Tibial Shaft Research Articles

Reduction of Operative Time, Intraoperative Radiographs, and Anterior Knee Pain With the Lateral Parapatellar Approach for Tibial Shaft Fracture Nailing: A Case Series.

Background Tibia fracture is a common indication for operative intervention in orthopedics. Usage of Intramedullary nailing provides a minimally invasive technique with good results. Positioning, operative time, and radiation exposure are major points in such cases. This study described the semi-extended lateral parapatellar intramedullary technique as a technique that helps achieve and maintain reduction, simplifies nail insertion, and decreases fluoroscopy and operative time. Methodology This prospective case series study included nine patients with tibial shaft fractures operated at Royal Rehabilitation Center from April to October 2023 by intramedullary nailing and extra-articular lateral parapatellar insertion technique using the semi-extended knee position. Duration of surgery, intraoperative radiation exposure, and anterior knee pain score were assessed for all patients. Results The average duration of surgery was 63.78 ± 5.3 minutes, and the average intraoperative imaging was 94 (85-103). The average union time was 18 ±2 weeks. The mean Kujala score was 90.9% ± 2.3% six months after the surgery. All patients regained a comparable range of motion in their knees and ankles. One patient reported minimal pain at the pin site but did not require any analgesia. Conclusion The lateral parapatellar approach for tibial shaft fracture nailing has the advantage of reducing operative time, the number of intraoperative radiographs, and lower postoperative anterior knee pain. Additionally, this approach did not cause patellar instability.

Gait and strength assessment following surgical repair by intramedullary nailing of isolated tibial shaft fracture.

The objective of the study was to evaluate the long-term strength and gait outcomes after intramedullary nailing of isolated tibial diaphyseal fractures. This retrospective cohort study was conducted at an academic Level I trauma center. Fifteen participants with isolated tibial diaphyseal fractures (OTA/AO 42) at least 2 years postoperative from intramedullary nailing (IMN) provided informed consent. The average age was 40 ± 14 (range, 24-69); there were nine men and six women. Knee flexion-extension strength data were collected. Temporal-spatial, kinematic, and kinetic gait parameters were measured and compared to historic control data. Participants completed the SF-36 and shortened musculoskeletal function assessment questionnaires. The mean length of follow-up between surgery and gait analysis was 6 ± 2 years. The fractured limb demonstrated deficits in quadriceps strength between 9.8% and 23.4% compared to the unaffected limb. Temporal-spatial parameters revealed slower walking speed, shorter stride length, decreased cadence, and shorter single-limb support time in the fractured limb. Altered kinematic and kinetic findings included a knee extension shift during stance, with an increased knee flexor moment demand and decreased total knee power during loading and midstance. These findings represent deficits in concentric and eccentric knee extensor activity. Additionally, the fractured limb demonstrated decreased ankle dorsiflexion during stance and diminished ankle push-off power. Long-term outcomes after IMN of tibial diaphyseal fractures demonstrate decreased quadriceps strength and altered gait parameters that may have implications to the high incidence of knee and ankle pain in the fractured limb.

Intraoperative Measurement of Tibial Rotation With Lateral Axis Views Using C-arm for Tibial Fractures.

Malrotation of tibial fractures after intramedullary nailing remains an unsolved problem. The incidence of malrotation >10° on computer tomography (CT) measurements has been highin cases of tibial shaft fractures. We aimed to assess the accuracy of a novel method for the measurement of tibial rotation using lateral axis views of the C-arm, to prevent postoperative malrotation. Consecutive patients with fresh tibial fractures treated by intramedullary nailing between January 2021 and December 2022 were included prospectively. Baselinetibial external rotation (TER) was measured preoperatively on the non-injured normal sidewith CT. After proximal or distal screw fixation, the C-arm TER was measured based on lateral axis views (tibial posterior condylar axisand bimalleolar axisviews). The C-arm TER was compared with the normal-side CT TER; when the difference was ≤5°, the procedure progressed, and screw fixation was carried out. The fractured-side CT TER was measured one week post-operatively. Twenty patients (13 males and seven females) were included. The mean age was 52.4 years. The Orthopaedic Trauma Association (OTA) classification was 42A in five patients, 42B in twelve patients, and 42C in three patients. The mean difference between C-arm TER and fractured-side CT TER was 2.3°±1.7°, with Pearson correlation coefficientr=0.968. The mean difference between normal-side CT TER and fractured-side CT TER was 4.8°±2.8°, and there was no incidence of malrotation >10°. The C-arm method was highly accurate in estimating CT measurements and preventing tibial malrotation.

Use of external fixator combined with titanium elastic nails in the treatment of tibia shaft fractures in children

Tibia shaft fractures are common in all age groups. For these fractures; Conservative and surgical treatment methods are available. In surgical treatment, numerous surgical methods such as plate screw fixation, external fixator, and titanium elastic nail and K-wire fixation have been defined. The aim of the present study was to present the results of patients for whom external fixator combined with titanium elastic nails or titanium elastic nails alone were applied due to tibia shaft fractures. The study included 40 patients treated for tibia shaft fracture in our clinic between January 2016 and January 2019. Combined external fixator (EF) fixation was applied to patients who were found to be instable after Titanium elastic nail (TEN) application during the surgery. In clinical evaluation, Flynn classification, time to fracture union, fluoroscopy count, reoperation and time to full weight bearing were used. The results of patients for whom EF combined with TEN were applied were compared with the patients who had only TEN. Thirty patients were treated using TEN and 10 patients using EF combined with TEN. After 12 months of follow-ups, fracture union was achieved in all patients. There were 5% sagittal and 2.5% coronal plane angulation. Patients developed angular deformity of an average of 2.43 ± 1.9 degrees in the coronal plane and 2.65 ± 1.9 degrees in sagittal plane. Lower percentages of angular and rotational deformity were observed compared to the literature. Despite the disadvantages of using a greater number of fluoroscopy and longer operation periods in patients who underwent TEN+EF, these patients were mobilized earlier. It was concluded that combined EF application is a more feasible method in patients with pediatric tibia shaft fracture for whom stable fixation cannot be achieved with TEN.

Assessing the effectiveness of intramedullary nailing for tibial shaft fractures in a low-income setting: a prospective study in Yemen.

Tibial shaft fractures are common injuries that can be treated with various methods, including interlocked intramedullary nail (IMN). However, there is limited data on the clinical outcomes of IMN for tibial shaft fractures in Yemen. To evaluate the clinical outcomes of primary IMN for tibial shaft fractures in Yemen. This was a prospective study of 134 patients who underwent primary IMN for tibial shaft fractures et al.-Thawra Modern General Hospital in Sana'a, Yemen, between June 2016 and June 2020. The patients were between 18 and 70years old, and the fractures were classified according to the AO classification system. The fractures were treated with IMN using a standard technique. The patients were followed up for a minimum of 2years. The outcome measures included union time, complications, and functional scores. The mean union time was 17weeks. The overall complication rate was 18.7%. The most common complications were infection (8.2%), delayed union (6.7%), and nonunion (3.7%). The mean functional scores at the final follow-up were 91.4 for the Knee Society Score and 90.2 for the American Orthopaedic Foot and Ankle Society Score. Primary IMN is an effective and reliable method for treating tibial shaft fractures in Yemen, with acceptable union time, complication rate, and functional outcomes.

No Difference in Short-Term Complications following Treatment of Closed Tibial Shaft Fractures with Intramedullary Nailing versus Plate Fixation.

Tibial shaft fractures are treated with both intramedullary nailing (IMN) and plate fixation (ORIF). Using a large national database, we aimed to explore the differences in thirty-day complication rates between IMN and ORIF. Patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had undergone either tibial IMN or ORIF for closed fractures from 2010 to 2018 were identified using current procedural terminology (CPT) codes. After excluding all patients with open fractures, the propensity score was matching. Univariate and multivariate logistic regressions were used to identify risk factors associated with the thirty-day incidence of complications in the two cohorts. A total of 5,400 patients were identified with 3,902 (72.3%) undergoing IMN and 1,498 (27.7%) ORIF. After excluding any ICD-10 diagnosis codes not pertaining to closed, traumatic tibial shaft fractures, 2,136 IMN and 621 ORIF cases remained. After matching, the baseline demographics were not significantly different between the cohorts. Following matching, the rate of any adverse event (aae) did not differ significantly between the IMN (7.08% (n = 44)) and ORIF (8.86% (n = 55)) cohorts (p=0.13). There was also no significant difference in operative time (IMN = 98.5 min, ORIF = 100 min; p=0.3) or length of stay (IMN = 3.7 days, ORIF = 3.3 days; p=0.08) between the cohorts. There were no significant differences in short-term complications between cohorts. These are important data for the surgeon when considering surgical management of closed tibial shaft fractures.

Mode of Injury, Involvement of Bones and Post-Operative Surgical Outcomes of Patients presented with Lower Limbs Fractures attended at a Tertiary Care Hospital at Tourist City of Bangladesh

Background: Surgical management is very much crucial among the lower limb fracture patients.
 Objective: The purpose of the present study was to find out the mode of injury, involvement of bones and post-operative surgical outcomes of patients presented with lower limbs fractures patients.
 Methodology: This prospective hospital-based study was conducted in the Department of Orthopaedic and Traumatology at Cox’s Bazar Medical College Hospital, Cox’s bazar, Bangladesh from January 2019 to June 2022 for a period of three and half years. All the patients who were presented with the clinical features of fracture of lower limbs were selected as study population. The patients were managed by conservative or surgical way. The outcomes of both procedures were recorded.
 Results: A total number of 370 cases were recruited for this study. The mean age with SD of the study population was 18.2±11.56 years. Among these road traffic accident was the most common mode of injury which was 204(55.0%) cases. Open type of fracture was found in 141(38.0%) cases and the close was found in 229(62.0%) cases. The most common bones involved was the shaft of tibia and fibula which was 159(43.0%) cases. During conservative treatment mal-union was reported in 193(66.8%) cases and the rest of the 96(33.2%) patients had shown the stiffness. Among 81 operated cases majority were recovered which was 70(86.0%) cases. However, death was found in 2(2.0%) cases. Minor and major infection were reported in 6(8.0%) cases and 3(4.0%) cases respectively.
 Conclusion: In conclusion the most common mode of injury is road traffic accident with the involvement of shaft of tibia and fibula with majority improvement.
 [Journal of National Institute of Neurosciences Bangladesh, January 2023;9(1):60-64]

The Use of the Lateral Tibial Line to Assess Ankle Alignment: A Preliminary Investigation

Category: Ankle; Trauma Introduction/Purpose: Although the medial clear space (MCS) is commonly used to assess talar alignment and ankle stability, its measurement is variable with multiple reported “normal” values. We have observed that the lateral tibial shaft is a reliable landmark to assess talar alignment. The objective of the current investigation was to determine the normal relationship of the lateral tibia to the superolateral talus using a tangent drawn inferiorly from the lateral tibial shaft, which we refer to as the “lateral tibial line” (LTL). Methods: The relationship of the LTL to the superolateral talus was assessed and characterized on ninety-nine standing ankle mortise radiographs in uninjured patients. This relationship was quantified by measuring the distance (in millimeters) between the LTL and the superolateral talus. Additionally, the inter-observer reliability of the LTL measurement, determined by three reviewers, was recorded and compared to medial clear space measurements. Results: The median value for the lateral tibial line was -0.50 mm with an interquartile range of -1.4mm - 0.0mm. The LTL was within 1mm of the lateral talus in 176 of 297 reviewer measurements (59.3%). Moreover, it was either lateral to or was at most 1mm medial to the lateral talus in 90.9% of cases. The LTL measurement also demonstrated good inter-observer reliability (0.764, 95% CI: 0.670-0.834), similar to the measurement of MCS (0.742, 95% CI: 0.539-0.846). Conclusion: The LTL is easily measured with good reliability for assessing the anatomic relationship of the tibia and talus. It uncommonly fell more than 1 mm medial to the superolateral talus. In other words, it was uncommon for the talus to shift lateral to this line, as might be seen with displaced ankle fractures. These findings will hopefully serve as a standard for future studies evaluating the role of the LTL in assessing lateral displacement and stability of isolated fibula fractures.

Assessment of Changes in Hindfoot Alignment of Total Ankle Arthroplasty for Ankle Osteoarthritis on Weightbearing Subtalar X-ray View.

Recovering normal hindfoot alignment and correcting deformity of the ankle joint following total ankle arthroplasty (TAA) in osteoarthritis (OA) is essential for improving clinical outcomes and increasing long-term survival. We aim to evaluate hindfoot alignment following standard TAA compared to TAA with a total talar prosthesis ("combined TAA") in varus-type OA patients. This retrospective study was conducted between 2010 and 2022. We included 27 patients (30 feet) who underwent standard TAA and 19 patients (22 feet) who underwent combined TAA. Hindfoot alignment at the subtalar joint was measured by weightbearing subtalar radiographic view before and after surgery. In the standard TAA, the angle between the tibial shaft axis and the articular surface of the talar dome joint (TTS) changed from 75 to 87 degrees (P < .01), the angle between the tibial axis and the surface on the middle facet (TMC) from 89 to 94 degrees (P < .01), and the angle between the tibial axis and the surface on the posterior facet (TPC) from 80 to 84 degrees (P < .01). The angle between the articular surface of the talar dome and the posterior facet of the calcaneus (SIA) decreased from 4.7 to -2.5 degrees (P < .01). In the combined TAA, TTS angle changed from 77 to 88 degrees (P < .01), TMC angle from 93 to 101 degrees (P < .01), TPC angle from 84 to 90 degrees (P < .05), and SIA from 6.6 to 2.1 degrees (P < .01). Varus deviation to the subtalar joint (TMC, TPC) significantly improved postoperatively in both groups. However, TPC was smaller than TTS and SIA was negative in standard TAA, and TPC was larger than TTS and SIA was positive in combined TAA. The amount of correction of the subtalar joint differed depending on the ligament dissection of the subtalar joint and shape of the talar component. Level III, retrospective cohort study.

Intramedullary vs Plate Fixation of Distal Fibular Fractures: Use Rates, Fracture Patterns, Patient Characteristics, and Complication Rates

Category: Trauma; Ankle Introduction/Purpose: The traditional surgical treatment for distal fibula fractures is open reduction and plate fixation (PF). However, intramedullary fixation (IMF) has been shown to provide advantages over plate fixation, particularly in patients and injuries with higher risks of soft tissue complications. Current evidence comparing the two fixation types remains scarce and is limited by modest sample sizes. Using a large national database, this retrospective cohort study aims to examine differences in use rates, associated fracture patterns, patient characteristics (e.g. age, gender, comorbidities, Elixhauser Comorbidity Index (ECI)), and complication rates between fibular IMF and PF within the United States. Methods: Patients (age≥18) with lower leg or ankle fractures treated with fibular IMF or PF between October 2015 and October 2021 were identified using a United States insurance claims database. The monthly ratio of IMF-treated patients to PF-treated patients was tracked over time to compare use rates. Fracture patterns were determined using fracture diagnoses within one month preceding surgery. Further analyses of patient characteristics and complication rates only included fibula fracture patients with 12 months of post-operative follow-up, and patients with concomitant upper tibia or tibia shaft fractures were excluded. To compare complication rates, a 1:4 (IMF:PF) matched comparison was performed, controlling for age, gender, high-energy (i.e. pilon, lower tibia, and trimalleolar) fractures, diabetes, tobacco use, obesity, and chronic kidney disease (CKD). Comparisons were conducted using chi-squared tests for categorical variables and t-tests for means. Ordinary least squares regression was used to visualize the trend in monthly relative use rates. Results: In total, 39329 patients (2294 IMF, 37035 PF) were identified. IMF use trended upwards relative to PF use over time (Figure 1). Tibia and fibula shaft fractures were the most common fractures in IMF patients versus trimalleolar and bimalleolar fractures in PF patients. A higher proportion of IMF patients had open fractures (p &lt; 0.01). 627 IMF and 29703 PF patients were included for further analysis of patient characteristics and complications. The IMF cohort was younger, with higher mean ECI, fewer females, and higher rates of CKD (ps &lt; 0.01). No significant differences in diabetes, tobacco use, or obesity rates were identified. Among 316 IMF and 1254 PF matched patients, no significant differences in infection, nonunion, malunion, revision, hardware removal, pulmonary embolism, and deep vein thrombosis rates were found. Conclusion: The upward trend in the ratio of IMF-treated to PF-treated patients suggests that the popularity of IMF is steadily rising. The higher rate of concomitant tibia shaft fractures and open fractures seen among IMF-treated patients in this study is consistent with the use of fibular IMF in cases involving higher-energy trauma and soft-tissue disruption. Higher ECI scores and rates of CKD in IMF patients also suggest that IMF is used more frequently in medically complex patients with impaired wound healing. Lastly, fibular IMF appears to be a viable alternative to PF when used in similar populations.

High Energy Trauma In Relation To the Genesis of Non-Union in Tibial Shaft Fractures

Objective: To determine the relationship of high-energy trauma with non-union of the tibial shaft fractures. Material and Methods: Observational, retrospective and cross-sectional study that included patients with a diagnosis of tibial non-union with a history of high-energy trauma; high-energy trauma was assessed in relation to the genesis of non-union in tibial shaft fractures; the relationship between both variables was determined. Data were analyzed using measures of central tendency and X2 test. Results: A total of 201 patients were obtained in total tibial shaft fractures from 2014 to 2018 (5 years), both of high and low energy trauma, female sex 42 patients (20.89 %), male 159 patients (79.10 %), with an average of 36.9 years of age; total non-union in all patients 37 patients (18.40 %), the external fixator in non-union in 17 patients (45.94 %), patients with plaque and posterior non-union with high energy trauma in 10 patients (27.02 %). Non-union was recorded with high-energy trauma at 55.22 % and 44.77 % low energy trauma with a statistical significance of p = 0.00058 and an X2 of 11.82 (RM = 23 and 95 % CI 21.6-25.4). Conclusions: High-energy trauma is related to the genesis of non-union of any type in tibial shaft fractures.

A Review of Tibial Shaft Fracture Fixation Methods

Tibial shaft fractures are a commonly seen injury in orthopedic trauma patients. Fractures commonly occur following high energy mechanisms, such as motor vehicle collisions. There are multiple ways to stabilize tibial shaft fractures. Knowledge of the indications, contraindications, techniques, and complications associated with each technique allows the orthopedic surgeon to make the appropriate decision for each patient by providing both fracture and patient characteristics. This review discusses the indications, techniques, outcomes, and complications associated with intramedullary nailing, minimally invasive percutaneous plate osteosynthesis, and external fixation of tibial shaft fractures.

Comparative Study of Surgical Treatment for Concomitant Ankle Joint Injury in Tibia Shaft Fracture

Comparative Study of Surgical Treatment for Concomitant Ankle Joint Injury in Tibia Shaft Fracture

Intramedullary Nailing versus Minimally Invasive Plate Osteosynthesis for Distal Tibia Shaft Fractures: Retrospective Comparison of Functional and Cosmetic Outcomes

Intramedullary Nailing versus Minimally Invasive Plate Osteosynthesis for Distal Tibia Shaft Fractures: Retrospective Comparison of Functional and Cosmetic Outcomes

Tibial Malrotation after Intramedullary Locked Tibia Nailing and its Computed Tomography-Based Assessment

Objectives To assess the incidence and degree of malrotation of tibia after fixation with intramedullary nail for tibial shaft fractures and its measurement by computed tomography (CT). The study also aims to assess the value of CT-based torsion angle in such cases. Material and Methods In this prospective study, fifty patients with closed/open fracture of tibia shaft (proximal 1/3, middle 1/3 or distal 1/3) with or without fracture of fibula were chosen and operated with closed/open reduction internal fixation with reamed intramedullary locked nail. Torsion angle calculated by post-operative CT and revision done for selected cases when tibial malrotation was more than 10 degrees than the control (normal side). Results The range of malreduction was from 43 degrees of external rotation to 12 degrees internal rotation. 15 of the 50 (30%) tibia operated showed malrotation and 5 (10%) were above 20 degrees. The repetition of torsion angle showed a variation of 3.2 to 4.3 degrees. Some injury patterns showed more malrotation than the others. Conclusion Assessment of tibial malrotation following intramedullary nailing has shown higher incidence of malalignment than previously reported in the literature. CT-based torsion angle calculation can be used as a reliable indicator of malrotation.

Distal Tibial Fractures – Surgical Outcome Following Minimally Invasive Percutaneous Plate Osteosynthesis

Objectives With preservation of the vascularity of the bone, preservation of the soft tissue envelope and containment of the fracture haematoma, minimally invasive procedures provide fixation in a biologically sound manner. With these in view, this study was conducted to evaluate the technique of surgical management in distal tibial fractures treated by internal fixation with locking compression plate (LCP) and screws through the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique. Material and Methods In this cohort study, 21 patients with distal tibial fractures who were admitted to the hospital between November 2014 and August 2016 were tracked for at least 10 weeks and up to 39 weeks. Adults who were fit enough for surgery, both male and female, participated in the study. MIPPO procedures were followed for every case. In this investigation, a total of 21 cases were examined. Results 86% of cases with proper bone union were able to bear their full weight at or before the 18-week mark. Complete weight bearing was permitted for the final three patients (14%) at or before 39 weeks. Ninety per cent of patients had fracture union rates that were satisfactory to excellent at 23 weeks. Also, delayed unions were noted in three individuals; two cases experienced ankle stiffness, one as a result of prolonged immobilization and the other as a result of an intra-articular fracture. There were no infections or wound breakdowns during this trial. Conclusion The MIPPO technique with LCP plates is a good choice when intramedullary nailing is inadequate for metaphyseal and distal tibia shaft fractures. Also, early fracture union is easily accomplished using the MIPPO technique and careful application of these plates.

A large mixed pattern aneurysmal bone cysts: An extremely rare case with unusual radiological findings and management sequela

A mixed pattern of aneurysmal bone cysts (ABCs) is an extremely rare anatomic subtype. Typical ABCs usually arise in the metaphysis of long bones, predominantly in childhood-age patients. Here, we report a case of a 37-year-old female presenting with the left leg pain and mass for 2 years. Conventional radiographs and computed tomography scans revealed a well-demarcated expansile lytic lesion at the diaphysis of the left tibia. Magnetic resonance imaging showed fluid-fluid levels with associated bone edema. These findings were suggestive of ABC. An open incisional biopsy was done and was confirmatory. After 8 months, the patient showed radiographic complete ossification of the lesion with persistent symptoms. Excision and intralesional curettage of the lesion was performed and supported with a tibia locking plate. On 18 months of follow-up, the patient was asymptomatic, with no recurrence observed on conventional radiographs.

Growth rate affects blood flow rate to the tibia of the dinosaur Maiasaura

AbstractFossil bones were once living tissues that demanded internal blood perfusion in proportion to their metabolic requirements. Metabolic rates were primarily associated with bone growth (modeling) in the juvenile stages and with alteration and repair of existing bone affected by weight bearing and locomotion (remodeling) in later stages. This study estimates blood flow rates to the tibia shafts of the Late Cretaceous hadrosaurid Maiasaura peeblesorum, based on the size of the primary nutrient foramina in fossil bones. Foramen size quantitatively reflects arterial size and hence blood flow rate. The results showed that the bone metabolic intensity of juveniles (ca. 1 year old) was greater than fourfold higher than that of 6- to 11-year-old adults. This difference is much greater than expected from standard metabolic scaling and is interpreted as a shift from the high metabolic demands for primary bone modeling in the rapidly growing juveniles to a lower metabolic demand of adults to remodel their bones for repair of microfractures accumulated during locomotion and weight bearing. Large nutrient foramina of adults indicate a high level of cursorial locomotion characteristic of tachymetabolic endotherms. The practical value of these results is that juvenile and adult stages should be treated separately in interspecific analyses of bone perfusion in relation to body mass.

Three-dimensional analysis of posttraumatic tibial shaft malunion and correction based on the healthy, contralateral leg

Three-dimensional (3D) analysis and implementation with patient-specific cutting and repositioning blocks enables correction of complex tibial malunions. Correction can be planned using the contralateral side or astatistical model. Patient-specific 3D-printed cutting guide blocks enable aprecise osteotomy and reduction guide blocks help to achieve anatomical reduction. Depending on the type and extent of correction, fibula osteotomy may need to be considered to achieve the desired reduction. a)Poor soft tissue (flap surgery, adherent skin in field of operation); b)infection; c)peripheral artery disease (stageIII andIV classified according to Fontaine, critical transcutaneous oxygen partial pressure, TcPO2); d)general contraindication to surgery. Before surgery, a3D model of both lower legs is created based on computed tomography (CT) scans. Analysis of the deformity based on the contralateral side in a3D computer model (CASPA) and planning of the osteotomy. If the contralateral side also has adeformity, astatistical model can be used. Printing of patient-specific guides made of nylon (PA2200) for the osteotomy and reduction. Surgery is performed in supine position, antibiotic prophylaxis, thigh tourniquet, which is used as needed. Ventrolateral approach to the tibia. Attachment of the patient-specific osteotomy guide, performance of the osteotomy. Reduction using the guide. Fibula osteotomy through alateral approach is performed if the reduction of the tibia is hindered by the fibula. This can be performed freehand or with patient-specific guides. Wound closure. Compartment monitoring. Passive mobilization of the ankle in the cast as soon as the wound healing has progressed. Partial weightbearing in alower leg cast for at least 6-12weeks, depending on the routinely performed radiographic assessment 6weeks postoperatively. Thromboprophylaxis with low molecular weight heparin until cast removal. Patient-specific correction of malunions are generally good. This could be confirmed for distal tibial corrections. For tibial shaft deformities, the final results are still pending. Preliminary results, however, show good feasibility with apseudarthrosis rate of 10% without postoperative infection.

Management of limb length discrepancy after bone sarcoma resection about the knee in the skeletally immature.

Patients with bone sarcomas increasingly choose limb salvage. This can lead to issues with limb length discrepancy (LLD) for the skeletally immature. We synthesize management options into an algorithm and report our results. Patients with bone sarcomas involving any location from the femoral diaphysis to the tibial diaphysis 12 years or younger were reviewed. Our clinical pathway prescribed patients with metadiaphyseal lesions to intercalary allograft reconstruction, epiphyseal lesions and less than 5 cm expected LLD to osteoarticular allograft and patients with more than 5 cm expected LLD to extendable prosthesis. Twenty patients met inclusion criteria: 11 with osteoarticular allografts, 5 with extendable prostheses and 4 with intercalary allografts; median age 11.5 years; median follow-up 8.2 years; and final median LLD 1.6 cm. Five patients had contralateral epiphysiodesis, two patients underwent contralateral femoral shortening and a median of 6 (range 4-8) lengthenings were performed for extendable prostheses. Four patients had residual LLD over 3 cm. There were 13 revisions in 8 patients and 2 amputations. Limb-salvage in paediatric bone sarcoma of the knee can be managed with multiple techniques producing satisfactory results in regards to LLD. Careful pre-operative planning and shared decision making is a requisite given the high rate of secondary procedures for both LLD and reconstructive failures. Level of evidence: Level III Retrospective Comparative Study.