Distal Tibial Fixation Research Articles

Combined two-centre experience of single-entry telescopic rods identifies characteristic modes of failure.

The Fassier Duval (FD) rod is a third-generation telescopic implant for children with osteogenesis imperfecta (OI). Threaded fixation enables proximal insertion without opening the knee or ankle joint. We have reviewed our combined two-centre experience with this implant. In total, 34 children with a mean age of five years (1 to 14) with severe OI have undergone rodding of 72 lower limb long bones (27 tibial, 45 femoral) for recurrent fractures with progressive deformity despite optimized bone health and bisphosphonate therapy. Data were collected prospectively, with 1.5 to 11 years follow-up. A total of 24 patients (33%) required exchange of implants (14 femora and ten tibiae) including 11 rods bending with refracture. Four (5%) required reoperation with implant retention. Loss of proximal fixation in the femur and distal fixation in the tibia were common. Four patients developed coxa vara requiring surgical correction. In total, 13 patients experienced further fractures without rod bending; eight required implant revision. There was one deep infection. The five-year survival rate, with rod revision as the endpoint, was 63% (95% confidence interval (CI) 44% to 77%) for femoral rods, with a mean age at implantation of 4.8 years (1.3 to 14.8), and 64% (95% CI 36% to 82%) for tibial rods, with a mean age at implantation of 5.2 years (2.0 to 13.8). FD rods are easier to implant but do not improve on the revision rates reported for second generation T-piece rods. Proximal femoral fixation is problematic in younger children with a partially ossified greater trochanter. Distal tibial fixation typically fails after two years. Future generation implants should address proximal femoral and distal tibial fixation to avoid the majority of complications in this series. Cite this article: Bone Joint J 2020;102-B(8):1048-1055.

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

PurposeSoft tissue healing is of paramount importance in distal tibial fractures for a successful outcome. There is an increasing trend of using anterolateral plate due to an adequate soft tissue cover on anterolateral distal tibia. The aim of this study was to evaluate the results and complications of minimally invasive anterolateral locking plate in distal tibial fractures. MethodsThis is a retrospective study of 42 patients with distal tibial fractures treated with minimally invasive anterolateral tibial plating. This study evaluates the bone and soft tissue healing along with emphasis on complications related to bone and soft tissue healing. ResultsFull weight bearing was allowed in mean time period of 4.95 months (3–12 months). A major local complication of a wound which required revision surgery was seen in one case. Minor complications were identified in 9 cases which comprised 4 cases of marginal necrosis of the surgical wound, 1 case of superficial infection, 1 case of sensory disturbance over the anterolateral foot, 1 case of muscle hernia and 2 cases of delayed union. Mean distance between the posterolateral and anterolateral incision was 5.7 cm (4.5–8 cm). ConclusionThe minimally invasive distal tibial fixation with anterolateral plating is a safe method of stabilization. Distance between anterolateral and posterolateral incision can be placed less than 7 cm apart depending on fracture pattern with proper surgical timing and technique.

Surgical Technique: Aperture Fixation in PCL Reconstruction: Applying Biomechanics to Surgery

Biomechanical studies suggest reducing the effective graft length during transtibial posterior cruciate ligament (PCL) reconstruction by augmenting the distal tibial fixation with a proximal screw near the tibial tunnel aperture could increase graft stiffness and provide a more stable reconstruction. However, it remains unknown to what extent this mechanical theory influences in vivo graft performance over time. We developed a technique to augment tibial distal fixation with a proximal screw near the tibial tunnel aperture to shorten the effective graft length and increase graft stiffness. We retrospectively reviewed all 10 patients who had isolated PCL reconstructions with combined distal and proximal tibial fixation from 2003 to 2007. Mean age of the patients was 36.5 years. We measured ROM and obtained Tegner, International Knee Documentation Committee (IKDC), and Lysholm scores. Anteroposterior stability was evaluated with a KT-2000 arthrometer. Minimum followup was 1 year (mean, 2.5 years; range, 1-4.8 years). Mean Tegner scores before injury and at last followup were 7.3 and 6.5, respectively. Mean postoperative IKDC score was 87 versus a preoperative IKDC score of 43. Mean Lysholm score was 89 at last followup. All patients achieved full terminal extension. No patient had greater than a 5-mm difference in anterior or posterior displacement from the contralateral knee as measured by a KT-2000 arthrometer postoperatively (0.93 ± 0.79 mm). In this small series, augmentation of tibial distal fixation with a proximal screw near the tibial tunnel aperture during reconstruction of the isolated PCL rupture restored function, motion, and stability. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Biomechanics of Initial Tibial Fixation in Posterior Cruciate Ligament Reconstruction

Clinical success of posterior cruciate ligament (PCL) reconstruction continues to lag behind that of its anterior counterpart. The tibial site of PCL graft fixation has been a focus of recent research. This study examined the effect of combined distal and proximal tibial fixation on the ability of a transtibial PCL reconstruction to restore intact knee kinematics and in situ forces of the intact PCL. Biomechanical study. Ten human cadaveric knees were tested. A 134-N posterior tibial load was applied using a robotic/universal force moment sensor testing system at 0 degrees, 30 degrees, 60 degrees, 90 degrees, and 120 degrees of knee flexion. Each knee was tested under 4 conditions: intact, PCL-deficient, single-bundle transtibial reconstruction with distal tibial fixation, and single-bundle transtibial reconstruction with combined distal and proximal tibial fixation. Knee kinematics in 5 degrees of freedom for each condition were recorded and in situ forces of the intact PCL and the PCL grafts were determined. Reconstruction with combined fixation resulted in significantly less posterior tibial translation than reconstruction with distal fixation at 30 degrees, 90 degrees, and 120 degrees (P < .05), and restored intact knee kinematics at 90 degrees and 120 degrees (P > .05). Reconstruction with combined fixation more closely restored intact PCL in situ forces at 90 degrees (P < .05). Transtibial reconstruction with combined fixation more closely restores intact knee kinematics and in situ forces in the PCL at initial fixation than does reconstruction with distal tibial fixation. The improved kinematics and in situ forces seen with the combined fixation may be attributed to decreased functional graft length and increased stiffness of the PCL graft. Combined tibial fixation may provide a more stable reconstruction at initial fixation.

Mechanical performance of hybrid Ilizarov external fixator in comparison with Ilizarov circular external fixator

Objective. The aim of this study was to determine the stiffness characteristics of the standard and hybrid Ilizarov fixators. Design. Five different frame models (one standard and four hybrid Ilizarov) were designed. Four full rings were used in the standard Ilizarov frame. Two rings were placed proximal and two rings were placed distal to the osteotomy line with two wires at 90° to each other on each ring. The distal tibial fixation of all the hybrid configurations and standard Ilizarov fixator were the same, and only the proximal fixations were different. In hybrid models, different numbers of 90° femoral arches (1–3) were fixed to the proximal segment by using the half-pins with different numbers (2–4) and different angles to each other (45° and 90°). Background. Numerous investigations have been performed to compare the mechanical properties of different frames. The Ilizarov method of fracture fixation and limb lengthening has recently gained international recognition. But its application is difficult in some anatomic localization, so that hybrid ring fixation frames of various configurations are gaining clinical popularity. Methods. Five different frame models were applied to the sheep tibial bones. The midpoint of the tibial bones was osteotomised and the osteotomy distracted for 2 cm. Four identical samples for each model were created and each identical sample of each model ( n=1) were tested four times in axial compression, antero-posterior and medio-lateral bending, and torsion. Results. In standard Ilizarov fixator, axial and bending stiffness was found to be more than all hybrid Ilizarov fixator models. Between the hybrid fixators, higher axial and bending stiffness was found when the number of femoral arches and half-pins were increased. Different angles between the half-pins formed 67% alteration in medio-lateral bending stiffness. No significant difference was found for torsional stiffness between the fixator models. Conclusions. For optimum fixator stiffness in hybrid fixators, at least three femoral arches and four half-pins must be used and these half-pins should be placed at 90° angles and at different planes to each other. However, it should be remembered that, hybrid fixator models had less axial and bending stiffness than standard Ilizarov fixator model. Relevance For optimum fixator stiffness in hybrid fixators, at least three femoral arches and four half-pins must be used. However, it should be remembered that, hybrid fixator models had less axial and bending stiffness than standard Ilizarov fixator model.

Collapsing the tibial bone tunnel in hamstring autograft reconstruction of the anterior cruciate ligament

The use of double staples is an accepted method for fixation of hamstring anterior cruciate ligament (ACL) grafts at the distal tibial site. In the last year, we have modified the 2-staple technique that we have been using for distal tibial fixation of our double loop hamstring ACL autografts. Previously, we had impacted the graft with 2 toothed staples onto the cortex distal to the opening of the tibial tunnel. The modification we report here involves driving the proximal staple into the tibial tunnel roof, thus collapsing the tunnel onto the tendon during fixation. The distal staple is introduced in the usual manner. Clinical follow-up including subjective and objective KT-1000 arthrometry has indicated no difference in the early results compared with the former staple technique. Radiologic follow-up showed tunnel obliteration and filling in the area of the proximal staple, suggesting early graft incorporation in callus. While early results are encouraging, long-term follow-up and pullout studies will be reported. It would appear that collapsing the bony tunnel by the proximal staple may be a simple method of providing fracture callus to increase the stiffness of the tibial graft fixation, with no major or minor complications. Animal experiments are being carried out to objectively define the mechanical advantage of the graft incorporation by callus.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 2 (February), 2001: pp E6–E6