It is important to review treatment considerations and provide a framework to guide decision making for nonsurgical and surgical treatment of distal tibia physeal fractures in pediatric patients. In most closed injuries, attempted closed reduction and immobilization is the initial treatment for stabilization of these fractures. Postreduction fracture alignment evaluation with a focus on residual fracture displacement at the articular surface and the physis combined with residual angulation will guide further treatment after closed reduction. Discussion of commonly occurring distal tibia physeal fracture patterns includes treatment-specific recommendations for Salter-Harris type II distal tibia fractures, medial malleolar physeal fractures, and transitional distal tibia physeal fractures including triplane fractures and Tillaux fracture patterns. Treatment recommendations include intraoperative considerations covering surgical approach, reduction techniques, and fixation options for specific fracture patterns. Surgeons should be knowledgeable about the role of skeletal maturity assessment when deciding acceptable fracture alignment, treatment strategies, follow-up, and physeal monitoring. Pertinent topics in the discussion of complications include the occurrence rate and clinical relevance of posttraumatic physeal arrest, as well as rates of further complications for specific fracture patterns and how these are influenced by surgical intervention.

Bone density, structure, and estimated strength in children with congenital heart disease. A CHAMPS* cohort study.

Opening Wedge Distal Tibial Osteotomy.

Fracture risk estimates can be used clinically to inform treatment decision-making in osteoporosis. Current fracture risk assessment tools have a low sensitivity in predicting fractures in males. This study aims to evaluate and validate the performance of a new fracture prediction tool - the Microarchitecture Fracture Risk Assessment Calculator (FRAC) - in a multi-centre cohort (MrOS) of older community-dwelling men. The performance of FRAC was assessed in a population of 1586 men aged $\geq 77$ years in the US. All participants underwent HR-pQCT scanning (61 m) of the distal radius and distal tibia. Incident fracture information was collected every 4 months from the study visit. The FRAC 5-year and 10-year risk of major osteoporotic fracture (MOF) and any osteoporotic fracture (AOF) was calculated for all participants. The model calibration was assessed by fitting Fine Gray competing risk regression models. The model discrimination was assessed using receiver operator characteristic curves (ROCs) and area under the curve (AUCs). Over the 10-year follow-up period, 129 men experienced an incident major osteoporotic fracture. The FRAC models showed good generalizability of the 5-year risk estimates (regression slope 0.8-1.1) to MrOS cohort. The FRAC models displayed an improved model performance (AUC = 0.685-0.703) relative to reference models of FRAX (AUC = 0.641) and FN aBMD alone (AUC = 0.636) for the 5-year MOF risk estimates. A sub-analysis on individuals classified as moderate risk by FRAX (10-20% MOF risk) found that FRAC aided in stratifying risk, particularly for the 5-year risk estimates (FRAC AUC = 0.691-0.706). The FRAC models demonstrated strong performance and generalizability to an external cohort of older men. This validation of FRAC suggests its potential use as an alternate assessment tool for osteoporotic fracture risk and may have value in targeting moderate-risk subgroups to aid treatment decisions.

Objective : To present the results of the management of Gustilo and Anderson type IIIB open fractures of both bones of the leg in the Surgery department of the Ouahigouya Regional University Hospital Center (CHUR-OHG). Methodology : A retrospective descriptive study was conducted on patients admitted for type IIIB open fractures of both leg bones and treated between January 1, 2022 , and June 30, 2024, at the CHUR-OHG. Sociodemographic, clinical, therapeutic, and outcome variables were collected and analyzed. Results: Thirty-two cases were collected. The mean age of the patients was 34.5 ± 3 years. There were 22 men and 10 women, with a male-to-female ratio of 2.2. Road traffic accidents were the main cause (96.88%). According to the AO classification, type A fractures of the distal tibia represented 53.13% of cases, and 60% of fibular fractures were located in the diaphysis. The mean time to treatment was 12.56 hours. Empirical antibiotic therapy was systematically administered, and amoxicillin plus clavulanic acid was the main antibiotic used in 53.12% of cases . Debridement and excision were performed . Tibial fixation was performed in 62.50% of cases, and fibular pinning combined with external fixation in 18.75% of cases. Skin coverage was achieved in 43.75% with a fasciocutaneous flap, in 46.87% with directed healing followed by a skin graft, and in 9.38% with muscle flaps. Complications included infection in 37.50% and nonunion in 25%. The mean time to union was 9.81 months in 26 patients. The anatomical and functional results obtained were generally good (37.50%) and excellent in 15.62% of cases. Conclusion: Gustilo and Anderson type IIIB open fractures of both lower leg bones are frequently encountered in road traffic accidents. Young people were most commonly affected, with a male predominance. Medical and surgical treatment involving debridement and bone stabilization generally yields good anatomical and functional results. The postoperative course was often complicated, with bone infection and nonunion being the main complications. Keywords: Open fracture; Leg; Gustilo IIIB; External fixator; Complications.

Medial plating versus newly designed intramedullary nail with distal interlocking system for distal tibia fractures: A biomechanical study with finite element analysis

Introduction:Complex articular fractures of the proximal (plateau) and distal (pilon) tibia carry a substantial risk of deep surgical site infections (SSIs), often resulting in serious complications and hospital readmissions. The TOBRA study is a multicenter, randomized controlled trial designed to determine if the combination of vancomycin plus tobramycin powder is more effective than vancomycin alone in decreasing the risk of deep SSIs after definitive fixation of these high-risk fractures.Methods and Analysis:Adults aged 18–80 years with at least one risk factor for infection (eg, open fracture, fasciotomy) are randomized 1:1 to receive either 1 gram of vancomycin alone or 1 gram of vancomycin plus 1.2 grams of tobramycin applied directly into the wound at the time of closure. The primary outcome is a deep SSI requiring surgery within 182 days of fixation, adjudicated by an expert panel blinded to treatment allocation. Secondary outcomes include infection subtypes (gram-negative, culture-negative), wound complications, and adverse drug reactions. The study uses Bayesian Cox regression to evaluate the primary end point, with superiority defined as a posterior probability greater than 0.95. The trial will enroll 1550 participants across sites in the Major Extremity Trauma Research Consortium (METRC). Findings will help guide antibiotic prophylaxis strategies in orthopaedic trauma patients at high risk of infection.Ethics and Dissemination:Ethical approval has been granted by the Pearl Institutional Review Board, the Department of Defense Human Research Protections Office, and the local Institutional Review Board at each participating site. Alongside journal publications, dissemination activities include sharing results with participating trial sites and patients and data sharing (upon reasonable request) with researchers.

Introduction: Giant cell tumor of bone typically arises from the epiphysis of long bones; involvement of the distal tibia is a relative rarity, especially in adolescents. While this tumor is benign, GCTB may behave quite aggressively with recurrence or even pulmonary metastasis. The case below describes the natural history of a distal tibial GCTB that was complicated by recurrence and lung metastasis, detailing the use of multiple modalities of management. Case presentation: A 17-year-old female patient presented with an eight-month history of progressive swelling and pain in the left ankle. Imaging showed an expansile lytic lesion in the distal tibia; biopsy confirmed GCTB. She then underwent wide excision with reconstruction using a fibular graft and talofibular arthrodesis. Two years later, during surveillance imaging, pulmonary nodules consistent with metastasis were shown; she was thus treated with monthly intravenous zoledronic acid, 4 mg for six months. In 2019, a local recurrence was detected and treated with curettage and augmentation with bone cement. On follow-up in 2021, the patient had no pain, was fully ambulatory, and was without further recurrence or metastatic progression. Discussion: Distal tibial GCTB has a high tendency for recurrence despite adequate resection due to the poor soft-tissue cover surrounding it. Though pulmonary metastasis is rare, the case indicates the importance of long-term thoracic surveillance. Zoledronic acid in this case contributed to the radiological stabilization of metastatic lesions and thus appears as a possible adjunct in recurrent or metastatic GCTB. Conclusion: This case illustrates the indolent course of the distal tibial GCTB and represents an example of tailored multi-modality treatment with extended follow-up. Zoledronic acid may offer effective disease stabilization to a highly selected patient population at high risk. Keywords: Giant cell tumor, progression, recurrence, distal tibia, fibular graft, arthrodesis

Background/Objectives: Mueller–Weiss syndrome (MWS) is a rare condition characterized by spontaneous adult-onset osteonecrosis of the navicular bone. This study aimed to assess the diagnostic value of quantitative and semi-quantitative standardized uptake value (SUV) measurements on Tc-99m MDP SPECT/CT for differentiating MWS from other foot pathologies. Methods: We retrospectively reviewed 21 MWS patients who underwent SPECT/CT and compared them with 10 feet from 5 non-MWS patients as controls. MWS severity was staged using the Maceira classification. Volumes of interest (VOIs) were defined in the lateral navicular and distal tibia. SUVmax values were measured for the navicular bone (N), tibial metaphysis (Tm), and diaphysis (Td). Uptake ratios (N/Tm and N/Td) were calculated for semi-quantitative comparison. Results: MWS patients showed significantly higher SUVmax in the navicular compared with controls (9.2 vs. 1.5, p < 0.001). Both N/Tm and N/Td ratios were also significantly elevated (p < 0.001). SUVmax and uptake ratios positively correlated with Maceira stage and visual navicular uptake intensity. Diagnostic thresholds of N SUVmax > 3.77 (AUC = 0.93), N/Tm > 1.139 (AUC = 0.95), and N/Td > 0.93 (AUC = 0.93) effectively distinguished MWS from non-MWS cases. Conclusions: Quantitative and semi-quantitative SUV analysis on SPECT/CT offers a reliable tool for diagnosing MWS and evaluating disease severity. Semi-quantitative ratios, by normalizing metabolic variability, provide a practical and reproducible alternative to absolute SUV measurements for early detection and treatment planning in MWS.

Introduction Total ankle arthroplasty (TAA) can be associated with postoperative difficulties during the rehabilitation phase. A unified, tailored approach to rehabilitation and postoperative care is essential for the patients.The objective was to evaluate clinical effectiveness of the algorithm developed for postoperative management of TAA patients to improve functional recovery, reduce postoperative complications for greater patient satisfaction. Material and methods The study included 28 patients with impaired distal tibia and the ankle. The surgical treatment performed after a comprehensive examination included segmental resection of the distal tibia and ankle replacement of the original design. The implant had an articulating ankle joint and the distal tibia replacement. The algorithm developed for postoperative rehabilitation relied on a six-level approach borrowed from rehabilitation guidelines for total ankle arthroplasty devised at the Massachusetts General Hospital. Results Postoperative management included multimodal analgesia with a regional component, multi‑level prophylaxis of infection, antithrombotic protection and staged immobilization with early controlled loading. Primary wound healing was observed in all patients. The mean postoperative swelling measured with the visual swelling scale decreased from (3.8 ± 0.6) to (0.9 ± 0.4) scores after six weeks. Dorsiflexion measured (20 ± 3)°, plantar flexion was (36 ± 4)°, and 100 % of patients could regain a stable biphasic gait pattern at 16 weeks. Discussion There are few detailed protocols for postoperative care and rehabilitation of TAA patients. The algorithm offered showed the effectiveness with the gait being almost normal with the range of motion and strength restored at four months. Patients reported high satisfaction measured with functional scales and subjective quality of life assessment. Conclusion The step-by-step six-phase algorithm developed for postoperative management and rehabilitation of patients treated with segmental tibia resection and TAA facilitated a lower risk of postoperative complications, reduced function recovery time and high satisfaction ratings.

Both bone and muscle function decline with age and are anatomically and functionally related. However, whether and to what extent muscle function (ie, strength and power) may predict longitudinal changes in bone microarchitecture and strength is unclear. The Osteoporotic Fractures in Men (MrOS) Study included assessments of peak jump power (W) from a force plate and maximum grip strength (kg) from a dynamometer, both normalized to body weight at Visit 4 (2014-2016). We investigated associations of jump power and grip strength with annual % change in volumetric bone mineral density (BMD), microarchitecture, and strength at the distal tibia (DT) and radius (DR) from high-resolution peripheral quantitative computed tomography (HR-pQCT) between Visit 4 and Visit 5 (2020-2022; 6.2 ± 0.6yr follow-up; N = 225; age 82.8 ± 3.0yr; 89% White). Mean jump power was 22.9 ± 5.6W/kg and grip strength was 0.49 ± 0.1kg/kg. During follow-up (median[IQR]), failure load (-0.88[-1.71,-0.31]%), total BMD (-0.57[-1.12,-0.18]%), cortical BMD (-1.24[-2.03,-0.67]%), trabecular BMD (-0.05[-0.47,0.20]%), and trabecular thickness (-0.37[-0.64,-0.12]%) declined at the DT, while at the DR, failure load (-1.02[-2.19,-0.04]%), total BMD (-0.64[-1.20,-0.18]%), and cortical BMD (-1.38[-2.15,-0.71]%) declined (all p≤ .05). Significant increases were observed for total area at both skeletal sites (DT: 0.04[0.01,0.08]%; DR: 0.07[-0.06,0.16]%; both p≤ .05). Multivariable linear regression models were adjusted for age, White race, clinic site, respective HR-pQCT initial values, % weight change, alcohol consumption, medication count, chronic disease history, falls, and hip pain. Higher grip strength was significantly associated with a smaller %/year increase in total area at the DT (p≤ .05) but not at the DR. Neither jump power nor grip strength were associated with change in failure load, BMD, or trabecular thickness at either skeletal site. Associations between grip strength and changes in tibial bone geometry provide insight into potential mechanisms for bone loss and targets for musculoskeletal interventions to reduce fracture risk.

Limited research is available on the bone health of female warfighters graduating from combat leadership courses like the US Army Ranger Training Course since combat roles opened to women in 2015. This investigation aimed to characterise the bone density, microarchitecture and strength of a small cohort of these female elite warfighters (FEW) to aid in understanding the physical resilience necessary for women to succeed in such courses. FEW (n=11) were assessed for body composition and whole-body areal bone mineral density (aBMD) and content (BMC) by DXA, bone microarchitecture at two distal tibia sites by high-resolution peripheral quantitative CT (HR-pQCT) and health and lifestyle outcomes by survey. Two female comparison cohorts (CC) of Army basic combat trainees were matched (3:1), to provide context to the FEW. FEW were similar to CC1 and CC2 in height, and lower in body fat (p<0.05). FEW whole-body aBMD and BMC were higher than CC1 (both p<0.01, Cohen's D=0.233 and 0.785, respectively). HR-pQCT measures demonstrated greater total density (13.4%; p=0.01), bone volume fraction (12.9%; p=0.03) and 26.0% higher estimated failure load (p<0.01) in the FEW compared with CC1 at the metaphysis. At the diaphysis, FEW tibiae had 10.2% higher estimated compressive stiffness and 10.3% higher estimated failure load (both p<0.05) than CC2 with no differences in other bone health measures. Lifestyle and health factors were similar between groups. Greater BMC and more favourable bone properties at the distal tibia were observed in the FEW compared with basic combat trainees, supplementing previous findings of exceptional body composition of women graduating from elite combat leadership courses. Considering the prevalence of BSI in female warfighters, further study is warranted to determine how bone status affects probability of course success.

The management of recurrent clubfoot (RCF) in children of walking age is challenging, especially when secondary anatomic changes such as talar flattening are present. The purpose of this study was to report our experience with the use of anterior distal tibial hemi-epiphysiodesis (ADTH) in children with RCF and fixed equinus, to evaluate clinical and radiographic outcomes, and to compare our results with the available literature. This is a retrospective review of 14 patients (20 distal tibiae) treated with ADTH at our pediatric orthopedics referral institution between September 2021 and November 2022. The mean age at surgery was 10.1 years, and the mean follow-up was 23.7 months. Preoperative anterior-posterior (AP) and lateral radiographs and annual postoperative AP and lateral weight-bearing radiographs were reviewed to assess anterior distal tibial angle (ADTA), screw spread angle (SSA), and the correlation between SSA and ADTA variation. Clinical assessment was performed by measuring maximum ankle dorsiflexion and using the AOFAS scale. Complications were also recorded. Preoperative mean dorsiflexion was -7.1 ± 7.5 ° with negative values indicating plantarflexion. At final follow-up, mean dorsiflexion was 1.8 ± 8.2 °, with a statistically significant mean correction rate of 8.9 ± 11.14 °. Final ADTA and SSA showed 12.8 ± 8.4 ° (P < 0.001) and 20.8 ± 16.9 ° (P < 0.005) of improvement, respectively. There was also a good correlation (r = 0.642) between the change in SSA and the change in ADTA. Plate and screws were removed in 1/20 cases (5%). ADTH in patients with RCF and fixed equinus reduces pain, minimizes equinus, and improves SSA and ADTA with limited complications.

Methotrexate (MTX) is one of the most commonly used therapeutic agents for rheumatologic inflammatory diseases and is generally considered a safe medication. Its negative effects on bone mineral density and the occurrence of fractures were first described as side effects of high-dose MTX in pediatric cancer patients. MTX-associated osteopathy in adults receiving moderate or low doses of MTX (up to 25mg/week) for rheumatic musculoskeletal disorders remains a controversial topic. The pathogenesis and clinical significance of MTX-associated osteopathy are still incompletely understood. Clinically, it presents as atraumatic stress fractures of the distal or proximal tibia and the calcaneus, most often in elderly women with longstanding rheumatic musculoskeletal diseases, particularly rheumatoid arthritis (RA) and reduced bone mineral density. Its characteristic hallmark remains the imaging finding of band- or meander-shaped fractures along the growth plate, which are commonly multiple. The diagnosis is challenging and requires the exclusion of other causes of lower limb pain. Moreover, overlapping risk factors for insufficiency fractures are common and should be carefully investigated. The diagnosis must be made with caution, as the clinical consequences are discontinuation of MTX. In this paper, we describe four female patients with RA who presented with stress, meander-shaped fractures of the calcaneus and tibia (two with multiple fractures), showing rapid clinical improvement after MTX discontinuation, which can be attributed to MTX-associated osteopathy. Additionally, we performed a systematic review of this condition, focusing on its most common clinical and radiological features, as well as the effects of MTX on bone mineral density and fracture risk.

Despite the large number of scientific publications currently available on the variability of human morphological traits during different periods of ontogenesis, interest in this type of research continues. The aim of this study was to identify the characteristics of somatometric parameters in modern children aged 8–12 years living in the Moscow region. Materials and methods. Anthropometric measurements were taken from 228 children aged 8–12 years, attending a Moscow school. Using calibrated instruments, length, girth, and width measurements, as well as skinfold thickness on the trunk and limbs, were measured. Results. New data were obtained on the characteristics of anthropometric parameters in schoolchildren aged 8–12 years of both sexes. In both groups of boys and girls, body weight, length, girth, and width measurements increase according to the physiological laws of growth and development as they move from one age group to another, older one. The increase in skinfold thickness is not directly related to age; The level of body fat in children aged 9–12 years of both sexes did not differ. No significant differences were found between boys and girls within the same age group for body length, body weight, waist and hip circumference, or body mass index, indicating similar morphological characteristics of physical development in children who have not yet reached puberty. Compared to boys, the girls group showed significantly greater heights at the sternal, radial, styloid, digital, pubic, and tibial points, indicating longer legs in the girls group.The diameters of the distal femur and tibia are larger in boys; no differences were found for other diameters. The circumference measurements and the difference between the tense and relaxed arm circumferences were higher in boys across all age groups. Conclusion. It has been shown that more rapid changes between the ages of 8–12 years occur during growth processes associated with an increase in body length. The values of the WG are independent of growth processes, indicating an individual level of body fat.

Introduction:Fractures involving the distal third of both bone leg are one of the common long bone fractures with significant concern owing to the amount of soft-tissue damage incurred and poor prognosis with respect to fracture fixation.Aim:The aim of the study is to evaluate whether fibula fixation is necessary along with internal fixation of extra-articular distal tibia fractures by comparing the clinico-radiological and functional outcome of patients of extra-articular distal third tibia fractures with fibula “fixed” and fibula “not fixed” group.Materials and Methods:A prospective cohort study with a sample size of 30 patients was conducted in Sri Ramachandra Institute of Higher Education and Research between March 2023 and May 2024. Fibula fixation was done in one group, and the fibula was not fixed in the control group. Research methodology includes radiological evaluation for coronal and sagittal plane malalignment, Radiographic Union Score for Tibial fractures (RUST) scoring, and clinically, rotational malalignment and presence of post-operative infection. All cases were followed up for a minimum duration of 6 months to assess union of tibia fractures in both groups.Results:Tibial bone union rate was better in the fibula not fixed (control) group compared to the fibula fixed group (P = 0.032), confirmed by the RUST scoring (P = 0.047), which was statistically significant.Conclusion:There was no significant improvement with additional fibula fixation in the healing of distal tibia fractures, but rather causes greater morbidity in terms of wound infections and delayed healing of the tibia. This clearly demonstrates that fibula fixation in extra-articular distal tibia fractures when the fracture does not affect the syndesmosis or ankle mortise is not necessary, and is associated with a higher risk of tibial non-union.

Hexapod external fixation for treating joint displacement and soft tissue contractures in mistreated ankle fractures: a case series.

Stabilization of the distal fibula and tibia to enable elongation-free healing of the ruptured syndesmotic ligaments. Unstable syndesmotic injuries. Unstable syndesmotic injuries in combination with an ankle fracture. Subacute or chronic syndesmotic injury in combination with another procedure (debridement, fibular osteotomy, new osteosynthesis, ligament reconstruction). Soft tissue infection. Stabilization of the distance between the fibula and tibia after repositioning using astrong suture cord, which is fixed to the cortex of the tibia and fibula via two buttons. The cord-button construct is inserted minimally invasively under image intensifier control. Two weeks of partial weight bearing with 15 kg weight, rigid ankle joint orthosis (walker) for 6weeks, accompanied by physical therapy. The results published to date demonstrate with strong evidence that cord-and-button fixation is superior to screw fixation in terms of clinical scores, correct reduction, and reoperation rates. This applies both to isolated unstable syndesmotic injuries and to syndesmotic injuries combined with fibula fractures. Another advantage of this surgical technique is that implant removal is not necessary in most cases. The disadvantage of this procedure is the high implant cost.

Tibia pilon fractures are complex injuries associated with ankle articular cartilage damage and soft tissue compromise. Modern circular external fixation methods are useful in their surgical management, especially for open fractures, severe soft tissue injury, fracture patterns with bone loss or compromise, severe cartilage loss, and certain patient factors. Surgical techniques involve ring block concepts, strategic distal tibia wire placements, hexapod fixators with software-guided bone alignment, and other uses of circular external fixation including ankle joint distraction, augmentation of internal fixation to create integrated constructs, intentional limb deformation for soft tissue defects, bone transport, and primary arthrodesis. Circular external fixation has comparable and sometimes favorable outcomes versus all internal fixation techniques and can be the treatment of choice for certain complex pilon cases.

Circular frame management of distal tibial fractures; 15 years of practice in a tertiary referral unit.