Tibial Crest Research Articles

Stimulation of dental implant osseointegration by low-Intensity pulsed ultrasound: An in vivo preliminary study in a porcine model.

Several studies have evaluated the interest of Low Intensity Pulsed Ultrasound (LIPUS) in the osseointegration of dental implants in murine or rabbit models. However, the thinness and narrowness bones make it difficult to study the effect of LIPUS. The purpose of this study is to assess the ability of LIPUS to stimulate bone formation in contact with a titanium dental implant in a porcine model. Eight adults mini-pigs were used. An implant is placed on each tibial crest in the metaphysis. The right side was treated with LIPUS at 1 MHz and 300 mW/cm2 of acoustic intensity during 15 minutes per day on 5 consecutive days and during 42 days. The left side was not treated. The Bone Volume/Total Volume ratio (BV/TV), the Intersection Surface (IS) of the volume of interest by the binarized bone and the Trabecular bone Thickness (TbTh) around the implant were analyzed. At 42 days, BV/TV ratio is significantly higher on the treated side (42,1+/-8,76% versus 32,31+/-10,11%, p < 0,02); as well as TbTh with 0,13+/-0,01 mm versus 0,10+/-0,01 mm (p < 0,01). IS is also significantly higher on the treated side (40,7 +/- 12,68 mm2 versus 33,68+/-9,44 mm2 at 200 μm from the implant surface; p < 0,01). The present study showed that LIPUS can significantly increase bone formation and accelerate the healing process at the bone-implant interface in a porcine model. Its low toxicity, low immunogenicity and non-invasion make it a complementary treatment of choice for improving the bone formation around titanium implants.

Safe corridors for external skeletal fixator pin placement in feline long bones.

External skeletal fixation is an established technique in cats for biological fixation of long bone fractures, stabilisation of the joints, and treatment of shearing injuries and angular deformities. As appropriate and accurate pin insertion is imperative for a successful outcome, knowledge of topographic anatomy and areas that are safe (safe corridors) for pin placement is integral to successful surgery. At present, however, safe corridors have not been determined fully in feline orthopaedics, with surgeons having to rely on knowledge based on canine orthopaedics. This study was performed to determine safe corridors for pin placement in feline long bones. The limbs of six feline cadavers were frozen. Only limbs with no history of orthopaedic conditions were used. Transverse sections through the limbs were examined, and anatomical structures were determined in relation to the bone. These structures were compared with those of the contralateral limbs, which were dissected for topographic assessment. Safe corridors were defined as topographic areas where no vital structures, muscles or joints were present. Examination of the humerus revealed safe corridors at its proximal craniolateral aspect and on the medial and lateral humeral condyles. Safe corridors of the antebrachium were identified on the lateral aspect of the olecranon, the distal two-thirds of the medial antebrachium and the distal third of the lateral antebrachium. Safe corridors in the femur consisted of a small area lateral to and just below the major trochanter, and on the medial and lateral femoral condyles. Evaluation of the tibia revealed safe corridors on the medial aspect of the entire tibia, the cranial aspect of the proximal tibia on the tibial crest and the area just proximal to the lateral malleolus. Safe corridors for pin placement during external skeletal fixation in feline limbs differed from those in canine limbs. Knowledge of canine anatomy may be inapplicable to pin placement in feline limbs undergoing external skeletal fixation.

Does PRGF Work? A Prospective Clinical Study in Dogs with A Novel Polylactic Acid Scaffold Injected with PRGF Using the Modified Maquet Technique.

Simple SummaryPRGF is a concentration of autologous platelets in a small volume of plasma, which is performed in a specific way and is an accessible resource in veterinary medicine. The PRGF has multiple demonstrated properties as antimicrobial, analgesic and anti-inflammatory but their osteoinductivity potential is controversial. We decided to use PRGF in combination with a PLA bioresorbable scaffold (a specific type of implant with osteoconduction properties) performed by 3D printing, and personalized for each patient, to determinate if the PRGF can produce osteoinduction and as a result, a faster bone healing and a faster patient recovery. Furthermore, in this study PLA scaffolds are proposed as an alternative for metallic implants to avoid the problems that those can cause. The MMT was the technique selected for solving the RCrCL as it is a variant of TTA that follows the same principle for the correction of the patellar tendon angle to neutralize distractive forces; however, this technique needs a lower amount of metallic implants for the scaffold fixation.Tibial tuberosity advancement is a surgical technique to restore the dynamical stability in the knee by advancing the insertion of the patellar ligament, for which it is necessary to advance the tibial crest, being maintained in the desired position usually by a cage and metallic implants. The purpose of this study was to replace the cage with a polylactic acid biodegradable scaffold designed for each patient by 3D printing, inserting platelet-rich in growth factors (PRGF) to demonstrate its osteoinductive properties. To this end, we used the modified Maquet technique to reduce the amount of metal to a minimum. Fifty-three dogs finished the study. The control and PRGF groups did not present any statistically significant differences in terms of ossification degree (p > 0.001) but they demonstrated satisfactory ossification compared to previous publications, although in the PRGF group three of the scaffolds suffered complete reabsorption. The PRGF and control groups did not show any statistically significant differences in terms of lameness degree (p > 0.001). However, the PRGF group showed at the first control some analgesic and anti-inflammatory properties but they were not enough for reducing the functional recovery time in a significant way. The PRGF group did not show any complications or negative results associated with their use.

Prediction of applied pressure on model lower limb exerted by an air pneumatic device

Air pneumatic compression is a concept used for management of venous disease, including oedema. A typical air pneumatic compression device (PCD) consists of an inflatable sleeve composed of either single or multiple pressure chambers that encircle a limb.The aim of this research was to develop a mathematical model to predict the pressure applied by an air pneumatic device to an irregular cross-sectional lower limb manikin.The radius of curvature at any cross-section of the lower limb (i.e. calf (gastrocnemius), tibial crest (anterior edge of the tibia bone)) is irregular, and differs amongst individuals and populations. The effectiveness of air pneumatic devices is difficult to predict with these irregular cross sections.A theoretical model was developed to calculate pressure applied by compression sleeves on a lower leg manikin and results compared against experimental pressure exerted on the manikin by a silicone-based PCD. This prediction was made at each of three positions.The theoretical model developed based on elliptical shaped forms predicted the pressure more accurately for the ankle to above ankle position, whereas the model based on circular shaped forms predicted the pressure more accurately for below the calf to below the knee position. Refinements to the theoretical model to predict the pressure applied by PCD are recommended.

In vivo three-dimensional isometry analysis of suture attachment sites for extracapsular suture stabilization of the canine stifle.

The study aimed to perform isometry analysis of a selection of suture attachment points for extracapsular stabilization with three-dimensional (3D) measurements and normal gait kinematics of the stifle joint. Thirteen client-owned dogs were recruited. Fluoroscopic images of the stifle during treadmill walking and computed tomography of the same joint were acquired. Stifle kinematics were reconstructed using 3D model-based fluoroscopic analysis. Variability of the distance between the femoral and tibial attachment sites across gait cycles was evaluated. The maximum length variation (MLV) and maximum length percent variation (MLPV) were quantified and used to determine the level of isometry of the attachment site combinations. A selection of combinations with lower mean MLV (<2.5mm) or MLPV(<8%) was identified from 315 combinations, and all the combinations involved femoral attachment sites near the distal pole of the lateral fabella. The combinations also involving tibial attachment sites near the proximal tibial crest showed improved isometry, with an MLPV<6%. Combinations using attachment sites around the distal pole of the lateral fabella and proximal tibial crest or caudal to the long digit extensor groove appeared to have improved isometry.

Reliability of tibial anterior crest as the anatomical reference of rotating alignment for tibial component in total knee arthroplasty

This study aimed to research whether anterior tibial crest is a reliable anatomical reference for rotational alignment of tibial component in TKA. The study included 122 patients who underwent computed tomography angiography (CTA) examination for unilateral lower extremity trauma with normal contralateral lower extremities, including 89 males and 33 females, with an average age of(51.4±16.4) years old(ranged 18 to 81 years old). Picture archiving and communication system (PACS) was used to mark 11 lines including the surgical epicondylar axis (SEA) connecting the most prominent points of the lateral epicondyle and the deepest point of the sulcus on the medial epicondyle of the femur, axis of medial border of patellar tendon (MEPT)connecting the middle of the posterior cruciate ligament (PCL) and medial border of the patellar tendon at the level of a standard tibial cut from 8 mm distal of the lateral tibial joint surface, transverse axis of tibia (TAT) at the level of a standard tibial cut from 8 mm distal of the lateral tibial joint surface, Akagi line connecting the projected middle of the PCL and medial border of the patellar tendon at the tibial attachment, the axis of the medial 1/3 of patellar tendon(M1/3) connecting the projected middle of PCL and the medial 1/3 of the patellar tendon at the patellar tendon attachment level, Insall line connecting the projected middle of the PCL and the medial 1/3 of tibial tubercle, the axis of medial border of tibial tubercle (MBTT) connecting the projected middle of the PCL and medial border of tibial tubercle, as well as the axis of the proximal anterior tibial crest (PATC), axis 1 of the middle anterior tibial crest (MATC1), axis 2 of the middle anterior tibial crest (MATC2) and the axis of the distal anterior tibial crest (DATC) which were marked by connecting the 4 equidistant points on the sharp anterior tibial crest and the projected middle of the PCL. The angles between TAT and SEA as well as the angles between other axes and the perpendicular to SEA were measured. Pairwise differences among the 10 tibial axes were examined using One-Way ANOVA and paired t-test. The angles between the axes of MEPT, Akagi line, M1/3, Insall line, MBTT, PATC, MATC1, MATC2, DATC and the perpendicular to SEA were (-1.6 ±4.5)° , (1.4 ±5.0)° , (10.2±5.1)°, (11.9±5.4)°, (3.6±4.8)°, (12.0±6.9)°, (7.2±8.6)°, (7.1±10.4)°, (6.6±13.5)°, respectively. The angle between TAT and SEA was (4.1±5.3)°. MEPT was external rotation compared to SEA. M1/3, Insall line and PATC were significantly greater than Akagi line, MBTT, TAT (P<0.001). MATC1, MATC2 and DATC were also significantly greater than Akagi line, MBTT axis and TAT (P<0.001). However, MATC1, MATC2 and DATC were also significantly less than M1/3 axis, Insall line and PATC(P<0.01). There were no significant statistical differences between MATC1, MATC2 and DATC(P>0.05). The middle tibial anterior crest can be used as a reference for rotational alignment of tibial component in TKA, and its reliability is better than Insall line, but worse than Akagi line, TAT and MBTT.

A modified Frosch approach for posterior tibial plateau fractures: Technical note and case series

Achieving the best possible articular congruity following a tibial plateau (TP) fracture is associated with better long-term functional outcomes; TP has an essential role in the movements of the knee joint and is well established that a not optimal reduction leads to articular instability and early osteoarthritis.In recent times, 3D reconstruction from CT scan has greatly contributed to improve the surgical treatment of these fractures since an accurate preoperative plan gives the possibility to decide the best interventional strategy before the surgical incision.Reduction of the posterior part of tibial plateau is not easily achievable with standard surgical access.Several posterolateral approaches, proposed by authors such as Frosch and Lobenhoffer, have been described over the years; these approaches can be divided into 2 groups: with or without osteotomy of the fibula.Main disadvantages of these techniques are the large skin incision, the difficulty of exposing the lateral part of the tibia, the high frequency of damages of the posterolateral TP corner, and in some cases the necessity of performing fibular head osteotomy.The surgical approach presented in this paper is a simple innovation of the well-known Frosch approach: skin incision is about 12 centimeters in length and runs in a “S” shape with the center positioned over the head of the fibula. It starts 2 centimeters laterally to the tibial crest 6 centimeters below the tibial tuberosity and is directed proximally, curving posteriorly at the level of fibular head and returning straight in the most proximal part; it terminates 4 centimeters posteriorly the lateral femoral condyle.This innovative approach allows the trauma surgeon to achieve an optimal exposure and control of posterior tibial plateau fractures, with the great advantage of being able to treat the lateral tibial plateau with the same surgical incision.

English

Because of plate development, it is now possible to perform tibial plateau leveling osteotomy (TPLO) in small-breed dogs with cranial cruciate ligament rupture. Compared with conventional treatment, faster walking and better function are reported post-TPLO. However, TPLO can be more difficult in toy-breed dogs than large-breed dogs. Because of the smaller bones, it is difficult to manipulate the bone fragments during surgery, and small movements of bones can cause major differences in limb alignment. In TPLO, a jig is conventionally recommended to increase the accuracy of alignment; however, installation of the jig can be difficult in small-breed dogs, and it may cause problems such as iatrogenic fracture. The present study thus aimed to evaluate the accuracy of TPLO without a jig in toy-breed dogs. Paired stifles (n=22) obtained from 11 toy-breed dogs cadavers (body weight range, 2.0-7.4 kg) were randomly assigned to a jig or non-jig group. Radiographic images were obtained preoperative and postoperative TPLO. Tibias were dissected from the hindlimb and measured for evaluation of accuracy. The following postoperative parameters were compared: tibial plateau angle, mechanical medial proximal tibial angle, osteotomy location, tibia crest thickness, gap between segments, and orientation line angles. There were no significant differences between the two groups, demonstrating that jig usage does not affect precision of TPLO in toy-breed dogs. Therefore, it is better not to use a jig in toy-breed dogs with relatively small bones, considering the risk of iatrogenic injury, cost and operation time

Tibial crest alignment technique-an effective technique to improve coronal alignment of tibial component in tka for arthritic knees

Introduction:Long term survivorship in Total Knee Arthroplasty is significantly dependent on prosthesis alignment.Accuracy of component positioning relies on alignment guides for making precise and accurate bone cuts.Hypotheses:The aim of this study was to determine, compare and analyse the coronal alignment of the tibial component of a single implant system using 3 different techniques.Methods:Retrospective study of cases from a prospectively collected database. Radiological assessment included measurement of the coronal alignment of tibial components of total knee arthroplasties, and its deviation from the mechanical axis. A comparison study of intramedullary, extramedullary and tibial crest alignment methods was performed.Results:66 consecutive patients (3 groups of 22 each). Mean BMI was 26. The mean angle of deviation from the mechanical axis was significantly lesser (p< 0.05) in the Tibial crest alignment group patients compared to the other 2 groups. Moreover, the number of outliers (+/-3 degrees) were 2 and 4 in the intra and extramedullary group, whereas there were none in the tibial crest group. The inter and intraclass correlation coefficient was 0.8 and 0.9 respectively.Conclusion:The Tibial Crest Alignment Technique is an effective technique to produce consistent results to achieve optimal coronal alignment of the tibial component in TKA, even in patients with high BMI.

Injury of the Tibial Nutrient Artery Canal during External Fixation for Lower Extremity Fractures: A Computed Tomography Study

The tibial nutrient artery (TNA) is the major diaphyseal artery of the tibia supplying two thirds of the inner osseous cortex. Hence, iatrogenic injury of the TNA endangers the integrity of the tibial blood supply and may compromise fracture healing. The incidence of its injury in the setting of external fixation for lower limb fractures has not been previously investigated. The aim of this study was to evaluate the incidence of TNA injury in the context of external fixation and to characterize the topography of the fixator pins in relation to the TNA canal (TNAC). Patients who underwent external fixation for distal femoral fractures and for tibial (proximal, shaft, and distal) fractures and had a postoperative computed tomography study were retrospectively included. The following parameters were retrieved: 1) Pin characteristics (orientation and cortical position of the pins), 2) The anatomic relationship between the TNAC and external fixation pin (topography above/below and at the level of the TNAC, and the distance between the pin and medial tibial plateau and/or the medial malleolus), and 3) The incidence of TNAC injury (complete/partial disruption of TNA lumen). A total of 105 patients with 214 tibial pins were analyzed. In 27 patients (26%), the TNAC was completely injured by the pins of the external fixator. In 13 patients (12%), the TNAC was partially injured. Of the 214 analyzed pins, 85 pins (40%) were located at the level of the TNAC (the TNAC and the pin are seen on the same axial slice). Most pins that were applied at the level of the TNAC belonged to a knee-bridging external fixator. Of those, ninety-three percent of the pins were anteromedially applied according to published surgical guidelines. Six percent of the pins were applied through the tibial crest and 1% anterolaterally. Of those 85 pins, 42 pins (49%) injured the TNAC at least partially. Based on the analyzed pins and the incidence of partial and complete injury of the TNAC, we observed that the tibial segment at which the tibial nutrient artery is endangered was located approximately (95% CI: 13–15 cm) from the medial tibia plateau and (95% CI: 22–25 cm) from the medial malleolus. Thus, TNAC injury by external fixation pins in the context of lower limb fractures can be considered common. Almost half of the pins applied at the middle third of the tibia injured the TNA, despite adherence to published surgical guidelines for external fixation. When possible, pin application at the middle third of tibia should be avoided to circumvent iatrogenic injury of the TNA and to safeguard tibial blood supply.

Lower-limb Flip-Flap: A simple reliable modification of adipofascial flap for extensive tibial crest cutaneous defect

IntroductionLarge cutaneous defects exposing the whole tibial crest are difficult to cover and are conventionally best treated with free flaps. This article describes a technical modification of the adipofascial flap in this indication. MethodsThe “flip-flap” is vascularized by the posterior tibial artery perforators harvested on the medial aspect of the leg. The hypodermal and fascial tissue is de-epidermized and elevated from the posterior midline up to the medial edge of the soleus muscle, then folded over the exposed tibial crest like a page of a book. ResultsA 27×6cm effect was successfully covered on a 72 year-old patient with vascular status precluding free flap. The flap healed by day 21. Discussion/conclusionThis technical modification is simple and allows coverage of large tibial crest skin defect when a free flap is not possible.

Tibiofemoral rotation alignment in the normal knee joints among Chinese adults: a CT analysis

BackgroundConsensus on tibial rotation in total knee arthroplasty (TKA) remains controversial. The present study aimed to investigate the closest anatomical reference to surgical epicondylar axis (SEA) among 10 tibial markers in Chinese adults.MethodsThis study included examination of 122 normal lower extremities. Briefly, 10 axes were drawn on the axial sections: transverse axis of tibia (TAT), axis of medial edge of patellar tendon (MEPT), axis of medial 1/3 of patellar tendon attachment (M1/3), Akagi line, Insall line, axis of medial border of tibial tubercle (MBTT), and axis of anterior border of the tibia 1–4 (ATC1–4). The mean angles between TAT and SEA and that between other axes and the line perpendicular to SEA were measured. Pairwise differences among the 10 tibial axes were examined by applying one-way analysis of variance (ANOVA) and paired t-test.ResultsIn all the knees, the mean angles of M1/3, Akagi line, Insall line, MBTT, ATC1, ATC2, ATC3, and ATC4 axes were compared to the line perpendicular to the projected SEA and found to be 10.2 ± 5.1°, 1.4 ± 5.0°, 11.9 ± 5.4°, 3.6 ± 4.8°, 12.0 ± 6.9°, 7.2 ± 8.6°, 7.1 ± 10.4°, and 6.6 ± 13.5° external rotation, respectively, and the MEPT axis was 1.6 ± 4.5° internal rotation. The mean angle for TAT was 4.1 ± 5.3° external rotation. The M1/3 and Insall line were significantly more externally rotated than Akagi line, MEPT, MBTT, TAT, ATC2, ATC3, and ATC4 axes. No significant differences were noted between the TAT axis and the MBTT axis and among the ATC2, ATC3, and ATC4 axes.ConclusionThe Akagi line, MBTT, and TAT showed good consistency with SEA in the axial femorotibial alignment with knee in extension. The middle segment of the anterior tibial crest also demonstrated good alignment consistency with SEA for the axial femorotibial alignment. Hence, these markers can be used as reliable references for rotational alignment of the tibial component in TKA.

The Extent of Metaplastic Hard Tissue Within the Appendicular Skeleton of the Nine‐Banded Armadillo (Dasypus novemcinctus)

The developmental and functional advantages of vertebrate metaplastic hard tissue is still relatively unclear. Metaplastic tissue forms from the direct transformation of one cell type to another. Specifically, mineralization of preformed dense connective tissue results in intratendinous metaplastic tissue, and has been described in a variety of taxa and elements including turtle shell, reptilian osteoderms, sturgeon scutes, dinosaur cranial and vertebral elements, ossified tendons, portions of bird skeletons, and tendinous entheses in mammalian bone. However, histological analysis of the extent of metaplastic hard tissues, both across Mammalia and within individual mammalian bones, is lacking. Here we serially sectioned both tibiae of a nine‐banded armadillo, Dasypus novemcinctus [Xenarthra: Cingulata], transversely and longitudinally to identify the existence and possible patterns of metaplastic hard tissue. All skeletal elements were processed using standard procedure for the preparation of undecalcified bone. We found evidence of metaplastic hard tissue in the tibial crest, as well as the medial side of the diaphysis and the proximal lateral side of the tibia. The metaplastic tissue in the tibial crest appears interstitially within a primary woven bone matrix. Along the lateral side, metaplastic tissue forms a thin patch in the mid‐cortex superficial to compact coarse cancellous bone. The presence of metaplastic hard tissue seems consistent with tendinous insertions through fibrous entheses along the length of the tibia and tibial crest. The entrapment of metaplastic tissue within the tibia is likely due to appositional bone growth at the enthesis. However, the presence of metaplastic hard tissue on the medial side of the mid‐diaphyseal and proximal portion of the tibia does not appear to be associated with any tendinous insertions. Previously, unassociated metaplastic tissue was found extensively in osteoderms, ankylosaur tail clubs, and dinosaur cranial ornamentation such as the parietal frill of Triceratops. Study of metaplastic hard tissue in modern bone, independent of tendinous insertions, can improve our understanding of its potential biomechanical advantages and thereby possibly provide clues to its use in ornamentation and within the appendicular skeleton. Metaplastic hard tissues have likely been misidentified and understudied in previous investigations of modern hard tissue microstructure. Additionally, because Xenarthra is proposed to be one of the four original clades of placental mammals, analysis of metaplastic tissue in the skeleton of D. novemcinctus could have implications for early mammalian bone development patterns.Support or Funding InformationPartial funding was provided by Montana State University Undergraduate Scholar’s ProgramFigure 1

To Study the Correlation Between the Height &amp; the Quadruple Semitendinosus Graft Diameters

Background: Diameter of hamstring graft is variable. Premature tendon amputation occurs because of inability to identify and release all accessory bands. Preoperative prediction of hamstring graft size, number and distance of accessory bands is useful for surgeon. Methodology: This is cross-sectional study included 60 patients. Correlation coefficient (Pearson’s r) was used. T-test was used to compare the variables in both genders. Result: There were correlations between the mean semitendinosus tendon diameters- femoral side (FD) and tibial side (TB) with height of patient (Pearson correlation for FD =0.442 and P&lt; 0.001) (Pearson correlation for TD =0.663 and P&lt; 0.001). For the semitendinosus tendons, the mean number of accessory bands was 1.48. The average distance of the most distal band (D1) to the tibial crest insertion was 6.7 ± 2.04 cm (range 3- 11 cm). In our study, distance of most proximal band to the tibial crest insertion was 11.5 cm (mean 8.5 cm). Conclusion: In our study, positive correlation between the height and the quadruple semitendinosus graft diameters was present. Semitendinosus graft diameters were more in males as compare to females. Third accessory band was present only in males (n=4) in our study. As height of patient increases, distance of distal band (D1) increases from tibial crest. There was inverse correlation between number of accessory bands and distance of the most distal band (D1) insertion. As number of bands less, the more is distance of proximal band from tibial crest.

Evaluation of a Functional Brace in ACL-Deficient Subjects Measuring Ground Reaction Forces and Contact Pressure: A Pilot Study

ABSTRACT Introduction An ideal functional brace for anterior cruciate ligament-deficient (ACLD) patients should control anterior movement of the tibia and simultaneously decrease the effects of ground reaction shearing force. The current study was aimed to compare the interface pressure between the anterior shell of a functional brace and proximal of tibia in both sound and ACLD limbs, and to assess the effect of using functional brace on the symmetry of vertical and anteroposterior components of ground reaction force and impulse of ground reaction force during level walking. Methods Seven unilateral ACLD men participated in this study. The interface pressure between the anterior shell and proximal of the tibia and ground reaction force was recorded by means of Novel Pliance X and Kistler force platform, respectively. Wilcoxon ranked-sign test and factor analysis repeated measure analysis of variance were used to analyze data. Results The use of functional brace had no significant effect on interface pressure and peak points of the ground reaction force. By use of a functional brace, the valley and the impulse of the vertical component of ground reaction force on ACLD limb increased significantly (P &lt; 0.05) and also improved limb symmetry of all parameters. The interface pressure was greater at distal contact points of the shell, which are at the middle level of the tibia crest. Conclusions The results suggest that functional brace could not apply force on proximal tibia especially at ACLD limb and therefore could not normalize vertical component of ground reaction force during level walking.

Revisiting the tibial crest as reference for the mechanical alignment of the tibial component in total knee arthroplasty: a cadaveric study on Caucasian tibiae.

The accuracy of the tibial crest (TC) in guiding the mechanical alignment of the tibial component in total knee arthroplasty (TKA) has been investigated in a few studies on Asian patients. No study analyzed the anatomical variants of the TC. We analyzed the morphological types of the TC in cadaveric tibiae of Caucasian subjects and assessed whether the TC may be considered an accurate guide for the mechanical alignment of the tibial component in TKA. The TC and mechanical axis (MA) were identified in 86 dried cadaveric tibiae by placing metal landmarks along the TC course and a guidewire overlapping the MA. Coronal view radiographs were taken in different positions of tibial axial rotation, and the relationships between the TC and MA were analyzed. The TC showed three different patterns, comprising a curved, mixed and straight course in 47 (54.6%), 21 (24.4%) and 18 (20.9%) tibiae, respectively. When a curved course was found, the TC intersected the MA at proximal and distal points located, on average 22.4% and 63.3% along the tibial length, respectively. When a straight course was found, the mean angle between the TC and MA was 2.9°. In 35% of the cases, the two axes differed by more than 3°. The TC of Caucasian subjects exhibits a marked variability in its course and relationship with the MA. Unlike the TC in Asian subjects, the TC of Caucasians cannot be considered an accurate anatomical reference to guide the coronal alignment of the tibial component in TKA.

Radiographic Assessment of the Depth of the Troclear Groove and Patellar Diameter in Dogs

Background: Patellar luxation is an alteration of bone development for which the indicated treatment is surgery. Failure to correct it may result in clinical worsening. The most commonly used surgical approach is the transposition of the tibial crest with trochleoplasty, which aims to accommodate 50% of the patella in the trochlea. The femoral groove and trochlea can be evaluated radiographically by tangential projection, tomography, or ultrasonography; however, all these methodologies have limitations. The objective of this study was to evaluate the depth of the trochlear groove in three regions and to compare it with the patellar diameter on simple mediolateral radiographic images.Materials, Methods &amp; Results: Fifty non-paired pelvic limbs of adult dogs of a specific breed, weighing less than 40 kg and without orthopedic changes, were used. In the mediolateral radiographic projection, three evaluators measured the femoral trochlear sulcus at three different points and the patellar diameter. After imaging examinations, all limbs were skeletonized, and the trochlea and patella were measured with a digital caliper in the same regions as that of the radiographic measurements. All post-skeletonization calculations were performed by an evaluator. The highest mean radiographic and ex vivo trochlear depth was 3.4 ± 1.2 mm and 2.7 ± 0.8 mm, respectively. The lowest mean radiographic and ex vivo patellar diameter was 7.7 ± 1.7 mm and 7.9 ± 1.6 mm, respectively. The average relationship between the trochlear depth and patellar diameter was less than 50% in all animals, with the highest radiographically determined ratio being 44.15% and that determined ex vivo as 34.17%. The mean patellar diameter calculated radiographically was similar among the animals.Discussion: Radiographic images made it possible to assess the patella and bone surface regions of the femoral condyles. A wide arthrotomy is necessary to perform sulcoplasty, and a simple preoperative planning examination, which can facilitate the measurement of the trochlear sulcus, is important to correctly determine the procedure. The fragments evaluated after skeletonization and radiographic evaluations showed an average relationship between the trochlear depth and patellar diameter of less than 50%, thus indicating that sulcoplasty may not be necessary in animals with a ratio less than 50%. The radiographic measurements in this study used specific reference points that became more difficult to reproduce after skeletonization reducing the reliability of ex vivo data. A large variation in results was noted in each area of the measured groove, thus indicating that the trochlear measurements should be breed-specific and that it is necessary to reduce the amplitude and standardize the values. The depths in the postskeletonization limbs resulted in lower means than that obtained radiographically. Notably, articular cartilage cannot be measured using radiology; thus, image-based measurements can overestimate the trochlear parameters. Developing histopathological evaluations, determining cartilage thickness by race, and evaluating the association with measurements using imaging techniques can enhance the accuracy of the results. The methodology for measuring the diameter of the patella was radiographically reliable; however, the mean value obtained cannot be extrapolated to all animals. We thus recommend that this evaluation be standardized based on race and on a case-by-case basis. Based on the results obtained, there is wide variation in the depth of the trochlear groove in dogs. Trochleoplasty is important; however, it is essential that the surgeon determines whether this surgical trauma is necessary.

Preoperative planning for tibial plateau leveling osteotomy based on proximal tibial width.

The purpose of this study was to evaluate the applicability and feasibility of a novel preoperative planning method for tibial plateau leveling osteotomy (TPLO) based on the width of the proximal tibia. All TPLO procedures were performed by the same surgeon. In preoperative planning, the width of the tibial crest to the caudal edge of the medial tibial plateau (W) was measured, and the saw blade size that was closest to the distance between the point of the cranial third W and the intercondylar tubercles was selected. The postoperative tibial plateau angle (TPA), distance of eccentricity (DOE), and minimum thickness of the tibial tuberosity remaining cranial to the osteotomy (tibial tuberosity width; TTW) were documented. Complications in the perioperative and follow-up periods were documented. Thirty-one TPLO procedures were performed in 28 dogs, including both small and large breeds. The postoperative TPA was 8.4 ± 2.0° and the DOE was 3.55 ± 2.88 mm. The ratio of the TTW to the preoperative W was 0.27 ± 0.06. There were no major complications, such as fractures of the tibial tuberosity or implant breakage. This preoperative planning method allowed appropriate planning for TPLO with a clear index that was based on the size of the tibia rather than the breed or weight of the dog. This method should be of benefit to the surgeon, whether an expert or a novice, and contribute to the success of TPLO.

Analysis of donor site complications at the anterior iliac crest harvest site for treatment of tibial plateau fractures

Introduction: In tibial plateau fractures with intraarticular depression and metaphyseal comminution, bone grafting or the use of a bone substitute may be required. Harvesting autologous iliac crest bone graft for other orthopedic procedures has complications. The aim of this study was to evaluate the complication rate after harvesting bone graft as used for the treatment of tibial plateau fractures. Patients and methods: Patients treated in a tertiary care hospital with operative intervention for tibial plateau fractures with iliac crest bone graft between January 2015 and December 2018 were included in this retrospective study. Patients’ records were evaluated and clinical evaluation was performed at follow-up. Results: 46 patients (20 females, 26 males, mean age 55.2±14.9 years) were included in this study. Follow-up was mean 4.3±1.2 years. Only minor complications such as hematoma could be identified; in one patient, repeat surgery for bleeding was performed. No nerve injuries, long-term pain, fractures, infections or wound healing disturbances could be seen. The use of a drain, the type of wound closure or amount of harvested bone did not influence complication rate. Conclusion: This study shows that harvesting of iliac crest bone graft for the treatment of tibial plateau fractures is a safe procedure with a very low complication rate. Keywords: Tibial plateau fractures Iliac crest bone graft Donor site complications

Experimental study on the improvement of Ilizarov transverse tibial bone transport and microcirculation reconstruction technique

Objective: To observe the effect of traditional and modified Ilizarov transverse tibial bone transport on microvascular regeneration of lower limbs in dogs. Methods: After general anesthesia on 10 experimental dogs, traditional and modified transverse tibial bone transport were performed on both tibias respectively. The control group was treated with the traditional method (the periosteum and bone flap were completely isolated), while the experimental group was treated with the modified method (the fibular periosteum of the open window bone flap was retained). All the external fixators were pulled outwards at a speed of 1 mm every day from 5 days after operation;after one week, the external fixators were moved back every 3 days for one week. The situation of wounds and activity of lower limbs were observed. Simultaneously, the angiogenesis was observed by digital subtraction angiography (DSA) through femoral artery at different stages, and the density of vascular endothelial cells measured by local tissue sections. The data before and after the operation were compared with paired t test. Results: The operation was successfully completed in 10 experimental dogs, and all wounds healed about 1 week after the operation. There was no significant abnormality in lower limb movements in all dogs. Peripheral blood vessel area in middle leg of lower limb in 4 weeks and 8 weeks after operation was (5.9±0.4) mm(2) and (6.9±0.6) mm(2) in control group and it was (6.2±0.6) mm(2) and (8.0±0.6) mm(2) in experimental group, respectively; all were significantly improved than those before the operation ((5.0±0.4) mm(2), (4.9±0.4) mm(2), respectively) (F=446.457, 829.192, both P<0.05). There was no significant differences in vessel area between the two groups at the 4th week after operation (t=1.216, P=0.240), but there was significant difference at the 8th week after operation between the two groups (t=4.423, P=0.000). The percentage of vascular endothelial cells in stained cells under endoscopy was 4.42%±0.28% and 5.63%±0.53% in the control group at the 8th week; and in the experimental group, it was 5.35%±0.26% and 7.18%±0.25%, respectively;all were significantly elevated than those before the operation; and there were significant differences between the two groups (t=7.35, 8.30, both P<0.05). Conclusion: Transverse tibial bone transport and microvascular network regeneration technology can reconstruct the microvasculature below the calf of dogs; the method of window-opening osteotomy is improved to "door" type window-opening, it can retain the lateral periosteum of tibial crest and regenerate the microvasculature network more abundantly.