) ml and 17.2% (5/29) vs. 41.4% (12/29), and the excellent rate was significantly higher than that in anatomical plate group: 86.2% 25/29) vs. 62.1% (18/29), and there were statistical differences (P 0.05). Conclusions Both of LISS plate and anatomical plate internal fixation for the treatment of tibial plateau fractures have good clinical efficacy, but the LISS plate has advantages of shorter operation time, less tissue trauma, less blood loss, quicker fracture healing and less postoperative adverse reaction. Key words: Tibial fractures; Surgical procedures, minimally invasive; Internal fixators; Retrospective studies

In cats with closed diaphyseal tibial fractures, does internal fixation, when compared to external fixation, result in a lower postoperative complication rate? Treatment. There were no publications that directly answered the PICO question. Zero. Both internal and external fixation are published techniques deployed in tibial fracture fixation in cats, however no study has directly compared the postoperative complications in these groups for closed diaphyseal tibial fractures. Given the lack of evidence to answer the PICO question, the veterinarian should consider their choice of stabilisation technique on the methods available and their personal experience. Both internal and external skeletal fixation (ESF) are published methods of feline tibial fracture fixation. A related study demonstrated that ESF has a high risk of complication for feline tibial fracture repair but given the absence of evidence for exclusively closed fracture types, this conclusion cannot be drawn for the PICO. How to apply this evidence in practice The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient's circumstances and owners' values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

What's New in Orthopaedic Trauma.

Objective To compare the value of arthroscopic assisted percutaneous internal fixation and open reduction and internal fixation in treatment of tibial plateau fracture.Methods The clinical data of 180 patients of tibial plateau fracture were analyzed retrospectively,including 112 patients of type Ⅱ fracture (group A) and 68 patients of type Ⅲ fracture (group B).The patients in group A and group B were divided into group A1 (56 patients),A2 (56 patients),B 1 (34 patients),B2 (34 patients) respectively according to the odd number and even number of admission date.The patients in group A1 and B1 received open reduction and internal fixation and the patients in group A2 and B2 received arthroscopic assisted percutaneous internal fixation.The postoperative functional recovery was compared and evaluated between the same type of tibial plateau fractures under different treatments.Results In group A1:the postoperative functional recovery,the excellent was 12 patients,the good was 26 patients,the middle good was 12 patients,the bad was 6 patients.The rate of the excellent and the good was 67.9％ (38/56).In group A2:the postoperative functional recovery,the excellent was 19 patients,the good was 34 patients,the middle good was 3 patients.The rate of the excellent and the good was 94.6％(53/56).The rate of the excellent and the good between group A1 and group A2 had significant difference (P ＜ 0.01).After operation for 6 months,the HSS scores of knee joint and degree of flex and extend in group A1 and A2 had significant difference [(73.21 ± 8.32) scores vs.(85.58 ±9.89) scores,(35.6 ±6.6)° vs.(55.1 ±8.8)°] (P ＜0.01).In group B1:the postoperative functional recovery,the excellent was 8 patients,the good was 16 patients,the middle good was 7 patients,the bad was 3 patiens.The rate of the excellent and the good was 70.6％(24/34).In group B2:the postoperative functional recovery,the excellent was 12 patients,the good was 21 patients,the middle good was 1 patient.The rate of the excellent and the good was 97.1％(33/34).The rate of the excellent and the good between group B1 and group B2 had significant difference(P ＜ 0.01).After operation for 6 months,the HSS scores of knee joint and degree of flex and extend in group B1 and B2 had significant difference [(75.32 ± 7.99) scores vs.(86.41 ±10.21) scores,(33.9 ±7.2)° vs.(56.6 ± 10.5)°](P＜0.01).Conclusions The efficacy of arthroscopic assisted percutaneous internal fixation is better than open reduction and internal fixation either in type Ⅱ fracture or in type Ⅲ fracture.This method is mini-invasive and is worthy to spread. Key words: Arthroscopes; Tibial fractures; Percutaneous internal fixation; Open reduction and internal fixation; HSS scores

Objective To explore the treatment of tibial plateau fractures with posterolateral collapse and posteromedial spilt. Methods During the period from January 2009 to January 2015, 17 tibial plateau fractures with posterolateral collapse and posteromedial spilt were surgically treated. They were 12 males and 5 females, with an average age of 32.4 years (from 21 to 52 years). Anteroposterior and lateral radiographs as well as computed tomography (CT) images were obtained in the course of preoperative radio-logical evaluation to determine the collapse and displacement. After the posteromedial bone spilt fragments were reduced and fixated via the posteromedial approach, the posterolateral collapse fragments were exposed via the fibular osteotomy approach and stabilized by lateral buttress following reduction. Hospital for Special Surgery (HSS) functional score and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were used at the final follow-ups to evaluate functional outcomes. Results Follow-ups with a mean duration of 18.3 months (range, from 12 to 24 months) were carried out in all the patients. All fractures healed within an average of 13.2 weeks (range, from 12 to 16 weeks). The HSS functional scores ranged from 60 to 100 points, averaging 89.6 points, giving 15 excellent cases, one good case and one fair case. The AOFAS functional scores ranged from 86 to 98 points, averaging 95.2 points. No loosening or breakage of the implants, or traumatic arthritis occurred in this series. Conclusion For tibial plateau fractures with posterolateral collapse and posteromedial spilt, a special type, it is an effective treatment to carry out open reduction and internal fixation of the posterolateral collapse fragments via the fibular osteotomy approach after reduction and stabilization of the posteromedial bone spilt fragments. Key words: Tibial fractures; Knee joint; Fracture fixation, internal; Osteotomy

Little is known about trends and predictors of hardware related infection following open reduction and internal fixation (ORIF) of extremity fractures, one of the major causes of failure following ORIF. The present study was designed and conducted to determine trends and predictors of infection-related hardware removal following ORIF of extremities using a nationally representative database. We used Nationwide Inpatient Sample data from 2002 to 2011 to identify cases of ORIF following upper and lower extremity fractures, as well as cases that underwent infection-related hardware removal following ORIF. Multivariate analysis was performed to identify independent predictors of infection-related hardware removal, controlling for patient demographics and comorbidities, hospital characteristics, site of fracture, and year. For all ORIF procedures, the highest rate of hardware removal related to infection was observed in tarsal fractures (5.56%), followed by tibial (3.65%) and carpal (3.37%) fractures. Hardware removal rates due to infection increased in all fractures except radial/ulnar fractures. Tarsal fractures(odds ratio (OR)=1.06, 95% confidence interval (CI): 1.04-1.09, P<0.001), tibial fractures (OR=1.04, 95% CI: 1.03-1.06, P<0.001) and those patients with diabetes mellitus (OR=2.64, 95% CI: 2.46-2.84, P<0.001), liver disease (OR=2.04, 95% CI: 1.84- 2.26, P<0.001), and rheumatoid arthritis (OR=2.06, 95% CI: 1.88-2.25 P<0.001) were the main predictors of infection-related removals; females were less likely to undergo removal due to infection (OR= 0.61, 95% CI: 0.59-0.63 P<0.001). Hardware removal rates due to infection increased in all fractures except radial/ulnar fractures. Diabetes, liver disease, and rheumatoid arthritis were important predictors of infection-related hardware removal. The study identified some risk factors for hardwarerelated infection following ORIF, such as diabetes, liver disease, and rheumatoid arthritis, that should be studied further in an attempt to implement strategies to reduce rate of infection following ORIF.

Objective To report the operative procedures and clinical outcomes of open reduction and internal fixation for the treatment of tibial plateau fractures involving anteromedial margin caused by hyperextension varus injury. Methods From December 2013 to December 2015, 11 patients with tibial plateau fracture involving anteromedial margin caused by hyperextension varus injury were treated at our department. They were 6 males and 5 females with a mean age of 42.3 years (range, from 19 to 65 years). Simple medial column fracture happened in 2, fractures of medial and lateral columns in 4, fractures of medial and posterior columns in 3, and 3-column fractures in 2 cases. The cortical bone fractures of anteromedial margin were fixated by open reduction and internal fixation using self-clipped joint line plating. Bone grafting was conducted if necessary. Results The 9 patients were followed up for an average of 17.6 months (range, from 12 to 30 months). All the fractures healed. The average time for radiographic bony union and full weight bearing was 11.4 weeks (range, from 9 to 14 weeks) and 16.1 weeks (range, from 14 to 19 weeks), respectively. On average, the Rasmussen’s radiological grading scored 16.9 (range, from 14 to 18) immediately after operation; the Hospital for Special Surgery scores of all the patients at 12 months postoperatively averaged 89.1 (range, from 75 to 94), yielding an excellent to good rate of 92.3%. The average range of motion of the affected knee was from 2.3° to 125.1°. There were significant differences in both tibial plateau angle and posterior slope angle on radiography between preoperation and postoperation (P 0.05). Partial incision necrosis occurred postoperatively in one case which was uneventfully healed after wound management. One case complicated with preoperative common peroneal nerve injury reported dorsal sense of numbness which was healed after administration of neurotrophic drugs. No screw loosening, plate breakage or fixation failure was found during follow-ups. Conclusions It is difficult to treat the tibial plateau fractures involving anteromedial margin caused by hyperextension varus injury. Internal fixation with joint line plating is an appropriate treatment for this fracture pattern, leading to satisfactory clinical outcomes. Key words: Tibial fractures; Fracture fixation, internal; Bone plates; Hyperextension; Varus