Tibial Fractures Research Articles

Combined Coronary Artery Bypass Grafting and Orthopedic Fixation in a Patient with Multiple Comorbidities: A Case Report

Background: Coronary artery disease (CAD) is a prevalent cardiovascular condition and leading cause of morbidity and mortality worldwide. The management of orthopedic injuries requiring surgical fixation is particularly complex in patients with comorbidities such as diabetes mellitus (DM) and hypertension (HTN). Coordinating the sequence, timing, and execution of coronary artery bypass grafting (CABG) and orthopedic fixation requires careful consideration of the patient’s overall health, surgical risks, and recovery potential. Case presentation: A 55-year-old male presented with a right distal tibial fracture following a fall. His medical history included HTN, type 2 diabetes mellitus (T2DM), and Kyrle’s skin disease. During his hospital stay, he was diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI). Severe multivessel CAD was confirmed by catheterization. After interdisciplinary consultation, simultaneous CABG and open reduction and internal fixation (ORIF) of the tibial fracture were performed. He was discharged in good condition and showed positive recovery during a one-month follow-up. Discussion: This case highlights the complexities of managing patients with multiple comorbidities who require both cardiac and orthopedic surgeries. This simultaneous approach allows for efficient treatment, leading to a shorter hospital stay and recovery period. This report supports the feasibility and benefits of simultaneous surgery in complex clinical scenarios, although further studies are required to establish broader guidelines. Conclusion: Our case emphasizes the importance of a multidisciplinary approach for managing patients with multiple comorbidities who require concurrent surgical intervention. Preoperative planning and specialty coordination ensured optimal outcomes. Further research is needed to develop standardized guidelines for intraoperative care of patients undergoing simultaneous procedures.

Novel perspectives on early diagnosis of acute compartment syndrome: the role of admission blood tests

Abstract Purpose The role of admission blood indicators in patients with acute compartment syndrome (ACS) remains debated. Our primary purpose was to observe variations of admission blood indicators in patients with ACS, while our secondary goal was to explore potential biomarkers related to ACS. Methods We collected information on patients with tibial fracture between January 2013 and July 2023, and divided them into ACS and non-ACS groups. Propensity score matching (PSM) analysis was performed to lower the impact of potential confounding variables such as demographics and comorbidities. Admission blood indicators were analyzed using univariate, logistic regression, and receiver operating characteristic (ROC) curve analyses. Then, we established a nomogram prediction model by using R language software. Results After propensity PSM analysis, 127 patients were included in each group. Although numerous blood indicators were found to be relevant to ACS on univariate analysis, logistic regression analysis showed that monocytes (MON, p = 0.015), systemic immune-inflammation index (SII, p = 0.011), and creatine kinase myocardial band (CKMB, p < 0.0001) were risk factors for ACS. Furthermore, ROC curve analysis identified 0.79 × 109/L, 1082.55, and 20.99 U/L as the cut-off values to differentiate ACS patients from patients with tibial fracture. We also found that this combination had the highest diagnostic accuracy. Then, we constructed a nomogram prediction model with AUC of 0.869 for the prediction model, with good consistency in the correction curve and good clinical practicality by decision curve analysis. Conclusions We found that the levels of MON, SII, and CKMB were related to ACS and may be potential biomarkers. We also identified their cut-off values to separate patients with ACS from those with tibial fracture, helping orthopedists promptly evaluate and take early measures. We established a nomogram prediction model that can efficiently predict ACS in patients with tibial fracture.

Tibial Malalignment is an Independent Predictor of Nonunion After Intramedullary Nailing of Tibial Shaft Fractures

OBJECTIVES: This study aimed to assess the relationship between postoperative alignment and nonunion in patients with tibial shaft fractures treated with intramedullary nailing. METHODS: Design: Retrospective case-control study. Setting: Single academic trauma center. Patients Selection Criteria: Adult patients with closed or open tibial shaft fractures (42A-C) treated with intramedullary nailing from 2007 to 2018. Outcomes Measures and Comparisons: Case patients with nonunion were compared to control patients with radiographic evidence of healing in terms of the postoperative tibial alignment measured in the coronal and sagittal planes. RESULTS: Of the 192 included patients (median age, 38 years; 76% male), 51 patients had a nonunion, and 141 patients had united fractures and served as the control group. A strong association between postoperative tibial malalignment in one plane and nonunion (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.1 to 8.3; P = 0.03) was demonstrated. This association was even greater for malalignment in both coronal and sagittal planes (OR, 5.7; 95% CI, 2.1 to 16.1; P < 0.001) after controlling for confounders. CONCLUSION: After controlling for confounding factors, postoperative malalignment in the coronal or sagittal plane was associated with significantly increased odds of tibial shaft nonunion after intramedullary nailing Level of Evidence: Therapeutic, Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of the Tobacco Heating System (THS) During Closed Lower Limb Fracture Healing in Trauma Smokers’ Patients

BACKGROUND: Since 1976, it's been recognized that increased cigarette consumption correlates with decreased bone density, hindering fracture healing and leading to prolonged hospitalization. Although prior research has shown the relatively less harmful effects of electronic nicotine delivery systems (ENDS) on bone cells in lab settings and animal models, clinical evidence regarding their impact on fracture healing remains scarce. This study aims to investigate whether switching to a tobacco heating system (THS) post-orthopedic surgery improves outcomes for smoking patients during tibia or femur fracture healing over a 6-month period. METHODS: The study is a prospective, open-label, non-parallel, single-center trial involving 150 patients from a Level 1 Trauma center, Germany, diagnosed and treated for closed tibia, closed femur shaft, or closed distal femur fractures (according to AO/OTA: 41A2-41C3, 42A-C, 43A-C, 32A-C, 33A2-3, 33B-C). Participants will be categorized into three groups based on smoking behavior: smokers (no intervention), THS (participants switching from cigarettes to THS), and ex-smokers (participants abstaining from cigarettes or ENDS during the study). Clinical, radiological, and laboratory data will be collected during preoperative and postoperative assessments at 6, 12, 18, and 24 weeks. The primary outcome will be the serum concentration of N-terminal propeptide procollagen type 1, a bone formation marker. Secondary outcomes include bone metabolism, healing, immunological, blood count, and clinical parameters. Approval for the study protocol and consent declarations was obtained from the ethics committee of the medical faculty of Eberhard Karls University (724/2022BO1). DISCUSSION: The study results will provide evidence that switching to THS previous orthopedic intervention improves clinical outcomes during closed tibia or femur fracture healing in smokers’ patients due to reduced bone resorption rate consequent to the diminished activity of cigarette smoke-activated osteoclast.

Effect of Ketorolac Administration on the Rate of Nonunion of Operatively Treated Pediatric Long-Bone Fractures

Background: Nonunion is a rare yet serious complication in pediatric fracture healing that can lead to patient morbidity and economic burden. The administration of nonsteroidal anti-inflammatory drugs (NSAIDs) has been associated with an increased risk of fracture nonunion in adults, but data are lacking in the pediatric population. This study examines the relationship between postoperative ketorolac administration and nonunion in operatively managed pediatric long-bone fractures. Methods: A retrospective cohort study was conducted with use of TriNetX, a research network that encompasses data from the United States, Canada, and Western Europe. A total of 462,260 patients from 52 health-care organizations met the inclusion criteria. Patients <18 years old with operatively managed upper or lower-extremity long-bone fractures were included. The exposure of interest was ketorolac administration within 30 days postoperatively between 2003 and 2023. Nonunion was identified and verified with use of the pertinent medical codes. Absolute risks and hazard ratios (HRs) were calculated for both study groups. Significance was set at p < 0.05. Results: After propensity score matching, 48,778 patients were identified per group. The incidence of nonunion was 2.19% in the ketorolac group and 0.93% in the non-ketorolac group (HR, 2.71; 95% confidence interval [CI]: 2.46, 3.21; p < 0.0001). Subgroup analyses demonstrated a higher risk of nonunion in patients with lower-extremity fractures (HR, 3.45; 95% CI: 3.14, 3.75; p < 0.0001) than in those with upper-extremity fractures (HR, 2.11; 95% CI: 1.84, 2.32; p < 0.0001). Among the fracture location subgroups, the greatest HR for nonunion was observed in patients with femoral fractures, followed sequentially by those with tibial and/or fibular fractures, humeral fractures, and radial and/or ulnar fractures. Conclusions: To our knowledge, this is the largest study to date to explore postoperative ketorolac use and nonunion in the setting of operatively managed pediatric long-bone fractures. Nonunion in children was rare, occurring in <1% of all included patients. Ketorolac administration was associated with a 2 to 3-fold increase in nonunion risks, with pronounced implications for patients with lower-extremity fractures, particularly those with femoral fractures. Clinicians should weigh the therapeutic advantages of non-opiate analgesia with ketorolac against the risk of nonunion in order to optimize postoperative pain management and recovery. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of external versus internal fixation for traumatic lower limb fractures in low- and middle-income countries

AimsLower limb fractures are common in low- and middle-income countries (LMICs) and represent a significant burden to the existing orthopaedic surgical infrastructure. In high income country (HIC) settings, internal fixation is the standard of care due to its superior outcomes. In LMICs, external fixation is often the surgical treatment of choice due to limited supplies, cost considerations, and its perceived lower complication rate. The aim of this systematic review protocol is identifying differences in rates of infection, nonunion, and malunion of extra-articular femoral and tibial shaft fractures in LMICs treated with either internal or external fixation.MethodsThis systematic review protocol describes a broad search of multiple databases to identify eligible papers. Studies must be published after 2000, include at least five patients, patients must be aged > 16 years or treated as skeletally mature, and the paper must describe a fracture of interest and at least one of our primary outcomes of interest. We did not place restrictions on language or journal. All abstracts and full texts will be screened and extracted by two independent reviewers. Risk of bias and quality of evidence will be analyzed using standardized appraisal tools. A random-effects meta-analysis followed by a subgroup analysis will be performed, given the anticipated heterogeneity among studies, if sufficient data are available.ConclusionThe lack of easily accessible LMIC outcome data, combined with international clinical guidelines that are often developed by HIC surgeons for use in HIC environments, makes the clinical decision-making process infinitely more difficult for surgeons in LMICs. This protocol will guide research on surgical management, outcomes, and complications of lower limb shaft fractures in LMICs, and can help guide policy development for better surgical intervention delivery and improve global surgical care.Cite this article: Bone Jt Open 2024;5(11):1020–1026.

Are Drains Associated With Infection After Operative Fixation of High-Risk Tibial Plateau and Pilon Fractures?

OBJECTIVES: To determine the association between closed suction drainage and postoperative infection in patients with tibial plateau or pilon fractures. Secondarily, this study assessed if intrawound vancomycin powder modified the association of closed surgical drains with infection. METHODS: Design: Secondary analysis of the Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial (VANCO) trial. Setting: 36 academic trauma centers. Patient Selection Criteria: All patients with high-risk tibia fractures (OTA/AO classification 41B/C or 43B/C) from the VANCO trial were considered. Closed suction drains were placed based on the treating surgeon’s discretion. Patients were randomly assigned to received 1-gram intrawound vancomycin powder in the surgical wound at definitive fixation or the standard infection prevention protocol at each center. Outcome Measures and Comparisons: Deep surgical site infection (SSI) within 6 months. Comparisons were made between patients treated with and without drains. Subgroup analysis also examined the effect of drains in patients with and without intrawound vancomycin powder. RESULTS: Of the 978 study patients, 197 (20%) were treated with drains. Deep infection rates did not significantly differ between patients with or without surgical drains (8% versus 8%, p=0.88). However, intrawound vancomycin powder significantly modified the association of surgical drains on deep SSI (interaction p=0.048). Specifically, patients with drains but no vancomycin powder had the highest deep infection rate (13%; 95% CI, 6% to 19%). When vancomycin powder was used in addition to a drain, deep SSI rates were reduced by 10% (95% CI, 2% to 17%, p=0.01). CONCLUSIONS: This study suggests that closed suction drains after operative fixation of high-risk tibia fractures may not be associated with deep infection in general. However, a secondary analysis raises the possibility that drains are associated with reduced deep infection rates if topical vancomycin powder is used but associated with increased infection rates if vancomycin powder is not used. LEVEL OF EVIDENCE: Level III

External fixation followed by cast immobilization in the management of gustilo-anderson iiia and iiib open tibial fractures

External fixation followed by cast immobilization in the management of gustilo-anderson iiia and iiib open tibial fractures

Evaluating the outcomes of three dimensional printing-assisted osteotomy on treating varus knee deformity from old tibial plateau fractures.

This study aimed to evaluate the outcomes of three-dimensional (3D) Printing-Assisted Osteotomy in treating varus knee deformity from old tibial plateau fractures. The study retrospectively analyzed patients with varus deformity induced by old-tibial plateau fractures between January 2019 and June 2023. All patients utilized 3D printed models for surgical planning. The Lysholm Knee Score (LKS), Visual Analog Scale (VAS) and Knee Society Score (KSS) were measured for functional outcomes. Medial Proximal Tibial Angle (MPTA), Joint Line Convergence Angle (JLCA), Mechanical Axis (%MA), Medial Tibial Plateau Depression (MTPD), and Femorotibial Angle (FTA) were measured for radiological outcomes. 15 patients (12 males and 3 females) were included in this study and followed up for 21.9 ± 8.6 (range, 12 to 28) months. Healing of the osteotomy sites were achieved in all patients at 15.8 ± 1.5 (range, 13 to 18) weeks. The knee varus deformities were significantly corrected as reflected by %MA (2.13 ± 13.1°(range, -20 to 22) versus 57.06 ± 9.8°(range, 41 to 70), p < 0.01), FTA (186.7 ± 3.2°(range, 181 to 193) versus 172.3 ± 2.1°(range, 169 to 175), p < 0.01), JLCA (5.8 ± 1.7°(range, 3 to 8) versus 1.3 ± 0.8°(range, 0 to 3), p < 0.01), and MPTA (5.6 ± 1.2°(range, 3 to 8) versus 1.2 ± 1.1°(range, -1 to 3), p < 0.01). Postoperative knee function showed dramatic improvements as reflected by VAS (4.6 ± 1.6 (range, 1 to 7) versus 0.7 ± 0.9 (range, 0 to 2), p < 0.01), KSS (50.1 ± 16.5 (range, 27 to 88) versus 88.5 ± 5.2 (range, 80 to 95), p < 0.01), and LKS (49.5 ± 10.2 (range, 37 to 69) versus 89.2 ± 2.5 (range, 87 to 94), p < 0.01). 3D printing technology provides a valuable tool for understanding deformities and optimizing osteotomy strategies, thereby improving surgical efficacy and treatment outcomes. Its clinical application is highly recommended.

Progress of fracture mapping technology based on CT three-dimensional reconstruction

Fracture Mapping is a new technology developed in recent years. This technology visually representing the morphology of fractures by overlaying fracture lines from multiple fracture models onto a standard model through three-dimensional reconstruction. Fracture mapping has been widely used in acetabular fracture, proximal humerus fractures, Pilon fracture, tibial plateau fractures, and so on. This technology provides a new research method for the diagnosis, classification, treatment selection, internal fixation design, and statistical analysis of common fracture sites. In addition, the fracture map can also provide a theoretical basis for the establishment of a biomechanical standardized fracture model. Herein, we reviewed various methods and the most advanced techniques for fracture mapping, and to discuss the issues existing in fracture mapping techniques, which will help in designing future studies that are closer to the ideal. Moreover, we outlined the fracture morphology features of fractures in various parts of the body, and discuss the implications of these fracture mapping studies for fracture treatment, thereby providing reference for research and clinical decision-making on bone and joint injuries to improve patient prognosis.

Atypical Tibial Fracture Following Chronic Bisphosphonate Use: A Case Report and Review of the Literature

Atypical Tibial Fracture Following Chronic Bisphosphonate Use: A Case Report and Review of the Literature

Evaluation of factors affecting development of complications in the early surgical treatment of distal tibial epiphyseal fractures

Evaluation of factors affecting development of complications in the early surgical treatment of distal tibial epiphyseal fractures

Functional Outcome of Bicondylar Fractures of Tibia Treated with Bicolumnar Plating and Uni Columnar Plating with CC Screw Fixation

Functional Outcome of Bicondylar Fractures of Tibia Treated with Bicolumnar Plating and Uni Columnar Plating with CC Screw Fixation

Tibial Insufficiency Fracture with Characteristics of an Atypical Fracture: A Rare Case and Literature Review

Background and Objectives: Osteoporosis is becoming more prevalent with the rise in the aging population, leading to the increased use of bisphosphonates for treatment. While these medications are effective in preventing osteoporotic fractures, long-term use has been associated with atypical insufficiency fractures, primarily in the femur. However, atypical fractures in other weight-bearing bones, such as the tibia, have rarely been reported. This study aims to present a case of an atypical insufficiency fracture of the tibia in an elderly female who has been on long-term bisphosphonate therapy and to review treatment outcomes within the context of the current literature. Patient concerns: A 76-year-old female presented with pain in the proximal right tibia, developing two months prior without trauma. She had been receiving long-term bisphosphonate therapy for osteoporosis, initially taking sodium risedronate orally for 4 years, followed by intravenous ibandronate for 10 years. Physical examination revealed localized tenderness, and radiographs showed cortical thickening and a horizontal fracture line in the proximal right tibia. MRI confirmed these findings, along with surrounding edema. The laboratory results were mostly normal, but the bone formation marker osteocalcin was significantly reduced. The patient had a history of insufficiency fractures in the ipsilateral tibia and contralateral femur, previously treated conservatively with teriparatide. A similar conservative approach was attempted but failed, leading to surgical intervention with intramedullary nailing and supplementary plating. At the 8-month follow-up, the patient showed successful fracture union and resolution of symptoms. Conclusion: Long-term use of bisphosphonates, though effective for osteoporosis, can lead to atypical insufficiency fractures, primarily in the femur but also occasionally in the tibia. Clinicians should consider this possibility when patients present with pain in weight-bearing bones without a history of trauma. Prompt diagnosis through thorough history-taking, physical examination, and appropriate imaging is essential to ensure timely management.

Concomitant Factors Associated With Tillaux-Chaput Fractures in Adults: A Case-Control Study.

Tillaux-Chaput fractures (TCFs) consist of fractures of the anterolateral distal tibia. They rarely occur in isolation in adults. When TCFs are missed, there is a risk of chronic pain, instability, and ankle osteoarthritis. This study aimed to identify which factors are related to the presence of TCFs in ankle injuries. A retrospective review of 1134 ankle fractures evaluated between 2013 and 2023 at a level 1 trauma center was performed. Inclusion criteria were patients aged ≥18 years, ankle radiographs and computed tomographic (CT) scan evaluation, and the presence of a TCF confirmed by CT scan. Exclusion criteria were prior ankle surgery, pilon, or distal tibial fractures. A musculoskeletal radiologist and a foot and ankle-trained orthopaedic surgeon classified the TCFs into type 1, an extraarticular avulsion; type 2, a fracture involving the incisura fibularis; and type 3, a fracture with impaction of the anterolateral tibial plafond. A matching control group of ankle fractures without TCF was created with a 1:2 ratio. The following variables were collected: sex, age (<50 vs >50 years), ankle dislocation or subluxation, Weber classification, Maisonneuve fracture, type of medial and posterior malleolar fracture, Lauge-Hansen classification, malleoli involved, and osteochondral lesion of the talus. Multivariate logistic regression was performed to detect which variables had an association with the TCF and their subtypes. P value <.05 was considered significant. A total of 481 ankle fractures had radiographs and CT scans available for evaluation, of which 83 (17.3%) had a TCF. Of these, 44.6% were type 1, 44.6% type 2, and 9.6% type 3. The mean age was 52.2 years; 66.3% were women. Six patients (7.2%) had an isolated TCF. Fifty-eight (69.9%), 50 (60.2%), and 62 (74.7%) ankles had involvement of the lateral, medial, and posterior malleolus, respectively. Age ≥50 years (OR 2.73, 95% CI 1.45-5.14) and pronation external rotation injuries (OR 2.94, 95% CI 1.43-6.06) had a significant association with TCF. Moreover, ankle dislocation or subluxation (OR 3.16, 95% CI 1.11-8.96) and the absence of posterior malleolar fracture (OR 5.97, 95% CI 1.65-21.6) were significantly associated with TCF type 2 and 3. In this study, age ≥50 years and pronation external rotation injuries were the unique independent risk factors for TCF. Furthermore, ankle dislocation or subluxation and the absence of posterior malleolar fractures increased the odds of having a more severe TCF. This study provides insights into the factors associated with TCF and its subtypes during adulthood.

[Translated article] Surgical treatment of ipsilateral bifocal tibial fractures: a challenge for the surgeon

Introduction The association of ipsilateral tibia fractures has a low incidence, being up to 3.2% of total tibia fractures. Currently there is no gold standard regarding the ideal surgical treatment.The objective of this study is to analyze the surgical treatment and the radiographic and functional results, as well as the associated complication rate of ipsilateral bifocal tibia fractures.Material and methods Retrospective observational study in our hospital from 2010 to 2022 of 24 patients who underwent bifocal fracture of the ipsilateral tibia. Demographic and surgical data and complications during follow-up were included.Results The 24 patients were classified into group 1 when they presented a fracture of the plateau and distal tibia (25%), group 2 with a fracture of the plateau and diaphysis (33%) and group 3 with a fracture of the diaphysis and distal tibia (42%). 3 patients underwent surgery with 1 implant and 21 patients with 2 implants. The average follow-up time in outpatient clinics was 2 and a half years. At one year, 22 patients (92%) had full weight bearing and 2 patients had partial weight bearing (8%) due to the sequelae of the fractures. The average time for consolidation of the diaphysis was 7.75 ± 2 months, with no significant differences observed between group 2 and group 3 (p = 0.06). The average time for consolidation of the metaphysis was 3.50 ± 1.5 months, with no significant differences observed between group 1 and group 2 (p = 0.065). 7 patients (30%) had complications during follow-up.Conclusions Bifocal tibia fractures can be treated using a combination of intramedullary nailing and plate osteosynthesis with good long-term results, obtaining an optimal union rate and low complications. In addition, it facilitates the reduction of the fracture, thus facilitating the patient's recovery and obtaining good long-term functional results.

Prediction of Fractures After Open Wedge High Tibial Osteotomy Based on the Distance From the Tibial Osteotomy Point to the Medial Edge of the Tibia

ObjectiveTo investigate the relationship between the distance from the medial tibial osteotomy point to the medial tibial edge and the development of lateral tibial hinge fracture (type II) and intra-articular tibial plateau fracture (type III) in patients who have degenerative disease undergoing open wedge high tibial osteotomy (OWHTO). This information will aid surgeons in avoiding the occurrence of fractures. MethodsThis retrospective study analyzed 304 patients who underwent OWHTO from January 2018 to January 2024 in the Affiliated Hospital of Qingdao University. The distance from the tibial osteotomy point to the medial tibial edge on imaging was analyzed to determine its association with fracture. A one-way analysis of variance was used to compare the differences in height, weight, body mass index (BMI), the distance from the medial tibial osteotomy point to the medial tibial edge, sex, left and right sides of the knee, and osteoporosis in the occurrence of type II and type III fractures. Receiver operating characteristic curves were used to identify the critical distances associated with type II and type III fractures. Logistic regression analysis was used to obtain the odds ratio (OR) of the critical distance adjusted for age, sex, left and right sides, BMI, and T value. ResultsThere were 40 fractures (13.3%) in 304 patients after OWHTO, comprising 21 type II fractures (7.0%) and 19 type III fractures (6.3%). A single-factor variance analysis showed that the tibial bone cutting distance to the medial tibial edge (P = 0.02) and osteoporosis (P = 0.01) were significantly different from the fracture. Receiver operating characteristic curves showed that the critical distances for type II and type III fractures were 40.5 and 47.1 mm, respectively. Logistic regression analysis showed that the ORs of type II and type III fractures were 1.061 (95% CI [confidence interval] = 1.010 to 1.115) and 1.064 (95% CI = 1.011 to 1.119), respectively. ConclusionIn patients undergoing OWHTO, the risk factors for type II and III fractures are osteoporosis and the distance from the tibial bone cutting point to the medial tibial edge. This distance should be minimized during OWHTO to avoid type II and III fractures.

Influence of custom dynamic orthoses on tibiotalar joint reaction force and contact Stress: A cadaveric study

Post-traumatic osteoarthritis (PTOA) often develops following tibial pilon fractures. Evidence suggesting PTOA development is driven by elevated articular contact stress from residual malreduction has led surgeons to strive for precise articular reduction, typically at the cost of extended operative time. Post-operative bracing using carbon fiber custom dynamic orthoses (CDOs) offers another means to decrease tibiotalar joint reaction force (JRF) and contact stress. The purpose of this cadaveric study was to measure how CDO stiffness influences ankle JRF and contact stress over the stance phase of gait.A servohydraulic load frame was used to test five cadaver ankles, with axial loading (240–330 N) and pneumatic actuation of the Achilles tendon (50–436 N) serving to quasi-statically model multiple points in the stance phase of gait. Three CDO rotational stiffness conditions were tested: (1) No CDO–0 Nm/deg, (2) low stiffness CDO–1.8 Nm/deg, and (3) moderate stiffness CDO–2.3 Nm/deg. JRF and contact stresses were measured using a piezoresistive pressure sensor inserted into the tibiotalar joint. An insole plantar pressure sensor placed between the cadaveric foot and CDO footplate measured limb/device interactions via the plantar center of pressure (COP).As limb loading progressed through stance, the plantar COP progressed from hindfoot to forefoot, as it would in normal gait. Both CDOs demonstrated decreases in JRF, reaching as high as 32% for the low CDO and 26% for the moderate CDO, with associated decreases in contact stress. This suggests that post-operative bracing could lessen PTOA risk after pilon fractures.

Evaluation of an Active Rehabilitation Program With Early Weightbearing and No Immobilization After Tibial Tubercle Distalization

Background: Abnormal patellar height (patella alta) has been reported to be one of the main predisposing factors for recurrent patellar dislocation, and it can be surgically corrected by distalizing tibial tubercle osteotomy (DTTO). Rehabilitation after DTTO often includes limitations on weightbearing and restrictions on knee range of motion by means of bracing, increasing the risk of slow progression of the rehabilitation. Hypothesis: An active rehabilitation program with no restrictions on weightbearing and range of movement would yield a low risk of postoperative complications and a fast recovery period. Study Design: Case series; Level of evidence, 4. Methods: Included were 102 consecutive knees in 80 patients who underwent DTTO between January 2010 and December 2017. In the majority of knees (89.2%), the patient underwent simultaneous medial patellofemoral ligament reconstruction. The mean age of the patients at the time of surgery was 19.39 ± 8.02 years, and 80.4% of the knees (82/102) were of female patients. The patients underwent an active rehabilitation program with immediate weightbearing as tolerated and active quadriceps and hip muscle exercises with no immobilization or bracing. The protocol was active (patient unsupervised), including daily exercises, as instructed by a physical therapist. Crutches were recommended for the first 3 to 4 weeks. Results: There were 3 acute failures of fixation (2.9% of knees) requiring revision surgery. In these cases, the patients had a fall, slip, or knee-twisting accident during the first 6 weeks after surgery. Two late failures characterized by tibial stress fracture at the distal part of the osteotomy level occurred at 2 and 3 months postoperatively and were considered unrelated to the early rehabilitation process. The stress fracture rate was 2%, and the overall DTTO failure rate was 6.9%. With the active rehabilitation program, adverse effects such as knee stiffness, arthrofibrosis, or delayed ability to perform daily activities were rare. Conclusion: An active rehabilitation program after DTTO was found to be safe and effective. Furthermore, the risk of failure related to surgical fixation strength and of later stress fracture was low.

Commentary on "Fixation of Proximal Tibial Fractures with Intramedullary Nail and Immediate Weightbearing: A Beneficial Alternative"

Commentary on "Fixation of Proximal Tibial Fractures with Intramedullary Nail and Immediate Weightbearing: A Beneficial Alternative"