Tibial Fragment Research Articles

Prone position fibula nail and tibia buttress plate for large Volkmann fracture-dislocations technical note and preliminary results on a short case series

Large posterolateral tibial fragments, known as Volkmann fractures, are common in ankle fracture-dislocations and typically require open reduction and fixation with interfragmentary screws and often buttress plates using a prone posterolateral approach. In this setting, fibula plating often necessitates dissection of the lateral window between the peroneal tendons and the skin, increasing wound-related complications. In recent years, intramedullary nailing of fibula fractures has gained popularity as a minimally invasive technique that allows load-sharing stabilization. However, this procedure has traditionally been performed in the supine position, which can pose challenges if a Volkmann-type fracture is present, requiring repositioning and losing access to the fibula through the posterolateral approach. Our objective is to describe a technique for fixing ankle fracture-dislocations with large posterolateral fragments using tibial buttress plates and fibula nails through a prone posterolateral approach without dissecting the lateral window. Additionally, we will present a case series with preliminary results.

The meniscotibial ligament does exist: An anatomic and histological description

PurposeTo describe the anatomical and histological characteristics of the human MTL (meniscotibial ligament) that keeps the meniscus stable and are rarely discussed. Study designDescriptive laboratory study. MethodsIn total, six fresh-frozen adult cadaver knees were dissected, and the dissection protocol were designed by two experienced anatomy professors. The anatomical morphology of MTL was observed. The main anatomical specimens included meniscus, tibial plateau, MTL. The osteotome was used to excise the portion of the tibial plateau, which could obtain the complex including partial meniscus, MTL, and a tibial fragment. A histopathologic study was performed by two experienced pathologists. ResultsMacroscopically, the MTL could be divided into two parts: medial meniscotibial ligament (MMTL)and lateral meniscotibial ligament (LMTL). The MMTL is distributed continuously, whereas the LMTL is discontinuous on the tibial plateau. The average length from the tibial attachment of the LMTL to the articular surface was 19 ± 1.0mm (mean ± SD). The average length from the tibial attachment of the MMTL to the articular surface was 10 ± 1.2 mm (mean ± SD). Microscopy of the MTL showed that the MTL is a ligamentous tissue, composed of a network of oriented collagenous fibers. ConclusionsIn all knees, the MTL was inserted on the outer edge of the meniscus, attaching to the tibia below the level of articular cartilage, which was key to maintaining the rotational stability of knee and the meniscus in the physiological position on the tibial plateau. Histological analysis of this ligament demonstrated that the MTL is a veritable ligamentous structure, which is made up of collagen type I–expressing fibroblasts. Clinical relevanceThis article contributes to the understanding of the anatomical and histological characteristics of the MTL. It is beneficial to promote the development of relevant surgical techniques for the MTL lesion.

Use of Tibial Cortical Autograft for the Osteotomy Site in Medial Opening-Wedge High Tibial Osteotomy.

Medial opening-wedge high tibial osteotomy (OWHTO) is a useful treatment option in patients with medial compartment osteoarthritis. Typically, the osteotomy site is filled with material such as autologous bone graft, allograft, or synthetic bone substitute. However, all these options have disadvantages. The purpose of this study was to describe tibial cortical autograft as an alternative to conventional graft options. It was hypothesized that the tibial rectangular cortical bone that is removed from the proximal medial cortical surface of the distal tibial fragment longitudinally could be a reliable option for recovery of the gap in the osteotomy area. Cohort study; Level of evidence, 3. A total of 520 patients with medial compartment osteoarthritis who underwent OWHTO between June 2009 and March 2019 were retrospectively analyzed. Patients were divided into 3 groups according to the graft material used to fill the osteotomy site: allograft in group A, iliac crest autograft in group B, and tibial autograft in group C. Bone union, evaluated by radiographs performed at 2 weeks, 4 weeks, 2 months, 3 months, 6 months, and 1 year postoperatively, was defined as occurring when at least 50% of the gap site was bridged with callus. Clinical assessment was performed using the International Knee Documentation Committee (IKDC) and Lysholm scores. Included were 122 patients: 40 patients in group A, 42 patients in group B, and 40 patients in group C. The mean correction was 13.87°± 3.58° in group A, 12.33°± 3.92° in group B, and 14.10°± 2.99° in group C. The mean time for radiological bone union was 6.95 ± 1.40 months in group A, 4.48 ± 1.02 months in group B, and 5.07 ± 1.70 months in group C. Patients in all groups had similar IKDC and Lysholm scores at the final follow-up. This is the first report of this specific procedure in the literature. All clinical and radiological findings showed that use of tibial cortical autograft was an efficient method in patients undergoing OWHTO.

Difference in the anterior displacement of the tibial tuberosity relative to the proximal tibial fragment between opening wedge and closed wedge high tibial osteotomies.

This study aimed to investigate the anterior-posterior (AP) displacement of the tibial tuberosity (TT) and to assess the difference between closed wedge and opening wedge high tibial osteotomies (OWHTO and CWHTO). One hundred consecutive knees with osteoarthritis that underwent OWHTO (50 knees) or CWHTO (50 knees) were investigated retrospectively. The femorotibial angle (FTA) was measured on AP radiographs of the knee. AP displacement of the TT, posterior tibial slope (PTS), the modified Blackburne-Peel index (mBPI), and the modified Caton-Deschamps index (mCDI) were measured on lateral radiographs of the knee. Patients had a mean correction angle of 12.58±2.84° and 18.98±5.14° (P<0.001), with a mean AP displacement of TT of 0.84±2.66mm and 7.78±3.41mm (P<0.001) in OWHTO and CWHTO, respectively. The AP displacement of the TT per correction of 1° was significantly greater in CWHTO than in OWHTO (P<0.001). A significant correlation was found between the correction angle and AP displacement of the TT in CWHTO (r=-0.523, P<0.001), but not in OWHTO. The change of PTS per correction of 1° was significantly greater in OWHTO than in CWHTO (P<0.001). The changes of mBPI and mCDI per correction of 1° were significantly greater in CWHTO than in OWHTO (P<0.001 and P<0.001, respectively). There was greater anterior displacement of the TT in CWHTO than in OWHTO, which was correlated with the correction angle. The results suggested that CWHTO would be better than OWHTO when a concomitant anteriorization of TT is required.

Results of Surgical Treatment of Ankle and Posterior Malleolus Fractures Using Different Surgical Techniques

Background. Almost half of the patients with ankle fractures have fracture of the posterior malleolus. Conclusions of the existing studies are contradictory and do not provide a decisive answer to the question of the need for fixation of the posterior tibial fragment.&#x0D; Aim of the study — to compare the radiologic and functional outcomes of osteosynthesis of the posterior tibial fragment in unstable ankle fractures using closed reduction and minimally invasive technique and direct open reduction using posterolateral and posteromedial surgical approaches.&#x0D; Methods. Prospective multicenter study enrolled 132 patients with complex ankle and posterior malleolus fractures. They were divided into three groups depending on the technique of fixation of posterior tibia. Functional and radiologic results of treatment were assessed at 12, 24, and 48 weeks after osteosynthesis. The AOFAS and Neer scales were used.&#x0D; Results. Bone union occurred in all patients at an average of 8.3±0.8 weeks after surgery. Analysis of postoperative CT scans showed that the use of posterior approaches provided statistically significantly more precise reduction of the fragments of posterior tibia. Functional results of patients of the second (posterolateral approach) and third (posteromedial approach) groups at 24 and 48 weeks of follow-up were statistically significantly superior to those of the first group. The median AOFAS score at 48 weeks of follow-up was 86 for group 2 patients and 90 — for group 3. The median scores on the Neer scale were 88 and 94 points respectively.&#x0D; Conclusion. Posterior approaches in the surgical treatment of patients with complex ankle and posterior malleolus fractures allow for more precise fragment open reduction compared to closed one. These patients also show better mid-term functional outcomes.

Mind the Anterior Tibial Tendon in Oblique Distal Third Tibial Fractures with Anterior Inferior Proximal Spike: A Case Report.

An oblique fracture of the distal third of the tibia, treated nonoperatively in a 14-year-old adolescent boy, did not unite because of ensnarement of the anterior tibial tendon (ATT) around an anterior inferior bony spike from the proximal tibial fragment. Computed tomography scan with 3-dimensional volume rendering aided in preoperative diagnosis. Surgical extraction of the tendon from within the fracture site and internal fixation led to successful union and full painless function. Beware of possible ATT entrapment as a cause of irreducibility of oblique distal third tibial fractures with an anterior inferior bony spike of the proximal fragment.

Analysis of the Ability of a Distal Tibial Anatomical Locking Plate to Capture the Distal Tibial Fragments in Patients with Pilon Fractures.

Although pilon fractures are rare in clinical practice, they are difficult to treat because of their complexity. Effective fixation of the fracture fragment is the key to the treatment of pilon fractures. Plate osteosynthesis is common clinically, but there are many types of plates and the evaluation of the effect of fixation plates is not comprehensive. This study attempted to compare the capture effect of different fixation plates on the fracture fragments based on 3D modeling and fine distinctions of fracture fragments. The computed tomography (CT) images before treatment of 127 patients with pilon fractures from January 2019 to December 2021 were retrospectively collected. The fracture lines were mapped and digitally displayed as 3D images using MIMICS 21 software. APLUS distal tibia anatomical locking plate (Plate A) and ZIMMER distal tibia anatomical plate (Plate B) were placed on a pseudo-bone model and CT scans were used to determine the number of screws in the major and minor fragments of pilon fractures. The frequency of the two plates capturing the fracture fragments was recorded. Under Assumption 1 or 2, Plate A performed significantly better than Plate B in capturing the major, Chaput, Volkmann, medial malleolus, and die-punch fracture fragments. Plate A captured markedly more minor fragments than Plate B under Assumption 2 but was not significantly different from Plate B under Assumption 1. Plate A or Plate B showed no obvious difference between major and minor capture rates under the same assumption, and A1 or B1 showed a markedly higher capture rate compared with A2 or B2. In addition, there was a significant positive correlation between the major capture rate and the major fragments in B1, and a significant negative correlation between the minor capture rate and the minor fragments in Plates A and B. However, there was no correlation between the major capture rate of Plate A and the major fragments. The APLUS distal tibial anatomical locking plate is superior to the ZIMMER distal tibia anatomical plate in the ability to capture distal tibial fragments in pilon fracture cases.

Techniques for Fixing Anterior Cruciate Ligament Tibial Avulsion Fractures in Multiligament Knee Injuries

Background: In patients with multiligament knee injuries, anterior cruciate ligament (ACL) tears are often reconstructed. Recent studies have shown good results when the ACL tibial avulsions are repaired. The advantages of ACL tibial avulsion repair are the preservation of the native anatomy, reduction in donor site morbidity, and lower risk of tunnel convergence. Indications &amp; Technique Description: We show 2 techniques for repairing ACL tibial avulsion fractures. The first case describes the use of hybrid fixation (screw and suture), with staged repair and reconstruction in a patient with high-energy knee fracture-dislocation. The second case describes the use of suture ACL repair via tunnels in a patient with a low-energy knee dislocation and an ACL tibial avulsion fracture. When repairing ACL tibial avulsion fractures, screw fixation is recommended for larger tibial fragments. In smaller comminuted fragments, tying sutures passed through the ACL via tibial tunnels may be more appropriate. Results: Several studies have demonstrated good postoperative results in patients following the fixation of ACL tibial avulsion fractures. Both screw and suture fixation are effective methods of repairing ACL tibial avulsion fractures and have similar postoperative outcomes. It has been found that screw fixation is associated with a higher risk of subsequent surgery and implant removal than suture fixation. Conclusion: The repair of ACL tibial avulsion fractures in multiligament knee injuries is an alternative to ACL reconstruction that demonstrates excellent postoperative patient outcomes, good patient satisfaction, and good return to sports. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form.

Two-staged management of ankle fracture-dislocations with a posterior fragment: computer-tomography-based classification, treatment and its outcome.

Trimalleolar fractures are difficult to treat and malreduction can lead to functional impairment. Involvement of the posterior malleolus has a poor predictive value. Current computed-tomography (CT)-based fracture classifications led to an increase in fixation of the posterior malleolus. The aim of this study was to describe the functional outcome after a two-stage stabilisation with direct fixation of the posterior fragment in trimalleolar dislocation fractures. In a retrospective study, all patients presenting with a trimalleolar dislocation fracture, an available CT scan, and a two-stage operative stabilisation including the posterior malleolus by a posterior approach were included. All fractures were treated with initial external fixator and delayed definitive stabilisation including fixation of the posterior malleolus. Next to clinical and radiological follow-up, outcome measures (Foot and Ankle Outcome Score (FAOS), Numeric Rating Scale (NRS), Activity of Daily Living (ADL), Hulsmans implant removal score) and complications were analysed. Between 2008 and 2019, of 320 trimalleolar dislocation fractures, 39 patients were included. Mean follow-up was 49months (standard deviation (SD) 29.7, range 16-148). Mean age was 60years (SD 15.3, 17-84) with 69% female patients. The mean FAOS was 93/100 (SD 9.7, 57-100), NRS 2 (interquartile range (IQR) 0-3) and ADL 2 (IQR 1-2). Four patients showed a postoperative infection, three re-operations had to be performed and implants were removed in 24 individuals. A two-stage procedure of trimalleolar dislocation fractures with in-direct reduction and fixation of the posterior tibial fragment through a posterior approach leads to good functional outcome scores with a low rate of complications.

Early presence of Homo sapiens in Southeast Asia by 86–68 kyr at Tam Pà Ling, Northern Laos

The timing of the first arrival of Homo sapiens in East Asia from Africa and the degree to which they interbred with or replaced local archaic populations is controversial. Previous discoveries from Tam Pà Ling cave (Laos) identified H. sapiens in Southeast Asia by at least 46 kyr. We report on a recently discovered frontal bone (TPL 6) and tibial fragment (TPL 7) found in the deepest layers of TPL. Bayesian modeling of luminescence dating of sediments and U-series and combined U-series-ESR dating of mammalian teeth reveals a depositional sequence spanning ~86 kyr. TPL 6 confirms the presence of H. sapiens by 70 ± 3 kyr, and TPL 7 extends this range to 77 ± 9 kyr, supporting an early dispersal of H. sapiens into Southeast Asia. Geometric morphometric analyses of TPL 6 suggest descent from a gracile immigrant population rather than evolution from or admixture with local archaic populations.

A Tillaux Fracture and Concurrent Nondisplaced Salter-Harris Type III Fracture of the Distal Fibula: A Case Report

The Salter-Harris classification system categorizes pediatric fractures in relation to the physis. A Salter-Harris type III fracture occurs from the physis extending to the epiphysis. Tillaux fractures are a type of Salter-Harris type III fracture that occurs due to incomplete fusion of the growth plate and includes the anterolateral tibial epiphysis. This specific fracture is unique to adolescents due to the anterior tibiofibular ligament's strength in relation to the growth plate, causing avulsion of the tibial fragment. The settings for a Tillaux fracture and a Salter-Harris type III fracture are uncommon due to the mechanism of injury, and it is incredibly rare to have two separate fractures of these classifications in the same ankle. In this case study, a 16-year-old male presented to the emergency department after sustaining trauma to the right ankle via a skateboarding accident. Initial radiographs showed no evidence of acute fracture, and CT imaging was performed. CT scan of the right lower leg found a Tillaux fracture of the distal right tibia with a 2 mm displacement and a nondisplaced Salter-Harris type III distal fibula fracture. Closed reduction and percutaneous screw fixation of the distal tibia fracture were performed. The repair of this fracture was complicated due to the presence of two distinct fractures. This case study aims to provide a viable option to successfully repair this complex presentation as well as explain imaging findings that differentiate this fracture from other pathologies that are not managed operatively.

Posteromedial Buttress Plate for Schatzker 6 Fractures as Double Column Fixation

Objective: Treatment of Schatzker Type 6 fractures is to use a posteromedial buttress plate as part of a double-column fixation technique. Materials &amp; Methods: The design of this study was a cross sectional study design and this study was conducted in DHQ Teaching Hospital Gujranwala. patients with posterior medial fracture of Schatzker type 6 and having associated damage of some soft tissue present within the joint underwent surgery at our institutional operation theatre. In this Study setting we included total 20 patients (14 male [70%] and 6 females [30%]) who came with Bicondylar fractures having Comminuted Posteromedial Fragments of tibia. Results: Of the Patients, 12 (60%) had excellent results, 5(25%) had good results , and 3 (15%) had fair results. In total, 17 patients (85%) achieved cheering results. Walking, Stability, and motion were good or excellent in all cases. Practical Implication: One of the main advantages of the posteromedial buttress plate fixation technique is that it provides support to the medial column of the tibia, which is an important weight-bearing structure in the lower extremity. By restoring the structural integrity of the medial column, the technique can help promote early weight-bearing and facilitate early rehabilitation. All displaced posteromedial tibial plateau fractures should be surgically stabilized and buttressed using plate to restore joint congruity and prevent late subluxation and early arthritis. The aim is to study the role of posteromedial plating in the management of complex tibial plateau fractures with a posteromedial fragment Conclusion: Use of a posteromedial buttress plate as part of a double-column fixation technique can be an effective approach for treating Schatzker Type 6 fractures. Keywords: Fixation of Posterior Column, Buttress plate, Schatzker 6 fracture

Early results of intramedullary nail fixation in distal tibia oblique osteotomy for the reduction of soft tissue complications.

During distal tibial oblique osteotomy, external fixators can increase pin site infection risk, whereas plates can cause wound necrosis, necessitating a compromise between soft-tissue position and length. We provide the first report of the early results of intramedullary nail fixation in these osteotomies for avoiding soft tissue complications. Ten ankles, classed as Takakura-Tanaka stages 3a to 4 and unclassified and treated via distal tibial oblique osteotomy for ankle osteoarthritis between 2017 and 2021, were included. Osteotomy was performed obliquely from the distal medial tibia to the tibiofibular joint. The distal tibial fragment was rotated distally in the coronal plane for realignment. An intramedullary nail fixation was applied for stabilization. The resulting gap was filled with iliac bone graft. Ankles were evaluated on the Japanese Society for Surgery of the Foot ankle-Hindfoot Scale and Self-Administered Foot Evaluation Questionnaire before surgery and at final follow-up. Radiographic assessments were performed. Bone union was achieved within 3 months in all patients. There were no cases of wound necrosis or correction loss postsurgery. Japanese Society scale scores significantly improved from 40.3 ± 15.9 to 87.5 ± 12.6 (P < 0.01). Mean self-evaluation scale scores (pain and pain-related, physical functioning and daily living, social functioning, general health and well-being) improved significantly. shoe-related scores did not change significantly but improved. There was no correction loss after surgery, with an average widening of 24.2 mm and opening angle of 22.6° at the osteotomy site. Our study showed that intramedullary nail for fixation of the osteotomy site in distal tibial oblique osteotomy effectively prevents soft tissues complications even in osteotomy sites with large openings.

Comparison of patellar position and moment arm between tibial plateau leveling osteotomy and cranial closing wedge ostectomy: An ex vivo study.

Tibial plateau leveling osteotomy (TPLO) and cranial closing wedge ostectomy (CCWO) are common treatments for cranial cruciate ligament disease. These two techniques mainly differ in whether the proximal tibial fragment contains the attachment site of the patellar ligament. Currently, no reports compare how these techniques affect the patellofemoral joint. This ex vivo study aimed to compare the effects of TPLO and CCWO on the patellar position and moment arm in healthy Beagles. TPLO and CCWO were performed on each stifle in six cadavers of Beagles. Pre- and postoperative mediolateral radiographs with the stifle angle at approximately 90° were obtained. The modified Blumensaat index (MBI), patellar ligament length to patella length ratio (PLL:PL), and patellar moment arm (PMA) were measured in each radiograph. Mixed-model multiple regression analyses for the MBI, PLL:PL, and PMA, with the surgical procedure as the independent variable, were then performed. The joint angle was included as an independent variable for MBI and PMA. The PLL:PL was decreased after TPLO. Additionally, the PLL:PL after TPLO was significantly lower than that after CCWO. The MBI decreased with flexion. Postoperative MBI values were reduced for both procedures, with lower values after CCWO than after TPLO. The PMA values decreased with flexion. Postoperative values for both methods were reduced in the PMA, with the values being lower after CCWO than after TPLO. Both TPLO and CCWO affect the patellofemoral joint. Compared with TPLO, CCWO produced more excellent downward traction on the patella. Therefore, CCWO may be used to correct the patellar alta and treat cranial cruciate ligament disease.

Fibular Fixation in Same-Level Distal Third Tibiofibular Fractures: Is Fibular Fracture Regarded as a Secondary Importance?

Although most studies focused on the alignment or union of the tibia in same-level distal third tibiofibular fractures, the outcome of a concomitant fibular fracture is generally regarded as being of secondary importance in the literature. This study aimed to assess the outcomes of fibular fractures in same-level distal third tibiofibular fractures. In this retrospective study, we enrolled 111 patients with same-level distal third tibiofibular fractures treated at our institute between January 2016 and August 2020. Tibial fractures were stabilized with intramedullary nailing, and the cases were divided into two groups based on whether they additionally underwent fibular fixation (group 1, 57 cases) or not (group 2, 54 cases). Clinical and radiographic outcomes were used for the evaluation of tibial and fibular alignments, union of the tibia and fibula, number of interlocking screws in the distal tibial fragment, range of motion of the ankle joint, and complications. No statistically significant differences in the tibial union rate or mean tibial alignment were observed between the two groups on either the immediate postoperative or final radiographs. The fibular union rate in group 1 was significantly higher than that in group 2 (fibular nonunion, 0 vs. 15; p < 0.001). Statistically significant differences in fibular displacement were observed on immediate postoperative radiographs between patients with fibular union and those without it. At the final follow-up, the mean range of ankle motion and lower extremity functional scale scores did not differ between the two groups. Regardless of whether fibular fixation was performed, the overall tibial alignment with intramedullary nailing was well restored and the union rate of the tibia was comparable in the two groups. Fibular nonunion is not uncommon in unfixed fibula fractures. Displacement of the fibula as seen on immediate postoperative radiographs was related to fibular nonunion.

Effectiveness of resisting torsional loads of various options for osteosynthesis of tibial fragments (according to the results of mathematical modeling)

Recently, there has been a trend towards high statistical indicators of the number of bone fractures of the lower limbs(47.3%), of which diaphyseal fractures of the lower leg bones make up 45‒56 %. Objective. Conduct a comparative analysisof the stress-strain state of leg models with a fracture of the tibia under the torsional loading combined with various optionsof osteosynthesis and depending on the patient's weight. Methods. A fracture was modeled in the middle third of the diaphysisof the tibia and three types of osteosynthesis — with the help of an external apparatus fixation (EAF), periosteal plate andintramedullary rod Bones were attached to the tibial plateau torque of 7 Nm and 12 Nm. Results. It was determined thatthe changes in stress levels in bone tissue depend linearly on the patient's weight. Under simulation conditions stabilizationof the fracture with the help of EAF and intramedullary stress rod in the fracture area were found significantly lowerthan the level of indicators of intact bone. In this same zone in the model with a bony plate, the value stress levels were lowerthan the intact model bone, but with an increase in the patient's weight to 120 kg, these indicators almost leveled off. The highest stress level was recorded in the distal part of the tibia in the model with intramedullary rod osteosynthesis, and inthe proximal one, the stresses that exceeded the parameters of the model with intact bone were determined under the conditions use of EAF. The largest in metal structures stress is detected in the periosteal plate. Conclusions. The highest stresses in the fracture zone (5.8‒9.9 MPa) and on the metal structure (360.0‒617.0 MPa) was recorded in a model with a bone plate. In the model with EAF in the zone of the fracture, the stresses were at the level of 0.1‒0.2 MPa, in the proximal part of the tibia — 6.3‒10.8 MPa, in the model with an intramedullary rod — 0.1‒0.2 MPa and 0.5‒0.9 MPa, respectively. In the distal partof the stress in the last model remained high — 11.7‒20.1 MPa.

Posteromedial Approach in Fracture Fixation of Malleoli and Posterior Edge of Tibia

Background. Surgical treatment of malleoli injuries is performed according to the principles of articular fractures management. It is particularly true for ankle injuries involving fractures of posterior edge of the tibia. The posteromedial approach enables to improve the results of surgical treatment of patients due to the direct reduction of tibia fragments.&#x0D; Aim of the study to evaluate the efficacy and advisability of the modified posteromedial approach in patients with unstable fractures of malleoli and posterior edge of the tibia.&#x0D; Methods. Twenty two patients with unstable fractures of malleoli and posterior edge of the tibia underwent surgical treatment via the posteromedial approach. The X-ray control was performed the next day after the surgery as well as 6, 12, 24 and 48 weeks from the osteosynthesis. The functional results were evaluated in 12, 24 and 48 weeks after the surgery with the use of AOFAS and Neer scales.&#x0D; Results. The average duration of postoperative period (9.33.8 days) was mainly determined by the state of the soft tissues. 91% of patients had anatomical reduction of posterior edge fragment of the tibia, 17 (77%) from 22 patients demonstrated fracture consolidation in X-rays 12 weeks after the surgery and all 22 patients (100%) 24 weeks after surgery. There were no cases of postoperative complications in patients 24 weeks after the surgery. While managing patients the range of motion in the ankle joint increased from 41.16.9 12 weeks after the surgery to 57.34.6 48 weeks after the surgery, that was statistically significant (p0.01). The functional results improved as well according to both AOFAS and Neer scales and this improvement was also statistically significant (p0.01).&#x0D; Conclusion. The is rather effective in Patients with unstable fractures of malleoli and posterior edge of the tibia had a statistically significant improvement in function after posteromedial approach.

Two-Step 3D-Guided Supramalleolar Osteotomy to Treat Varus Ankle osteoarthritis.

Success of valgus-type supramalleolar osteotomy (SMOT) depends on adequate correction of malalignment, which can be hard to achieve with current 2-dimensional (2D) planning and operative techniques. A personalized digital 3-dimensional (3D) workflow to virtually plan and perform a 2-step 3D-guided medial opening (MO) SMOT has the potential to improve precision of correction. Computed tomography (CT)-based Proplan medical 3D models were made to virtually plan the desired MO SMOT, and exported to 3-Matic medical to develop patient-specific 2-step cutting and wedge guides. Workflow accuracy was tested in this limited clinical pilot study (3 patients) by comparing the virtual planned position of the osteotomized distal tibial fragment with the 1-year post-MO SMOT configuration. Two millimeters or less translation deviation in every plane was defined as accurate. Primary outcome analysis of the osteotomized distal tibial fragment deviation showed a median translation in all planes of 0.7 (range 0-8.2) mm (interquartile range 1.55) with an excellent interrater reliability of the measurements (intraclass correlation coefficient 0.998). There was a strong reduction in ankle pain as reflected by an increase of the AOFAS-AH score and decrease of NRS pain score with an unrestricted hindfoot motion 1 year after surgery. 3D virtually planned bone cutting and wedge guides is a promising approach associated with minimal postoperative deviation from the desired correction in medial opening supramalleolar osteotomy.

Risk of interference between the tibial tunnel and locking screws in medial meniscus posterior root repair and open wedge high tibial osteotomy

PurposeTo evaluate whether the frequency of interference between locking screws for the plate fixation and tibial tunnels differs depending on the tibial tunnel positions in a surgical simulation of the transtibial pull-out repair of medial meniscus posterior root tears (MMPRTs) in patients undergoing biplanar open wedge high tibial osteotomy (OWHTO).MethodsSixty-five patients (75 knees) who underwent OWHTO with TomoFix small plate (Depuy Synthes, PA, USA) for medial knee osteoarthritis with varus malalignment were enrolled in this study. Surgical simulation of transtibial pull-out repair of MMPRTs was performed using postoperative computed tomography images. The tibial tunnel was created in the anatomical attachment area of the medial meniscus posterior root. Another aperture of the tibial tunnel was created on the anteromedial (AM) tibial cortex, the posteromedial (PM) tibial cortex, and the anterolateral (AL) tibial cortex in the proximal tibial fragment. The frequency of interference between the tibial tunnel and A–D locking screws was compared in the 3 tibial tunnel positions. In each tibial tunnel position, the locking plate position with and without interference between the tibial tunnel and at least one locking screw was compared.ResultsFor screw A, the frequency of interference with the tibial tunnel in the AL position was higher than that in the AM (P = 0.048) and PM positions (P < 0.001). For screws B and C, the frequency of interference with the tibial tunnel in the AM position was higher than that in the PM (P < 0.001, P = 0.007) and AL positions (P < 0.001, P = 0.001), respectively. For screw D, there was no difference in the frequency of interference with the tibial tunnel among the three positions. The frequency of interference between the tibial tunnel and at least one screw in the AM position was 100%, which was higher than that in the PM (P < 0.001) and AL positions (P < 0.001). In the PM position, the locking plate was placed more posteriorly in the group where the locking screw interfered with the tibial tunnel. In the AL position, the locking plate was placed more parallel to the medial/lateral axis of the tibial plateau in the interference group.ConclusionMaking the tibial tunnel in the AM position should be avoided because interference with locking screws was inevitable. When the tibial tunnel is created in the PM position, interference between the tibial tunnel and screw C should be paid attention. Anterior placement of the locking plate could be useful to prevent interference between locking screws and the tibial tunnel in the PM position. In addition, when the tibial tunnel is created in the AL position, interference between the tibial tunnel and especially screw A among screws A–C should be paid attention. Placing the locking plate in an anteromedial direction could be useful to prevent interference between locking screws and the tibial tunnel in the AL position.Level of evidenceIV

Quadrimalleolar Fractures of the Ankle: Principles and Medium-Term Results of Surgical Fixation

Category:Ankle; TraumaIntroduction/Purpose:Over the last decade, much attention has been paid to the fractures of the posterior malleolus as it became obvious that the mere presence of a posterior tibial fragment is associated with a less favorable prognosis in malleolar fractures. It seems logical to pay the anterior restraints of the ankle joint a similar attention as to the posterior ones. The anteriolateral distal tibia may be considered a 'fourth' or anterior malleolus. Here, we present a technique of fixation of trimalleolar fractures with additional fracture of the anterior tibial tubercle ('quadrimalleolar') or anterior fibular rim ('quadrimalleolar equivalent').Methods:Twenty-four patients with a mean age of 60 years were treated with open reduction and internal fixation of all 4 malleoli. There were 17 quadrimalleolar and 6 quadrimalleolar equivalent fractures. One patient had both anterior tibial and fibular avulsion fractures in addition to a trimalleolar ankle fracture. Surgical approaches and internal fixation were tailored individually. Twenty patients were operated in prone position with direct fixation of the posterior malleolus and 4 patients in supine position with indirect anterior to posterior screw fixation of the posterior malleolus under transfibular control of reduction.Results:After fixation of al 4 malleoli, only one patient (4%) required a syndesmotic screw for residual syndesmotic instability on intraoperative testing. There were no infections, and no wound healing problems. All patients went on to solid union. No late fusions were needed. Nineteen patients (79%) could be reevaluated after a mean of 77 months (range, 15 to 156 months) follow- up. The Foot Function Index averaged 15 (range, 50 to 0), the Olerud and Molander Score averaged 79 (range, 45 to 100) and the AOFAS Ankle and Hindfoot Scale averaged 87 (range, 39 to 100).Conclusion:Fixation of the anterior and posterior tibial fragments increases syndesmotic stability by providing a bone-to-bone fixation. Reduction of displaced anterior and posterior tibial rim fractures restores the physiological shape of the tibial incisura and therefore facilitates fibular reduction. In the majority of cases, this also restores articular congruity of the lateral tibial plafond.Anatomic reduction of the anterior and posterior malleolus in addition to medial and lateral malleolar fixation leads to favourable functional results despite a complex (quadrimalleolar) fracture pattern.