Midshaft Tibial Fractures Research Articles

Evaluation of a New Patellar Tendon Bearing Brace With Offloading Monitoring and Adjustability: A Pilot Study.

The patellar tendon-bearing (PTB) brace is a crucial device designed to lessen axial forces on the tibia. The newly designed PTB brace allows clinicians to measure offloading amount in the realtime. This study aimed to explore the relationship between a rise in displacement between the foot plate and calf shells of this new PTB brace and changes in the amount of offloading on the tibia. This pilot study used a sample of five individuals with midshaft tibia fractures to investigate the effectiveness of the PTB brace under different conditions. The PTB brace was tested in six different conditions, with the displacement between the foot plate and calf shells varying in increments of 0.5 cm, from 1 cm to 3.5 cm. The new PTB brace provided varying levels of offloading, ranging from 22% to 38%. As the vertical distance between the calf shells and foot plate increased, the offloading levels also increased significantly. The study observed significant differences in weight reduction (p = 0.02) and offloading percentages (p = 0.048) when comparing 1 cm and 1.5 cm displacement. The findings suggest that maintaining a distance of 1.5 cm or more between the calf shells and foot plate is effective in reducing weight and offloading on the tibia. These results have important implications for clinicians using PTB braces to treat tibia fractures, highlighting the importance of adjusting the displacement of the PTB brace to optimize patient outcomes.

Treatment of coxofemoral dislocation and short oblique mid shaft tibial fracture by modified toggle pin technique with locking compression plate method in a dog

Treatment of coxofemoral dislocation and short oblique mid shaft tibial fracture by modified toggle pin technique with locking compression plate method in a dog

Evaluation of Radiological and Functional Outcomes of Closed Complex Mid-shaft Tibia Fractures Treated with Primary Definitive All Wire Ilizarov Ring Fixator: A Prospective Study at Tertiary Care Centre of Nepal.

Introduction: Closed complex tibial shaft fractures are frequently encountered fractures in lower limb injuries. Various surgical methods for these fractures include primary or delayed fixation with intramedullary nails, minimal invasive plates, and primary definitive external stabilization using ring fixators. We conducted this study to evaluate the radiological and functional outcomes of primary definitive fixation of these fractures using an all-wire Ilizarov circular fixator. Objectives: The objectives of this study were to evaluate the radiological and functional outcomes of primary definitive fixation of closed complex tibial mid-shaft fractures in patients with compromised soft tissue status. Methodology: We defined Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) 42-B1 to AO/OTA 43-C3 fractures as complex tibial shaft fractures for this prospective observational study, and evaluated all 26 patients for the functional and radiographical progression according to ASAMI classification. Results: Twenty-six patients were stabilized with an all-wire circular ring fixator. The union time on average was 27.61 weeks. Among all patients, 7 (37.5%) cases had minor pin tract infections, and one (2.7%) patient landed a non-union, which required bone graft. Conclusion: With the use of an all-wire Ilizarov circular frame, there is a good mean time to union, fewer chances of re-operations, and good functional outcomes without any major complications.

A delay in flap coverage of open midshaft tibia fractures increases complications: A retrospective study

Background: This retrospective study aimed to assess whether delaying flap coverage in open midshaft tibia fractures leads to higher infection rates. Methods: Patients were recruited retrospectively from a tertiary trauma database between 2012 and 2020. Patients included were over 18-years old and had an open tibia fracture that required flap coverage with at least 6 months follow-up. The collected complications were deep infections, aseptic non-union, flap failure and revision surgery. Results: Group-A ( n = 18) and Group-B ( n = 37) were analysed. Deep infections rate was 6% in Group-A and 38% in Group-B which was significantly different, χ2(1, N = 55) = 6.4, p = 0.01. The rate of revision surgery was 17% in Group-A and 54% in Group-B and was significant, χ2(1, N = 55) = 7, p = 0.008. Binary logistic regression showed that Group-B were 10 times more likely to develop a deep infection (95% confidence interval 1.2–83, p = 0.034). Conclusion: Delaying soft tissue coverage of open tibia fractures for over a week increases the risk of deep infection and revision surgery.

Prospective study on functional and radiological outcome of suprapatellar approach for intramedullary nailing using semi extended knee position in tibial shaft fractures

Fractures of the tibia are one of the most common orthopedic injuries occurring most often in younger patients. Tibial fractures are frequently associated with high energy trauma mechanisms. Intramedullary nailing is one amongst the preferred treatment modalities for mid shaft tibial fractures. Standard Tibial nailing entry portals used are the infrapatellar and parapatellar approaches. Suprapatellar tibial nailing is a recent advance in the surgical technique for treatment of tibial shaft fractures. This method has shown reduced operative and fluoroscopy time and lesser pain incidence in previous studies. The semi extended position of the knee also allows for countering the deforming effect of the musculature pull of the quadriceps mechanism and also easier fluoroscopy imaging. The suprapatellar technique decreases the risk of perforation of posterior cortex by placing the starting point in line with the medullary canal. This technique also helps to reduce Varus and Valgus deformity by using the femoral trochlear groove as a guide to the starting point which maintains the mechanical axis of the lower extremity.Objectives of the study: To assess Functional outcomes of suprapatellar approach in mid shaft tibial fractures by Lower extremity functional score (LEFS).To assess Radiological outcomes of suprapatellar approach in mid shaft tibial fractures by the Radiological Union in Tibia Score (RUST).Study design: Prospective interventional studyStudy period: October 2019 to May 2021Source of data: Patients admitted with closed mid shaft tibial fractures as an inpatient in the Department of Orthopaedics, Victoria hospital and Bowring and Lady Curzon hospitals attached to BMCRI were included in the study satisfying the inclusion and exclusion criteriaMethodology: 20 patients with closed or open (type 1 and 2) mid shaft tibial fractures were treated using the suprapatellar approach. Functional outcome was measured using the Lower extremity functional score and radiological outcome was measured using the Radiological union in tibia score at immediate and last follow up intervals.Results: Our study group comprised of 20 patients between the ages 20 to 60 years. LEFS showed a statistically significant improvement from 23.35 at 6 weeks to 69.25 at 12 months. In our study analysis out of 20 patients, 11 patients had excellent LEFS score, 7 patients had good LEFS score and 2 patients had fair LEFS score. Also in our study 100% patients achieved union by 20 weeks with a mean RUST score of 7.4 at 6 weeks compared to a mean RUST score of 14.15 at 12 months.Conclusion: Suprapatellar nailing has shown shorter fluoroscopy less manoeuvrability and operative time, excellent to fair functional outcome of lower limb and reduced incidence of valgus and varus malalignment postoperatively. Suprapatellar nailing is a promising technique of tibial fracture fixation with satisfactory radiological and functional outcomes postoperatively.

Intraoperative fluoroscopic protocol to avoid rotational malalignment after nailing of tibia shaft fractures: introduction of the ‘C-Arm Rotational View (CARV)’

PurposeRotational malalignment (≥ 10°) is a frequent pitfall of intramedullary-nailing of tibial shaft fractures. This study aimed to develop an intraoperative fluoroscopy protocol, coined ‘C-Arm Rotational View (CARV)’, to significantly reduce the risk for rotational malalignment and to test its clinical feasibility.MethodsA cadaver and clinical feasibility study was conducted to develop the CARV-technique, that included a standardized intraoperative fluoroscopy sequence of predefined landmarks on the uninjured and injured leg in which the rotation of the C-arm was used to verify for rotational alignment. A mid-shaft tibia fracture was simulated in a cadaver and an unlocked intramedullary-nail was inserted. Random degrees of rotational malalignment were applied using a hand-held goniometer via reference wires at the fracture site. Ten surgeons, blinded for the applied rotation, performed rotational corrections according to (1) current clinical practice after single-leg and dual-leg draping, and (2) according to the CARV-protocol. The primary outcome measure was the accuracy of the corrections relative to neutral tibial alignment. The CARV-protocol was tested in a small clinical cohort.ResultsIn total, 180 rotational corrections were performed by 10 surgeons. Correction according to clinical practice using single-leg and dual-leg draping resulted in a median difference of, respectively, 10.0° (IQR 5.0°) and 10.0° (IQR 5.0°) relative to neutral alignment. Single-leg and dual-leg draping resulted in malalignment (≥10°) in, respectively, 67% and 58% of the corrections. Standardized correction using the CARV resulted in a median difference of 5.0° (IQR 5.0°) relative to neutral alignment, with only 12% categorized as malalignment (≥10°). The incidence of rotational malalignment after application of the CARV decreased from 67% and 58% to 12% (p = <0.001). Both consultants and residents successfully applied the CARV-protocol. Finally, three clinical patients with a tibial shaft fracture were treated according to the CARV-protocol, resulting all in acceptable alignment (<10°) based on postoperative CT-measurements.ConclusionThis study introduces an easy-to-use and clinically feasible standardized intraoperative fluoroscopy protocol coined ‘C-arm rotational view (CARV)’ to minimize the risk for rotational malalignment following intramedullary-nailing of tibial shaft fractures.

Short term outcome of Gustilo Anderson open type 3A mid shaft tibia fractures using intramedullary interlocking nail and external fixator

Aim: The purpose of the present study is to assess the outcome of treating Gustilo Anderson open Type 3A mid shaft tibia fracture with intramedullary interlocking nail as well as external fixator. Methodology: In this prospective cohort study, adult patients (≥18 years-old) with Gustilo 3A open tibia shaft fractures treated by either intramedullary nail or external fixation (EF) were involved. This study was directed for a period of twelve months from March 2021 to February 2022. After registration, patients were followed-up at 2, 6, 10, 14, and 18 weeks postoperatively. At these appointments, degree of callus formation at fracture site and surgical problems (e.g. infection, limb length discrepancy, malalignment) were assessed. Results: Out of 50 patients registered in the study, 26 were treated by IM nail and 24 by external fixation. Twenty-four patients (92.3%) in the IM nail group and 6 (25%) in the external fixation group had callus formation by the 10th week. The mean times to callus formation in the IM nail group and external fixation group were 8.2±2.6 weeks and 14.7±3.3 weeks, individually (p=0.000). Two (7.7%) patients in the IM nail group and 3 (12.5%) in the external fixation group developed infection (p=0.661).

The bad contretemps causes mid-shaft tibia and fibula fracture with traumatic amputation of 2nd toe: A case report

The bad contretemps causes mid-shaft tibia and fibula fracture with traumatic amputation of 2nd toe: A case report

Big data insights into predictors of acute compartment syndrome

BackgroundThere remain gaps in knowledge regarding the pathophysiology, initial diagnosis, treatment, and outcome of acute compartment syndrome (ACS). Most reported clinical outcomes are from smaller studies of heterogeneous patients. For a disease associated with a financial burden to society that represents billions of dollars worldwide the literature does not currently establish baseline diagnostic parameters and risk factors that may serve to predict treatment and outcomes. MethodsThis study looks at a very large cohort of trauma patients obtained from four recent years of the Trauma Quality Programs data from the American College of Surgeons. From 3,924,127 trauma cases - 203,500 patients with tibial fractures were identified and their records examined for demographic information, potential risk factors for compartment syndrome, an associated coded diagnosis of muscle necrosis, and presence of other outcomes associated with compartment syndrome. A recurrent multiple logistic regression model was used to identify factors predictive of fasciotomy. The results were compared to the reported results from the literature to validate the findings. ResultsThe rate of fasciotomy treatment for ACS was 4.3% in the cohort of identified patients. The analysis identified several clinical predictors of fasciotomy. Proximal and midshaft tibial fractures (P <0.0001) showed highest increases in the likelihood of ACS. Open fractures were twice (O.R [2.20–2.42]) as likely to have ACS. Having a complex fracture (P<0.0001), substance abuse disorder (P<0.0002), cirrhosis (P = 0.002) or smoking (P<0.0051) all increased the likelihood of ACS. Age decreased the likelihood by 1% per year (OR= [0.99–0.993]). Crush and penetrating injuries showed an important increase in the likelihood of ACS (O.R of 1.83 and 1.37 respectively). Additionally, sex, BMI, cirrhosis, tobacco smoking and fracture pattern as defined by OTA group and OTA subgroup had predictive value on actual myonecrosis. Fasciotomies for open tibial fractures were more likely to uncover significant muscle necrosis compared to closed fractures. Amputation resulted after 5.4% of fasciotomies. ConclusionThis big data approach shows us that ACS is primarily linked to the extent of soft tissue damage. However, newfound effect of some comorbidities like cirrhosis and hypertension on the risk of ACS imply other mechanisms.

Optimal location for fibular osteotomy to provide maximal compression to the tibia in the management of delayed union and hypertrophic non-union of the tibia

BackgroundTibial shaft fractures are the commonest long bone fracture, with early weight-bearing improving the rate of bony union. However, an intact fibula can act as a strut that splints the tibial segments and holds them apart. A fibular osteotomy, in which a 2.5 cm length of fibula is removed, has been used to treat delayed and hypertrophic non-union by increasing axial tibial loading. However, there is no consensus on the optimal site for the partial fibulectomy. MethodsNine leg specimens were obtained from formalin-embalmed cadavers. Transverse mid-shaft tibial fractures were created using an oscillating saw. A rig was designed to compress the legs with an adjustable axial load and measure the force within the fracture site in order to ascertain load transmission through the tibia over a range of weights. After 2.5cm-long fibulectomies were performed at one of three levels on each specimen, load transmission through the tibia was re-assessed. A beam structure model of the intact leg was designed to explain the findings. ResultsWith an intact fibula, mean tibial loading at 34 kg was 15.52 ± 3.26 kg, increasing to 17.42 ± 4.13 kg after fibular osteotomy. This increase was only significant where the osteotomy was performed proximal to or at the level of the tibial fracture. Modelling midshaft tibial loading using the Euler-Bernoulli beam theory showed that 80.5% of the original force was transmitted through the tibia with an intact fibula, rising to 81.1% after a distal fibulectomy, and 100% with a proximal fibulectomy. ConclusionThis study describes a novel method of measuring axial tibial forces. We demonstrated that a fibular osteotomy increases axial tibial loading regardless of location, with the greatest increase after proximal fibular osteotomy. A contributing factor for this can be explained by a simple beam model. We therefore recommend a proximal fibular osteotomy when it is performed in the treatment of delayed and non-union of tibial midshaft fractures.

Finite element analysis modeling of plates versus intramedullary nails in closed comminuted midshaft tibial fractures.

Background: Tibial shaft fractures are usually treated by interlocking nails or plates. The ideal implant choice depends on many variables. Aim: To assess the mechanical behavior of interlocking nails and plates in the treatment of closed comminuted midshaft fractures of the tibia using finite element analysis. Material and methods: This is a prospective study of 50 patients with a mean age of 28.4 years with closed comminuted fractures of the midshaft of the tibia. Data evaluation was done by Finite element analysis (FEA). Fixation was revised in two cases. Results: After load application, there were significant differences in both bending (P = 0.041) and strain percent (P = 0.017), reflecting that interlocking nails were superior to plates. There were also significant differences between titanium and stainless-steel materials in bending (p = 0.041) and strain percent (p = 0.017) after applying load, indicating that titanium was superior to stainless steel. Conclusion: Interlocking nails are superior to plates in treating midshaft tibial fractures. The use of blocking screws may be needed in interlocking nails depending on the pattern and extension of the fracture.

To compare the role of hybrid external fixation and MIPO in management of proximal tibial fracture

Background: The proximity to the ankle makes the surgical treatment more complicated than midshaft tibial fractures. The present study compared hybrid external fixation and MIPO in management of proximal tibial fracture. Materials and Methods: 64 cases of proximal tibia fracture of both genders were divided into 2 groups of 32 each. Group I patients were treated with hybrid external fixation and group II with MIPO. Parameters such as operative time, blood loss, hospital stay, healing time etc. were recorded. Results: Group I had 18 males and 14 females and group II had 20 males and 12 females. Operative time (min) was 90.3 and 110.4, blood loss (ml) was 124.7 and 205.2, hospital stay (Days) was 10.2 and 21.0, healing time (Weeks) was 8.2 and 16.7 and time of recovery to work (Days) was 10.4 and 32.1 in group I and II respectively. Conclusion: Hybrid external fixation found to be better than MIPO in management of proximal tibia fracture.

Bacillus Cereus Osteomyelitis in an Athlete: Case Report and Review of the Literature

Bacillus cereus is an aerobic Gram-positive, spore-forming rod, widely distributed in the environment. Although, most commonly known to cause gastrointestinal infections, B. cereus can also cause osteomyelitis and other deep-seated infections. Here we describe the case of an athlete who presented with B. cereus osteomyelitis following surgery for closed displaced mid shaft fracture of tibia and fibula sustained during a football match. The patient had internal reduction and fixation of the fracture; Cephazolin was given as prophylaxis. 9 weeks later he developed osteomyelitis, B. cereus was isolated from specimens collected during surgery which was treated with Teicoplanin and Ciprofloxacin. After initial improvement X-ray showed progressive posterior bone bridge at the site of the fracture and no obvious evolution of the distal aspect of the tibia in comparison with the previous radiography. The patient was then transferred to a referral hospital where he had another surgery to drain the pus and remove the intramedullary prosthesis. At this stage Clostridium aerotolerans and Propionibacterium acne were isolated from the tissues, treated successfully with metronidazole. Bacillus cereus osteomyelitis should be considered in the differential diagnosis for infection following limb trauma. It is prudent to use for prophylaxis Vancomycin or Teicoplanin in such situation instead of Cephazolin to which B. cereus is usually resistant due to the production of beta lactamases.

Intraoperative torsion control using the cortical step sign and diameter difference in tibial mid-shaft fractures.

Intramedullar nailing of tibial mid-shaft fractures is a common surgical treatment. Fracture reduction, however, remains challenging and maltorsion is a common discrepancy which aggravates functional impairment of gait and stability. The use of radiographic tools such as the cortical step sign (CSS) and the diameter difference sign (DDS) could improve fracture reduction. Therefore, the validity of the CSS and DDS was analyzed to facilitate detection of maltorsion in tibial mid-shaft fractures. Tibial mid-shaft fractures were induced in human cadaveric tibiae according to the AO classification type A3. Torsional discrepancies from 0° to 30° in-/external direction were enforced after intramedullary nailing. Fluoroscopic-guided fracture reduction was assessed in two planes via analysis of the medical cortical thickness (MCT), lateral cortical thickness (LCT), tibial diameter (TD), anterior cortical thickness (ACT), posterior cortical thickness (PCT) and the transverse diameter (TD) of the proximal and distal fracture fragment. The TD, LCT and ACT have shown a highly significant correlation to predict tibial maltorsion. While a model combining ACT, LCT, PCT and TD lateral was most suitable model to identify tibial maltorsion, a torsional discrepancy of 15°was most reliably detected with use of the TD and ACT. The present study has shown, that maltorsion can be reliably assessed by the CSS and DDS during fluoroscopy. Thus, torsional discrepancies in tibial mid-shaft fractures can be most reliably assessed in the lateral plane by analysis of the LCT and TD.

Amputation Rates in More Than 175,000 Open Tibia Fractures in the United States.

Open tibia fractures are often associated with considerable soft tissue injuries. Management of open tibia fractures can be challenging, and some patients require amputation. The patient and treatment factors have not been described on a population level in the United States. A retrospective analysis was completed using the 2000 to 2011 Nationwide Inpatient Sample. Amputation rates during the index hospitalization after open tibia fracture were computed based on injury, patient, and hospital characteristics in patients 18 years or older. The overall amputation rate in open tibia fractures during the index hospitalization was 2.2% (n=3769). Patients with midshaft tibia fractures comprised the largest portion of patients undergoing amputation (46.8% of total amputations) compared with distal tibia (34.0%) and proximal tibia (19.3%) fractures. Patients with no neurovascular injury comprised the largest portion of patients undergoing amputation (85.9%), followed by isolated arterial injury (11.1%), combined neurovascular injury (1.9%), and isolated nerve injury (1.1%). Amputation rates were significantly increased for midshaft tibia fractures with neurovascular injury (odds ratio, 12.39; 95% CI, 5.52-27.83) and distal tibia fractures with neurovascular injury (odds ratio, 5.45; 95% CI, 1.73-17.19) compared with tibia fractures with no neurovascular injury while controlling for confounders. On the basis of a review of the Nationwide In-patient Sample during the past decade, the authors have shown that the early amputation rate in open tibia fractures for all-comers is 2.2%. Rates of amputation varied based on fracture site, associated neurovascular injury, medical comorbidities, and hospital location. [Orthopedics. 2021;44(1):48-53.].

Minimally invasive plate osteosynthesis (MIPO) for mid-shaft fracture of the tibia (AO/OTA classification 42): A retrospective study

BackgroundThere is abundance of literature regarding the treatment of tibial mid-shaft fracture, and intramedullary nailing (IMN) is described as the treatment of choice. However, problems such as malunion and knee pain are known disadvantages of this approach. Minimally invasive plate osteosynthesis (MIPO) technique is another treatment option for tibial mid-shaft fracture.The purpose of this study is to evaluate the clinical, radiological results, and complication rates of tibial mid-shaft fractures treated with MIPO technique. Materials and methodThirty-seven skeletally mature patients who underwent MIPO for a mid-shaft fracture of tibia (AO/OTA classification 42) from June 2016 to May 2018 were retrospectively reviewed. A total of 37 patients (12 females, 25 males) with a mean age of 52.7 years (range 28–78 years) were included. The clinical and radiological outcomes, such as the Jeju Lower Extremity Trauma Scale (JLETS), time to callus formation, time to bony union, and complications such as delayed union, malunion, nonunion, and infection were assessed. ResultsBony union was achieved in all cases but one (36 cases). Average callus formation was observed in 10.7 (6.5–14.5) weeks. The average time to union was 19.8 (11.5–26.5) weeks. The average JLETS score was 46.9 (40–53) point. Malunion deformities were observed in 3 cases (8.1%). Two superficial infection cases all resolved spontaneously. There was no statistically significant difference in clinical and radiographic outcomes by different AO/OTA fracture types. ConclusionThe MIPO technique with locking compression plate provides stable fixation and satisfactory clinical and radiological results for mid-shaft fractures of tibia irrespective of the fracture type. Future study should aim to compare MIPO and IMN cases directly to clarify the differences and similarities between the two treatment modalities.

A quantitative serum biomarker of circulating collagen X effectively correlates with endochondral fracture healing.

Currently, there are no standardized methods for quantitatively measuring fracture repair. Physicians rely on subjective physical examinations and qualitative evaluation of radiographs to detect mineralized tissue. Since most fractures heal indirectly through a cartilage intermediate, these tools are limited in their diagnostic utility of early repair. Prior to converting to the bone, cartilage undergoes hypertrophic maturation, characterized by the deposition of a provisional collagen X matrix. The objective of this study was to characterize the kinetics of a novel collagen X biomarker relative to other biological measurements of fracture healing using a murine model of endochondral fracture repair in which a closed, mid-shaft tibia fracture was created using the classic drop-weight technique. Serum was collected 5 to 42 days post-fracture in male and female mice and compared to uninjured controls (n = 8-12). Collagen X in the serum was quantified using a recently validated ELISA-based bioassay ("Cxm")1 and compared to genetic and histological markers of fracture healing and inflammation. We found the Cxm biomarker reliably increased from baseline to a statistically unique peak 14 days post-fracture that then resolved to pre-fracture levels by 3 weeks following injury. The shape and timing of the Cxm curve followed the genetic and histological expression of collagen X but did not show a strong correlation with local inflammatory states. Assessment of fracture healing progress is crucial to making correct and timely clinical decisions for patients. This Cxm bioassay represents a minimally invasive, inexpensive technique that could provide reliable information on the biology of the fracture to significantly improve clinical care.

Patella Fracture Fixation Via Wide Awake Local Anesthesia No Tourniquet (Walant) Technique

Introduction:Fracture of the tibia are the most common long bone fracture, with an incidence greater than 75,000 per year in the US1. With the recent breakthrough of operation under WALANT (Wide Awake Local Anaesthesia No Tourniquet) technique. We reported a patient with midshaft tibia fracture who underwent plating under the WALANT techniqueMethodology:18 yearold gentleman sustained a closed fracture of his left tibia after his motorbike skidded. He wascounselled for the surgery to be done under the wide-awake technique as we have limited operating theatre time for the case to be done under general/regional anaesthesia. Preoperatively, the WALANT solution is prepared using 50 cc lidocaine 2%, 1cc of epinephrine, 10cc of sodium bicarbonate 8.4% then dilute into 50 cc normal saline. Total of 50 cc WALANT solution was injected along the planned skin incision and at subperiosteum 30 minutes before operation started.Result:Pain score patient remain 0-3/10 during and after removal of backslab, throughout the surgery and postoperatively. The use of epinephrine for hemostasis provide good surgical field view since there is minimal bleeding. Postoperatively the anaesthesia effect lasted for 6 hour and was patient able to move the leg straight away without have to keep lying in bed for 6 hours after spinal or drowsiness from sedation.Conclusion:Plating of tibia under WALANT is a good alternative for patient who have financial difficulty, high risk operation under general anaesthesia, hospital which have limited slot for operation under general anaesthesia and etc. Additionally, the strength and stability of the plate can be assessed intraoperatively by asking the patient to actively move his limb.Reference: Praemer A, Furner S, Rice DP. Musculoskeletal Conditions in the United States. Park Ridge, IL: American Academy of Orthopaedic Surgeons; 1992.

Targeting Adeno-Associated Virus Vectors for Local Delivery to Fractures and Systemic Delivery to the Skeleton

A panel of 18 recombinant adeno-associated virus (rAAV) variants, both natural and engineered, constitutively expressing Cre recombinase under the cytomegalovirus early enhancer/chicken β actin (CAG) promoter, were screened for their ability to transduce bone in Ai9 fluorescent reporter mice. Transgenic Cre-induced tdTomato expression served as a measure of transduction efficiency and alkaline phosphatase (AP) activity as an osteoblastic marker. Single injections of AAV8, AAV9, and AAV-DJ into midshaft tibial fractures yielded robust tdTomato expression in the callus. Next, the bone cell-specific promoters Sp7 and Col2.3 were tested to restrict Cre expression in an alternate model of systemic delivery by intravenous injection. Although CAG promoter constructs packaged into AAV8 produced high levels of tdTomato in the bone, liver, heart, spleen, and kidney, bone-specific promoter constructs restricted Cre expression to osseous tissues. AAV variants were further tested in vitro in a human osteoblast cell line (hFOB1.19), measuring GFP reporter expression by flow cytometry after 72 h. AAV2, AAV5, and AAV-DJ showed the highest transduction efficiency. In summary, we produced AAV vectors for selective and high-efficiency in vivo gene delivery to murine bone. The AAV8-Sp7-Cre vector has significant practical applications for inducing gene deletion postnatally in floxed mouse models.

Targeting adeno-associated viral vectors to fractures and the skeleton

Background & Aim Gene therapy in the context of the bone remains an underdeveloped field, and most approaches have focused on local delivery of therapeutic transgenes. Generating delivery systems capable of affecting the entire skeleton is particularly challenging compared to discrete organs. Viral vectors have great potential as delivery systems for gene editing technology. In particular, adeno-associated viruses (AAVs) have been identified as ideal candidates for gene therapy due to their high efficiency, low immunogenicity, and selective tropism towards different tissues. In this study we aimed to assess a panel of natural and engineered AAV variants for their tropism towards murine bone cells. Methods, Results & Conclusion We screened 18 natural and engineered recombinant AAV (rAAV) variants. AAVs constitutively expressed Cre-recombinase (under a CAG promoter) and transduction efficiency was assessed using a local injection into a murine tibial fracture model using the Ai9 tdTomato Cre reporter mouse line. Fluorescent alkaline phosphatase (AP) staining was used to identify whether transduced cells were osteoblastic. A single injection of rAAV was administered into midshaft tibial fractures at surgery and yielded robust tdTomato expression within the callus at 2 weeks for AAV8, AAV9, and AAV-DJ (Fig. 1a). Next, a model of systemic delivery by intravenous injection into the tail vein of Ai9 mice was performed, with Cre-expression restricted using bone cell-specific promoters Sp7 and Col2.3. At moderate doses (5 × 1011/mouse or ∼2.5 × 1013/kg) tdTomato+ osteoblasts and osteocytes were observed throughout the long bones (Fig. 1b). Minimal tdTomato expression was observed in other tissues including brain, heart, lung, liver, and spleen, indicating both Sp7 and Col2.3 were able to largely restrict Cre expression to bone cells. To summarize, we have identified AAV variants with a high tropism for murine bone cells, and vectors for high efficiency in vivo gene delivery to bone. The AAV8-Sp7-Cre vector has significant practical applications for inducing gene deletion in floxed mouse models in post-natal bone. Future work will validate AAV vectors that enable targeted CRISPR gene editing that have relevance to the treatment of genetic bone disease.