Tibial Fragment Research Articles

An Approach to Intraoperatively Identify the Coronal Plane Deformities of the Distal Tibia When Treating Tibial Fractures with Intramedullary Nail Fixation: a Retrospective Study.

ObjectiveTo develop a new approach to intraoperatively identify the presence of coronal plane deformities (both valgus and varus) when treating tibial fractures with closed reduction and intramedullary nail fixation.MethodsA retrospective analysis was conducted by enrolling 33 consecutive patients with tibial fractures who received closed reduction and intramedullary nail fixation from January 2018 to January 2019 at our trauma center. Out of the 33 patients, 23 were males and 10 were females and the average age was 41 years (ranging 22 to 69 years of age). Standard anteroposterior and lateral preoperative radiographs were routinely performed. After intraoperatively inserting the tibial intramedullary nail through the standard entry point, the parallel relationship between the distal horizontal interlocking screw and the tibiotalar joint surface on the anteroposterior fluoroscopy was used to determine the occurrence of valgus or varus deformities of the distal tibial fragment. Radiographic and clinical outcomes were analyzed using the average interval from injury to surgery, the lateral distal tibial angle (LDTA) of the unaffected and affected sides, complications and the Olerud–Molander ankle score.ResultsAll 33 patients were postoperatively followed for 13 to 25 months (mean 18.7 months). The fractures achieved bone union at an average of 4.3 months (ranging from 3 to 6 months). The total complication rate was 60.6% (20 cases), including four cases that showed deep vein thrombosis, one case showing an infection and delayed union and 15 cases showing slight to moderate anterior knee pain. The postoperative LDTA of the unaffected side measured 87.3° to 89.6 ° (average 88.7° ± 0.8°), and the LDTA of the affected side was 87.5° to 90.4° (average 88.9° ± 1.1°). There was no significant difference between the unaffected and affected sides (t = −1.865, P = 0.068). The intraoperative measurement indicated six cases of valgus angulation and three cases of varus angulation deformities, and all deformities were corrected during surgery. According to the Olerud–Molander ankle score, clinical outcomes demonstrated 22 excellent cases, eight good cases, two fair cases, and one poor case 12 months after surgery.ConclusionThe parallel relationship between the distal horizontal interlocking screw and tibiotalar joint surface on intraoperative anteroposterior films were able to determine the onset of valgus or varus angulations of the distal tibial fragment in the fracture zone after the tibial intramedullary nail was inserted through the standard entry point.

Unusual Occurrence of Incarceration and Breakage of the Coiled Shaft of the Intramedullary Reamer during Closed Intramedullary Nailing of Tibia.

Introduction:Intramedullary (IM) nailing is a well-established method of treating closed tibia shaft fracture. We hereby describe an unusual incidence of the incarceration of the flexible IM reamer in the distal fracture fragment with breakage of the coiled shaft of the reamer in the proximal third of tibia during closed IM nailing. This case report highlights the usefulness of making a small window in the tibia to aid retrograde removal of incarcerated reamer.Case Presentation:A 26-year-old male patient had road traffic accident and sustained a close fracture of the right distal 3rd tibia along with segmental fracture of the adjacent fibula. The tibia nailing was done under combined spinal and epidural anesthesia. The proximal tibia was approached by a midline incision with splitting of the patellar tendon. The reduction of the fracture fragments was done and the guide wire was inserted. The medullary canal was narrow and hence the initial reaming was started with the smallest available, that is, 8 mm reamer. After crossing the fracture site, we noticed that reamer coiled shaft got broken into multiple pieces in the medullary cavity at proximal 3rd tibia. The fracture site was exposed and a linear osteotomy was done in distal tibial fragment. Through this window, the broken reamer was pushed in the retrograde manner and was delivered out. Most of the broken metal pieces of the reamer shaft were removed with pituitary rongeur. An 8 mm solid IM nail was passed in antegrade manner across the fracture site and was locked distally and proximally. The operative wounds were irrigated and closure was done in layers. The patient was allowed partial weight bearing at 3 weeks post-surgery with gradually progressing to full weight bearing at 10 weeks after confirming clinical and radiological union.Conclusion:To handle this unusual occurrence one needs to stay calm, make a small window to aid retrograde removal of reamer and remove the fragmented pieces of the coiled shaft of the reamer. In tight medullary canal, it is desirable to have smaller diameter reamers, that is, 6 mm during the surgery.

Pathoanatomy of the Anterolateral Tibial Fragment in Ankle Fractures.

The anterior distal tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered a fourth, or anterior, malleolus (AM). Fractures of the AM may extend into the tibial incisura and tibial plafond. The purpose of this study was to analyze the pathoanatomy of AM fractures and associated ankle injuries. One hundred and forty patients (median age, 61.0 years) with a total of 140 acute malleolar fractures (OTA/AO 44) involving the anterolateral distal tibial rim were analyzed with computed tomography (CT) imaging. All components of the malleolar fractures were analyzed and classified. Fracture patterns were compared with those of all patients with malleolar fractures treated during the same 9-year period. Patients with fractures of the tibial pilon (OTA/AO 43) and patients <18 years of age were excluded. Of the 140 AM fractures, 52.9% were classified as type 1 (extra-articular avulsion); 35.7%, type 2 (incisura and plafond involvement); and 11.4%, type 3 (impaction of the anterolateral plafond). The fibula was fractured in 87.1%; the medial malleolus, in 66.4%; and the posterior malleolus, in 68.6%. An isolated AM fracture was seen in 4.3%. The size of the AM fractures correlated negatively with that of the posterior malleolar fractures. The proportion of pronation-abduction fractures increased and the proportion of supination-external rotation fractures decreased as the type of AM fracture increased. A fracture involving the AM occurred in 12.6% of all ankle fractures and occurred significantly more frequently in pronation-type injuries and elderly patients. No supination-adduction fractures with AM involvement were seen. The intraclass correlation coefficient for the proposed classification of the AM fractures was 0.961 (95% confidence interval [CI] = 0.933 to 0.980) for interobserver agreement and 0.941 (95% CI = 0.867 to 0.974) for intraobserver agreement. Knowledge of the 3D pathoanatomy of AM fractures and associated malleolar fractures may help with surgical decision-making and planning. CT imaging should be employed generously in the diagnosis of complex ankle fractures, in particular with pronation-type injuries. Depending on the individual 3D fracture pattern, fixation of displaced anterolateral distal tibial fragments potentially contributes to the restoration of joint congruity, tibiofibular alignment, and syndesmotic stability in complex malleolar fractures.

Can Hardware Removal be Avoided Using Bioresorbable Mg-Zn-Ca Screws After Medial Malleolar Fracture Fixation? Mid-Term Results of a First-In-Human Study

Twenty patients with isolated, bimalleolar, or trimalleolar ankle fractures were treated with bioresorbable screws made of Mg, 0.45wt% calcium (Ca) and 0.45wt% zinc (Zn) (ZX00). Patient-reported outcome measures (PROMs) including visual analogue scale (VAS) for pain, the presence of complications 6 and 12 months after surgery and the AOFAS scale after 12 months were reported. The functional outcomes were analysed through the range of motion (ROM) of the ankle joint with a standard goniometer. Degradation products and the bioresorbability of the screws were evaluated using plane radiographs. One patient was lost to follow-up. All patients were free of pain, no complications, shoe conflict or misalignement were reported after 12 months of follow-up. No Mg screws were surgically removed. An additional fixation of the distal fibula or the dorsal tibial fragment with conventional titanium implants (Ti) was performed in 17 patients. Within 12 months after primary refixation, 12 of these patients (71%) underwent a second surgery for Ti hardware removal. The mean AOFAS score was 89.8±7.1 and the difference between the treated and the non-treated site in the ROM of the talocrural joint was 2°±11° after 12 months. Radiolucent areas around the screws were attributed to degradation and did not affect clinical or functional outcomes. After one year, the Mg screw heads could not be detected in the plane radiographs of 17 patients which suggests that the majority of the screw head is degraded without introducing adverse reactions. At 6 and 12 months, the bioresorbable Mg screws show excellent PROMs without complications or need for screw removal. The resorbability of the screw heads in most of the patients after one year could also provide an advantage over conventional bio-inert implants by avoiding related skin irritation due for instance to shoe conflict.

Implantation of an attachment tube preserves knee extension after nonunion of Felix IV fracture: a case report

BackgroundWhile commonly utilized to fix tissue and muscles to megaprostheses to restore function and stability after tumor surgery, an attachment tube was used as a synthetic reconstruction of the knee joint’s extension mechanism after nonunion of Felix IV C fracture. Fixation of the tibial fragment, and therefore its osteointegration, is complicated after total knee arthroplasty, causing tibial tubercle dislocation.Case presentationA 61-year-old German patient presented to our clinic with Felix IV C fracture, persistent knee pain, and reduced knee extension strength. In this special case, mobilization and reattachment of the tibial tubercle was not possible because of necrosis and underlying tibial component. Therefore, we covered the defect with cement and used an polyethylene terephthalate tube for knee extension system augmentation. Follow-up after 10 months demonstrated a good clinical result.ConclusionThe management of Felix IV C fractures is complicated by the underlying prosthesis resulting in redislocation of the fragment and persistent symptoms of pain and reduced functionality. We here present a new surgical technique to treat periprosthetic fracture complicated by tibial tubercle dislocation. Good clinical and radiologic results on follow-up after 10 months indicate the use of attachment tubes as a suitable surgical technique to restore knee joint extension and to reduce knee pain after dislocated Felix IV C fracture.

English

BACKGROUND Fractures of both proximal and distal metaphyses with small distal fragment of tibia are not uncommon. Internal fixation using intramedullary nails alone could lead to misalignment. Using blocking screws (Poller screws) in addition to intramedullary nails would help in narrowing the medullary cavity and decreases the degree of misalignment and chances of displacement. The present study was conducted to evaluate functional and radiological outcome of blocking screws with intramedullary nail in the treatment of proximal and distal metaphyses fractures of tibia with short distal fragment. METHODS A prospective observational study of 34 patients with proximal and distal tibial metaphyses fractures was treated with statically locked intramedullary nailing with supplementary blocking screws. The study was conducted from January 2018 to December 2020 with a maximum follow up of 18 months. Medullary canal diameter was measured at the levels of fracture and isthmus. RESULTS Among the 34 patients, 29 (85.29 %) were males and 05 (14.70 %) were females with a male to female ratio of 5.8 : 1. The mean age was 34.97 ± 3.10 years. The mean healing period was 20 ± 1.45 weeks. 25/34 (73.52 %) of the patients showed Karlstrom and Olerud functional grading score of excellent. The fracture varus/valgus alignment was 1.9 ± 0.3 degrees. The mean antecurvatum/recurvatum alignment was 0.3 degrees. CONCLUSIONS Blocking screws act as reduction tools, help in reducing the medullary lumen of distal metaphyses and prevent failures in initial reduction. They extend the indication of intramedullary nailing to the distal segment of tibia and minimize the misalignment in terms of varus /valgus and/or antecurvatum/recurvatum. KEYWORDS Tibia, Intramedullary, Blocking Screws, Internal Fixation and Misalignment

Fixation of anterolateral distal tibial fractures: the anterior malleolus.

The anterior tibial rim with the anterolateral tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered an anterior or "fourth" malleolus. Fixation of adisplaced anterior tibial fragment in the treatment of malleolar fractures aims at providing abone-to-bone fixation of the anterior tibiofibular ligament and restoring the integrity of the tibial incisura. Displaced intra-articular fragments of the anterior tibia; fractures involving the tibial incisura; fractures with intercalary fragments; impaction of the anterior tibial plafond; syndesmotic avulsions producing instability or preventing reduction of the distal fibula into the tibial incisura. Critical local soft tissues preventing an anterolateral approach; missing consent to surgery by the patient; overall critical general condition preventing surgery to the extremities. Anterolateral approach over the tibial tubercle. Identification and mobilization of the anterior tibial fragment without dissecting the anterior syndesmosis. Reduction of the anterior tibial fragment with apointed reduction clamp. Fixation of extra-articular avulsion fractures (type1) with suture anchor. Screw fixation of larger fragments involving the joint surface and incisura (type2). Disimpaction, realignment of the joint surface, bone grafting as needed and plate fixation of impaction fractures of the anterolateral tibial plafond (type3). Mobilization with partial weight bearing (15-20 kg) in aspecial boot (ankle foot orthosis) or cast for 6-8weeks depending on the overall malleolar fracture pattern, bone quality and patient compliance. Few studies report the results of anterior tibial fractures in adults. Failure to fix displaced fragments frequently leads to nonunions. Overlooked Chaput fractures have been reported to result in malpositioning of the distal fibula in the tibial incisura leading to incongruity of the ankle mortise requiring revision surgery. Secondary avascular necrosis of the anterolateral tibial plafond may develop after joint impaction.

Rotational Changes in the Distal Tibial Fragment Relative to the Proximal Tibial Fragment at the Osteotomy Site after Open-Wedge High-Tibial Osteotomy.

The present study is aimed at assessing the changes in tibial rotation at the osteotomy site after an open-wedge, high-tibial osteotomy (OWHTO) and analysing the factors that affect rotational changes in the distal tibial fragment relative to the proximal tibial fragment at the same site. This study involved 53 patients (60 knees; 16 males and 37 females) with medial osteoarthritis (OA) who underwent OWHTO and preoperative and 3-month postoperative computed tomography (CT) scans. Rotational angles of the distal tibia were measured using Stryker OrthoMap 3D by comparing preoperative and postoperative CTs. The mean rotational angle yielded an external rotation of 2.9° ± 4.8°. There were 17 knees with internal rotations, 37 knees with external rotations, and one knee with no rotation. The rotational angle significantly correlated with the resultant change in the femorotibial angle (correction angle) and the angle between the ascending and transverse osteotomy lines on the anterior osteotomised surface on which a flange was formed with the distal tibial osteotomised surface (flange angle). The flange angle affected the rotation, but it may have been affected by our surgical technique. The rotational angle did not significantly correlate with the change in the angle of the posterior tibial slope or body mass index. There were significant correlations between the rotational angle and correction angle (r = 0.42, p < 0.05). Additionally, the rotational angle correlated with the flange angle (r = −0.41, p < 0.05).

Mechanical and structural peculiarities of tibia shaft nonunion and its influence for treatment

Objective. To study internal tensions in bone and soft tissues of shin at normal condition and at isolated tibia nonunion, the range of fragments displacement, callous structure and to sustain the conception of treatment. Methods. Due to finite element method we created three models: I — anatomic norm; II — transverse defect of 5 mm height on the middle-lower 1/3 border filled with collagen, III — as the second model with empty fibula defect of 10 mm height on the same level 2/3–1/3 border. In 45 patients with tibia shaft nonunion (term 4–18 months) we made resection of fibula fragment 10–15 mm on the same level of tibia nonunion with apparatus of external fixation. We studied the linear bone fragments displacement and callous structure. Results. At the axial loading in normal condition (I model) there was asymmetry of tensions in the lower part of shin bones on the lateral and medial sides. At the II model vertical tensions in the lower part of tibia decreased on the medial side up to 69 % and on the lateral side — up to 44 %, tensions increased in 5 times on the lateral side of fibula. The tangential stresses increased 3 times, their resulting force vector changed the outward direction and increased 7 times. In the III model tension distribution on the tibia surface became close to normal situation. In case of tibia nonunion there was fibrous-cartilages tissues, appeared because of transverse tensions. Patients walked with weight bearing from the first days after surgery, in 95.6 % bone fragments consolidation happened in 3.5–4 months. Conclusion. Excluding of fibula from bearing function due to its 10–15 mm resection on the level of nonunion will normalize the vector of loading in the tibia fragments and fibrous-cartilage regenerate and leads to it ossification.

How do lateral hinge and distraction affect three-dimensional rotation in open wedge high tibial osteotomy?

BackgroundOpen-wedge high tibial osteotomy (OWHTO) has extensively been used for the correction of medial knee osteoarthritis. The proximal tibia is osteotomized and distracted to enable the rotation of tibial fragments around the lateral hinge. Both, wedge inclination on the medial side and saw progression near the lateral cortex determine the hinge orientation. This study focused on the interaction between hinge orientation and distraction sites on the coronal, sagittal, and horizontal planes of the distracted plateau. MethodsThree parameters of wedge inclination, saw progression, and distraction site (i.e., posterior, middle, and anterior) were systematically varied. Using a three-dimensional (3D)-printing technique, the osteotomized tibiae were manufactured as the specimens for the in vitro experiments. In total, 27 variations (3 × 3 × 3) were tested. After distraction, the specimens were scanned by computed tomography and spatially registered with the original tibia to compare the 3D angles of the distracted plateaus. ResultsCoronal rotation is the main purpose of OWHTO; therefore, all the values of the coronal angles were positive and significantly higher than the other two. The sagittal and horizontal angles had relatively similar values. Distraction in the middle site seems to have the least impact on sagittal rotation. Large angles of hinge orientation show the superior ability in adjusting the sagittal rotation than small angles. However, the larger the horizontal angles the greater the wedge inclination. ConclusionsThe wedge inclination, saw progression, and distraction site constitute a complex mechanism that affects 3D rotations of the distracted plateau. The coronal angles are sensitive to hinge orientation and distraction site. The intraoperative planning of manipulating hinge orientation is an effective method to adjust sagittal rotation. A large angle of wedge inclination is an indicator of horizontal rotation, and it should be carefully mitigated to reduce the risk of cracking in the lateral hinge.

Surgical Fixation of Quadrimalleolar Fractures of the Ankle.

We present a technique of fixation of trimalleolar fractures with additional fracture of the anterior tibial tubercle ("quadrimalleolar") or anterior fibular rim ("quadrimalleolar equivalent"). Twenty-four patients with a mean age of 60 years were treated with open reduction and internal fixation of all 4 malleoli. There were 17 quadrimalleolar and 6 quadrimalleolar equivalent fractures. One patient had both anterior tibial and fibular avulsion fracture in addition to a trimalleolar ankle fracture. Surgical approaches and internal fixation were tailored individually. Twenty patients were operated in the prone position with direct fixation of the posterior malleolus and 4 patients in the supine position with anterior to posterior screw fixation of the posterior malleolus. After fixation of al 4 malleoli, only 1 patient (4%) required a syndesmotic screw for residual syndesmotic instability on intraoperative testing. There were no infections and no wound healing problems. All patients went on to solid union. Nineteen patients (79%) were followed for a mean of 77 months (range, 15-156 months). The Foot Function Index averaged 15 (range, 50 to 0), the Olerud and Molander Score averaged 79 (range, 45-100), and the American Orthopaedic Foot and Ankle Society Ankle and Hindfoot Scale averaged 87 (range, 39-100). Fixation of the anterior and posterior tibial fragments increases syndesmotic stability by providing a bone-to-bone fixation. Anatomic reduction of the anterior and posterior tibial rim restores the physiological shape of the tibial incisura and therefore facilitates fibular reduction.

Increased contact area of flange and decreased wedge volume of osteotomy site by open wedge distal tibial tuberosity arc osteotomy compared to the conventional technique

The purpose of this study was to evaluate the area of the osteotomy surface, including the flange and wedge volume, in open wedge high tibial osteotomy (OWHTO), distal tibial tuberosity osteotomy (DTO), and distal tibial tuberosity arc osteotomy (DTAO) using tibial sawbones. It was hypothesized that the area of the osteotomy surface, including the flange, in DTAO was larger than that in OWHTO and DTO and that the wedge volume in DTAO was smaller than that in OWHTO and DTO. Fifteen tibial sawbones were divided equally into three groups: OWHTO, DTO, and DTAO. The total area of the osteotomy surface in OWHTO, DTO, and DTAO was compared using image analysis software. The contact area of the flange and the wedge volume at wedge heights of 5, 10, and 15mm were compared among osteotomy types. One-way repeated-measures analysis of variance was used to compare the total area of the osteotomy surface, the contact area of the flange, and the wedge volume at 5, 10, and 15mm in OWHTO, DTO, and DTAO. The total area of the osteotomy surface in DTO and DTAO was significantly larger than that in OWHTO (P < 0.05). The contact area of the flange in DTAO was significantly larger than that in OWHTO at each wedge height (P < 0.05). In addition, the contact area of the flange in DTAO was significantly larger than that in DTO at wedge heights of 5 and 15mm (P < 0.05). The wedge volume in DTAO was significantly smaller than that in DTO at each wedge height (P < 0.05). This study demonstrated that an increase in the flange contact area and a decrease in the wedge volume in the opening gap were found in DTAO compared to DTO. This would be an advantage for anteroposterior screw insertion from the flange to the distal tibial fragment and bone union at the osteotomy site.

‘In-Out-In’ K-wires sliding in severe tibial deformities of osteogenesis imperfecta: a technical note

Severe infant osteogenesis imperfecta requires osteosynthesis. Intramedullary tibia’s osteosynthesis is a technical challenge given the deformity and the medullar canal’s narrowness. We describe an extramedullary technique: ‘In-Out-In’ K-wires sliding. We performed an anteromedial diaphysis approach. The periosteum was released while preserving its posterior vascular attachments. To obtain a straight leg, we did numerous osteotomies as many times as necessary. K-wires (‘In’) were introduced into the proximal epiphysis, and the medial malleolus (‘Out’) bordered the cortical and (‘In’) reach their opposite metaphysis. K-wires were cut, curved and impacted at their respective epiphysis ends to allow a telescopic effect. All tibial fragments are strapped on K-wires, and the periosteum was sutured over it. Our inclusion criteria were children with osteogenesis imperfecta operated before 6 years old whose verticalization was impossible. Seven patients (11 tibias) are included (2006–2016) with a mean surgery’s age of 3.3 ± 1.1 years old. All patients received intravenous bisphosphonates preoperatively. The follow-up was 6.1 ± 2.7 years. All patients could stand up with supports, and the flexion deformity correction was 46.7 ± 14.2°. Osteosynthesis was changed in nine tibias for the arrest of telescoping with flexion deformity recurrence and meantime first session-revision was 3.8 ± 1.7 years. At revision, K-wires overlap had decreased by 55 ± 23%. Including all surgeries, three distal K-wires migrations were observed, and the number of surgical procedures was 2.5/tibia. No growth arrest and other complications reported. ‘In-Out-In’ K-wires sliding can be considered in select cases where the absence of a medullary canal prevents the insertion of intramedullary rod or as a salvage or alternative procedure mode of fixation. It can perform in severe infant osteogenesis imperfecta under 6 years old with few complications and good survival time.

Eremotherium (Xenarthra, Mammalia) materials from the collections of Laboratório de Paleontologia e Evolução and Laboratório de Geologia of Universidade Federal de Goiás

This study presents the first survey of fossil mammal specimens housed at the collections of the Federal University of Goiás. Here, we describe a set of associated femur and vertebrae fragments, one fragment of tibia, and two left and right maxillary fragments, identified as Eremotherium. Despite its fragmentary condition, the size and morphological aspect of the materials show diagnostic characteristics that suggest their relationship with Eremotherium. These new specimens described here contribute to the paleontology of the Goiás State, which may provide future research investments in collections not yet known, which may increase the knowledge on Pleistocene mammals of Central Brazil.

A comparison of the direct and indirect methods of estimating skeletal height from tibial fragments in black South Africans.

The estimation of maximum bone length from its fragments is important in forensic anthropology as these length estimates can be used to estimate the total skeletal height (TSH), and thereby stature, of unknown skeletal remains. This is known as the indirect method of stature estimation. Alternatively, TSH can be estimated directly from bone fragments without first estimating maximum bone length. While regression equations for estimating maximum bone length from its fragments exist for long bones of the upper and lower limbs, these equations are population- and sex-specific and their use on populations other than the one they were derived from is not recommended. The aim of this study was therefore to develop formulae for estimating maximum tibial length from its fragments in black South Africans, which previously did not exist, and to compare the accuracies of the direct and indirect methods of estimating TSH from tibial fragments. Several measurements representing fragments were measured on the tibiae of 99 male and 99 female black South Africans, and equations estimating tibial length from these measurements were derived. Correlation coefficients of each equation were significant, and all equations estimated tibial length with moderate to high accuracy. A comparison of the standard errors of estimate (SEEs) between the direct and indirect methods of stature estimation indicate that the direct method is more accurate and should be used to estimate stature from tibial fragments when such equations exist.

Stage treatment of patient with gunshot shin wound possessing bone and soft tissue defects in conditions of osteomyelitis

The paper presents a case of severe gunshot wound of the shin in a 16-year-old adolescent as a result of gunshot from a small distance. Comminuted fracture of the tibia, damage of the anterior tibial artery, defect of the soft tissue in the injured area were detected. When admitted to the hospital, the patient underwent surgical treatment of the wound and fixation of fragments in carboxylic rod apparatus of external transosseous fixation. Osteomyelitis was developed. Ten days later, reosteosynthesis was performed. The first stage of bilocal osteosynthesis of the right shin was implemented, necrotized soft tissues and bone fragments and detritus were removed, initial purulent process was arrested. There was started distraction of the distal fragment of the tibia obtained as a result of its corticotomy in the lower third into the bone defect measuring 5 cm, which occurred when implementing surgical treatment of the wound. Twenty-eight days after, open alignment of tibial fragments in the upper third and reinstallation of Ilizarov apparatus was performed. The site of fragment junction was closed with unfree skin flap on the pedicle measuring 4 6 cm, the transplant bed was closed with full-layer skin graft using Parins technique. The further consolidation of fragments was reached simultaneously with maturation of the bone regenerate. The total period of fixation in Ilizarov apparatus lasted for 8 months. The bone and soft tissue structural integrity was restored, full function of the lower limb and adjacent joints was reached. Ilizarov apparatus is indispensable in multistage treatment of gunshot fractures and provides dynamic correction in changeable conditions; it permits to preserve the limb and its functionality.

Non-locked and locked small fragment straight plates have a similar behavior in buttressing the posteromedial shear tibial plateau fragment: a biomechanical analysis of three different fixations

PurposeThe aim of this study is to compare the biomechanical behavior of three different fixation constructions currently used for buttressing the posteromedial shearing tibial plateau fragment. Our hypothesis is that non-locked implants provide sufficient comparable stability in posteromedial tibial plateau fractures as locked implants.MethodsFifteen left synthetic tibiae from a single manufacturing batch were used to create a posteromedial shear tibial plateau fracture. The fracture was buttressed with three different posteriorly placed five-hole straight small-fragment plate. Five models were fixed with a one-third tubular plate (TTP), five models with a dynamic compression plate (DCP), and five models with a locking compression plate (LCP). All groups were tested to vertical subsidence (Stage 1). In the same experiment (Stage 2), TTP and DCP groups were tested until catastrophic failure. Force versus displacement curves were obtained in the two stages of the experiment.ResultsStage 1 – There was no significant difference in stiffness (p = 0.89), subsidence up to 2 mm (p = 0.38), and energy (p = 0.36) among the three fixation constructions. Stage 2 – Yield load revealed significantly less yield strength for the TTP group as compared with the DCP group (p = 0.048). However, there was no significant difference in maximum load to failure among the TTP and DCP fixation constructions (p = 0.16).ConclusionPlacement of either a locked or non-locked small fragment straight plate to buttress the posteromedial shear tibial plateau fragment has a similar biomechanical behavior. When the implant is positioned to buttress the shearing fragment it maximizes biomechanical stiffness.

Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial shaft fractures: a retrospective cohort study

BackgroundThe purpose of this study was to evaluate the association between epidemiological, clinical and radiographic factors of patients with tibial shaft fractures and the occurrence of acute compartment syndrome.Methods270 consecutive adult patients sustaining 273 tibial shaft fractures between January 2005 and December 2009 were included in this retrospective cohort study. The outcome measure was acute compartment syndrome. Patient-related (age, sex), fracture-related (high- vs. low-energy injury, isolated trauma vs. polytrauma, closed vs. open fracture) and radiological parameters (AO/OTA classification, presence or absence of a noncontiguous tibial plateau or pilon fracture, distance from the centre of the tibial fracture to the talar dome, distance between tibial and fibular fracture if associated, and angulation, translation and over-riding of main tibial fragments) were evaluated regarding their potential association with acute compartment syndrome. Univariate analysis was performed and each covariate was adjusted for age and sex. Finally, a multivariable logistic regression model was built, and odds ratios and 95% confidence intervals were obtained. Statistical significance was defined as p < 0.05.ResultsAcute compartment syndrome developed in 31 (11.4%) cases. In the multivariable regression model, four covariates remained statistically significantly associated with acute compartment syndrome: polytrauma, closed fracture, associated tibial plateau or pilon fracture and distance from the centre of the tibial fracture to the talar dome ≥15 cm.ConclusionsOne radiological parameter related to the occurrence of acute compartment syndrome has been highlighted in this study, namely a longer distance from the centre of the tibial fracture to the talar dome, meaning a more proximal fracture. This observation may be useful when clinical findings are difficult to assess (doubtful clinical signs, obtunded, sedated or intubated patients). However, larger studies are mandatory to confirm and refine the prediction of acute compartment syndrome occurrence. Radiographic signs of significant displacement were not found to be correlated to acute compartment syndrome development. Finally, the higher rate of acute compartment syndrome occurring in tibial shaft fractures associated to other musculoskeletal, thoraco-abdominal or cranio-cerebral injuries must raise the level of suspicion of any surgeon managing multiply injured patients.

Effect of Fibular Height and Lateral Tibial Condylar Geometry on Lateral Cortical Hinge Fracture in Open Wedge High Tibial Osteotomy

To evaluate whether the fibular position and lateral proximal tibial geometry affect the osteotomy configuration and lateral hinge fracture (LHF) during open wedge high tibial osteotomy (OWHTO). From March 2014 to January 2016, patients who underwent OWHTO for isolated medial compartment osteoarthritis of the knee were retrospectively reviewed. To identify whether the fibular position and lateral proximal tibial geometry affect the osteotomy configuration, the fibular height, fibular anteroposterior position, lateral tibial condylar width, and lateral tibial condylar slope were evaluated on plain radiograph or computed tomography (CT). Thereafter, the correlation of these parameters with the thickness of the proximal fragment around the osteotomy end and LHFs was determined. A total of 123 OWHTOs including 30 LHFs (24.3%) were evaluated. High fibular head and small tibial condylar width and slope were related to thin thickness of the proximal tibial fragment, particularly on the posterior side (fibular height, P= .005; condylar width, P= .002; condylar slope, P= .01). The fibular height was shorter in the LHF group than in the non-LHF group on both plain radiography and CT (fibular height [plain radiography], 18.3 ± 1.6 vs 20.2 ± 2.1mm; P < .001; fibular height [CT], 17.4 ± 1.1 vs 19.6 ± 2.0mm; P < .001). The lateral tibial condylar width and slope were also smaller in the LHF group compared with the non-LHF group (tibial condylar width, 21.2 ± 4.9 vs 23.4 ± 4.5mm; P= .023; tibial condylar slope, 37.7 ± 6.6 vs 41.3 ± 7.6mm; P= .027). The fibular position and lateral proximal tibial geometry affect the osteotomy configuration and LHFs. A highly positioned fibula was related to a small lateral tibial condyle, which induced a thin proximal fragment. This finding was related to a higher risk of LHFs. Therefore, understanding the fibular height and lateral proximal tibial geometry may be helpful for the prediction of the osteotomy configuration and development of LHFs. Level III, case-control study.

Using tibial fragments to reconstruct the total skeletal height of black South Africans

Stature is an important component of the biological profile of unknown skeletal remains and regression equations for estimating stature have been derived for a number of bones. However, bones are rarely recovered intact in both forensic and archaeological cases, and regression formulae for fragmentary remains have therefore been developed. These equations are, however, both sex- and population-specific, and while formulae exist for many populations, those using fragmentary tibiae do not exist for black South Africans. The aim of this study was therefore to establish regression equations for estimating total skeletal height (TSH), and thereby stature, from tibial fragments in a black South African population. A sample of 99 male and 99 female black South African skeletons were obtained from the Raymond A. Dart Collection of Human Skeletons and the TSH of each skeleton was calculated using the anatomical method. Eleven additional measurements representing tibial fragments were taken on each tibia, and both uni- and multivariate equations were established for estimating TSH from these fragments. All tibial variables were significantly, positively correlated with TSH, and equation correlations ranged between 0.41 and 0.91. The range of standard errors of estimate for the derived sex-specific (3.43–5.06 cm) and sex-pooled (3.44–5.94 cm) multivariate equations were slightly larger than those reported for intact tibiae in black (2.78–3.06 cm) and white (2.59–3.16 cm) South Africans. All uni- and multivariate-equations estimated TSH with moderate to high accuracy, which indicates that in the absence of intact tibiae, the equations presented in this study can be used to give accurate estimates of TSH, and thereby stature, for black South Africans.