Tibial Shaft Research Articles

Outcomes of Conservative versus Operative Management in Fracture Shaft Tibia and Fracture Shaft Femur in Pediatric Age Group

Background: Tibia is more often involved in open fractures because of its subcutaneous location. Severe open fractures of tibia are associated with high complication rate and poor long term outcomes. 70% of pediatric tibial fractures are isolated injuries and approximately 30% of pediatric shaft tibia fractures are associated with fibula fracture. AIM: The aim is to study clinical and radiological outcomes of patient with tibial and femoral fractures, who are treated with closed reduction and internal fixation with nailing versus treated conservatively by casting. Material and method: 40 cases with femur or tibia fractures treated with nailing and conservatively between 1st January 2022 to 30thNovember 2022 at rural medical college, loni a rural tertiary care hospital was analyzed retrospectively out of which 16 patients treated conservatively and 4 patients underwent operative management for tibia fractures while 16 patients were treated operatively and 4 patients treated conservatively for femur fractures. Results: Total 40 patients of shaft femur and shaft tibia fractures were treated conservatively with cast application and Closed reduction and internal fixation by elastic nailing. In comparision for simple transverse fracture, we can conclude that in most patients fracture can be treated conservatively to minimize soft tissue damage but only in unacceptable criteria for conservative management we can opt for minimally invasive procedure like TENS nailing. Conclusion: Immobilization time is shorter in surgical group but we have started mobilizing with cast application. It is the only advantage of surgical management which has been given in conservatively managed patients. Outcomes after 3 months.

MANAGEMENT OF COMPLICATED TRAUMA BY LIMB RECONSTRUCTION SYSTEM (MONO-LATERAL EXTERNAL FIXATOR) IN LOWER EXTREMITY

Introduction: High velocity trauma is the cause of maximum number of fatality in the younger age group worldwide. In the field of trauma surgery open fractures of the leg remain with the higher complication rate. Treatment options include wound debridement reduction and immobilization with cast, open reduction and plate fixation, external fixation, and IM nailing. Limb reconstruction system (LRS) is a unilateral rail system which consists of Schanz pins, rail rods, and sliding clamps. LRS was considered as definitive management for open fractures. LRS with its modular attachments, it is specifically designed to enable the surgeon to perform simple and effective surgery as it offers rigid fixation of fracture fragments, allows early weight bearing, and reduces the economic burden. Aim: The aim of the study was to determine the efficacy of mono-lateral external fixator LRS for management of the lower extremity long bone fracture (tibia/femur). Methods: A prospective study was carried out where 26 cases of lower extremity trauma (complicated) managed by LRS over a period of 5–6 months. The patients ranged from age 13 years to 67 years. Majority were male and predominant mode of injury was road side accidents. Majority of case were exposed to multiple the surgeries before LRS application. Most of the cases are of infection non-union. All the patients were treated at our hospital. These surgeries were done from June, 2005 to 2007. Any bone fragments that were protruding out we recovered with sterile dressing. The patient were taken to the operating room and treated by pulsed lavage and debridement the wound and splints. In patients, whose bone was exposed, as the wound condition improved the patients were planned for flap rotation. Assessment of quality of regenerate was done by plain radiography and clinical assessment at every follow-up. Final assessment for bone results and functional results was done using Association of the study and application of the method of Ilizarov (ASAMI) score. Results: Among 26 patients, bony results as per ASAMI score were excellent in 73.07% (n=19), good in 19.23% (n=5), fair in 3.84% (n=1), and poor in 3.84% (n=1). Functional results were excellent in 84.7% (n=22), good in 11.5% (n=3), and fair in 3.8% (n=1). All the 26 cases of lower extremity fracture were kept on LRS external fixator for a period of 5–6 months on an average depending on the rate of union, after which the fixator was removed. For 2 patients nailing was done after LRS frame removal. Average time for frame removal was 28 weeks. In most cases union was complete by 7–8 months, the least being 5 months for a tibia shaft fracture. The average hospital stay for the patients was 7 days and as compared to multi staged surgery financial burden was reduced by 40%. The average time of return to work for the patients was 3 weeks. Conclusion: Overall LRS proved to be an effective modality of treatment in cases of the lower extremity fracture with bone loss as definite modality of treatment for damage control as well as for achieving union and lengthening/transportation, deformity correction simultaneously, with the advantage of simple surgical technique, ease of application, minimal invasive, strong fixation, high patient compliance, early weight bearing, easy wound management, and the lower rate of complication.

Long-term analysis of chronic pain associated with lower extremity injuries

IntroductionThe main objective of this study is to examine chronic pain and limping in relation to lower extremity and pelvic fracture location in addition to fracture combinations if multiple fractures are present on the same leg that have not been previously reported. We hypothesize that fracture pattern and location of lower extremity and pelvis fractures of multiple injured patients influence their long-term pain outcome.Materials and methodsRetrospective cohort study. Patients with treated multiple lower limb and pelvic fractures at a level 1 trauma center and followed up for at least 10 years postinjury were assessed. Lower leg pain subdivided into persistent, load-dependent and intermittent pain, as well as limping were recorded by using self-administered patient questionnaires and standardized physical examinations performed by a trauma surgeon. Descriptive statistics were used to present comparative measurements between groups.ResultsFifty-seven percent of patients (n = 301) showed chronic lower limb pain 10 years postinjury. Ten percent of all patients with chronic pain displayed persistent pain, and here the most common fracture combination was tibial shaft fractures in combination with femoral shaft or proximal tibial fractures (13%). One hundred fifty-one patients reported load-dependent pain, with the most common fracture combinations being fractures of the foot in combination with femoral shaft fractures or distal tibial fractures (11%). One hundred twenty patients reported intermittent pain, with the most common fracture combinations involving the shaft of the tibia with either the femoral shaft or distal tibia (9%). Two hundred fifteen patients showed a persistent limp, and here the most common fractures were fractures of the femoral shaft (19%), tibial shaft (17%), and pelvis (15%).ConclusionsIn multiple injured patients with lower extremity injuries, the combination of fractures and their location are critical factors in long-term outcome. Patients with chronic persistent or load-dependent pain often had underlying femoral shaft fractures in combination with joint fractures.

What Is the Rate of Displacement of Occult Posterior Malleolus Fractures in Nailed Tibial Shaft Fractures?

To describe the radiographic consequences of posterior malleolus fractures (PMF) present with tibial shaft fractures fixed with intramedullary nails. Retrospective cohort study. Level 1 trauma center. Seven hundred thirty-three patients with tibial shaft fractures. Intramedullary nail fixation and prophylactic articular fixation. Displacement of PMF with intramedullary nail insertion. Seven hundred thirty-three patients were identified with tibial shaft fractures treated with intramedullary nail fixation at a Level 1 trauma center without a uniform preoperative computed tomography protocol. One hundred thirty-three patients had an identifiable PMF appreciated on preoperative imaging. Of the 600 remaining patients without a known PMF, 29 had PMF identified after nail insertion: 24 patients with nondisplaced fractures that all healed radiographically at final follow-up, 3 patients had fractures <30% of the articular surface displaced 1-2 mm, and 2 patients had fractures >30% of the joint surface that displaced 1-2 mm. The incidence of radiographically observable PMF associated with tibial shaft fractures is high, even without a preoperative computed tomography screening protocol in place. In patients without an appreciable PMF on injury films, less than 1% (2/600) had displacement of a large, clinically significant PMF with nail placement. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Влияние телескопического интрамедуллярного остеосинтеза большеберцовой кости на рост сегмента: пилотное экспериментальное исследование

Introduction Telescopic intramedullary osteosynthesis (TIO) is used in children with osteogenesis imperfecta and other diseases accompanied by frequent fractures and deformities of long bones due to pathological bone tissue featuring reduced strength properties. Purpose In an animal experiment to study the growth characteristics of an intact tibia under conditions of intramedullary reinforcement with a telescopic rod. Material and methods A non‑randomized controlled study was conducted on 4 animals (puppies, littermates) that underwent TIO of the right limb tibia with a telescopic titanium rod (outer diameter of 4.2 mm) at the age of 5 months. X-ray parameters (length of the tibia, angles of inclination of the articular surfaces, telescoping magnitude) were studied before surgery, on the day of rod placement, and after the end of spontaneous growth of the segment (7 months after surgery). The contralateral left tibia served as a control, and its X-ray parameters were studied at the same time-points. Results Transphyseal reinforcement with a telescopic rod caused growth retardation with loss of length in only one case out of four (8 mm or 4.8 % of residual growth). In other cases, no difference in the length of the tibias of the right and left lower extremities was found. Eccentric insertion of the transphyseal rods into the posterior third of the distal epiphysis (due to the natural anatomy of the canine tibial shaft) formed an angular deformity during growth: a significant increase in the distal anterior and lateral tibial angles of the operated limb compared to the intact limb. The amount of divergenceof the parts of the rods was, on average, 11.3 mm. There were no cases of migration of intramedullary rods or loss of fixation of threaded sections in the epiphyses. Conclusion Under experimental conditions, the slowing down of longitudinal bone growth is not a constantly observed effect. Titanium telescopic rods are not prone to blocking during the limb growth or to losing the position of the threaded parts in the epiphyses. The eccentric passage of the rods through the growth zones causes angular deformities in the course of growth of the segment.

Treatment of Diaphyseal Tibial Fractures Distal to a Total Knee Arthroplasty by Intramedullary Nailing Is Safe and Effective.

To report the clinical result of a series of patients who underwent intramedullary nailing (IMN) of tibial shaft fractures distal to a total knee arthroplasty (TKA). Retrospective case series. Level-1 trauma center. Patients who sustained a tibial shaft fracture distal to a TKA treated with an IMN. IMN of tibial shaft fractures distal to a TKA. Postoperative weight-bearing status, readmissions, and complications or failure of treatment within 90 days; Knee Injury and Osteoarthritis Outcome Scores at the final follow-up; failure of treatment; and revision surgery. Nine patients were included. The average age was 71.4 years (range 55-87 years). All TKAs were cemented. The average distance between the tibial keel and the cortical density of the tibial tubercle was 24.1 mm (range 19.5-26.7 mm). Six nails were inserted using an infrapatellar portal, 2 were inserted using a suprapatellar portal, and 1 was inserted using a lateral parapatellar approach. The median nail diameter was 10 mm (range 9-12 mm). All fractures were healed at the final follow-up. There were no infections or arthroplasty-related complications. Knee Injury and Osteoarthritis Outcome Scores ranged from 100% to 74% (median 82%). Overall, we report on the largest cohort in the literature undergoing IMN of a tibial shaft fracture distal to a TKA. We demonstrate that IMN of diaphyseal tibial fractures distal to a TKA can be performed safely. We additionally demonstrate that this treatment is highly effective in achieving fracture union with no arthroplasty-related complications. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Multimodal analgesia is superior to opiates alone after tibial fracture in patients with substance abuse history.

Objectives: To evaluate the effectiveness of multimodal analgesia in patients with a tibial shaft fracture. Design: Retrospective review. Setting: Large, urban, academic center. Patients: One hundred thirty-eight patients were evaluated before implementation of multimodal analgesia. Thirty-four patients were evaluated after implementation. All patients were treated operatively with internal fixation for their tibial shaft fracture. Patients with polytrauma were excluded. Intervention: Multimodal analgesia. Main Outcome Measures: Pain levels at rest and with movement were assessed. Morphine milligram equivalents (MMEs) dosed per patient were calculated each day. Length of stay was also documented. Results: After implementation of a multimodal analgesic program, there was a statistically significant decrease in pain score at rest (4.7-4.0, P = 0.034) and with movement (5.8-4.8, P = 0.007). MMEs dosed in the multimodal analgesic program correlated with pain score (R2 = 0.5), whereas before implementation of the program, MMEs dosed were not dependent on pain score (R2 = 0.007). Patients with a history of substance abuse had the most profound effect from this paradigm change. For those with a history of substance abuse, treatment of pain using a multimodal approach reduces MMEs dosed and length of stay (5.7-3.1 days, P = 0.016). Conclusions: Multimodal analgesia improves patient pain scores both at rest and during movement. In patients with a history of substance abuse, multimodal analgesia not only decreases pain but also decreases length of stay and MMEs dosed to levels consistent with someone who does not have a substance abuse history. Level of Evidence: Therapeutic Level III.

Evaluation of Radiological and Functional Results of Long Bone Diaphyseal Fractures in Children Aged 5-15 Years Who Underwent Titanium Elastic Nail

Objective: In this study, we aimed to evaluate the radiological and functional results of titanium elastic nail (TEN), which was used as a surgical method in pediatric long bone diaphyseal fractures between 5-15 years of age, by comparing it with the clinical features of the patient and the fracture.Methods: In this study, 44 patients (11 girls, 33 boys) aged 5-15 years (mean 9.86 ±2.84) were included. The clinical features of the patient, family satisfaction, evaluation of the fracture according to Flynn Criteria, time to bone union, stay in the hospital, and school absence was examined.Results: TEN was applied mostly to the femur (n;18), tibia (n;14), and forearm (n;12) diaphysis fractures, respectively. Most of the fractures were seen as a result of high energy and closed middle diaphysis, the transverse fracture pattern was the most. Most of the fracture surgeries were performed with the closed method. The family satisfaction of the patients was at a high level. In the evaluation of fractures according to Flynn Criteria, most of the results were excellent, but no poor results were observed. Bone union time was higher in patients aged ten years and older and undergoing open surgery, and less in transverse fracture shape (p&amp;lt;0.05). The time not to attend school was highest in open fracture type, tibia fractures, and open surgery patients (p&amp;lt;0.05). Ulna union time was 13.1 ± 1.8 weeks, which was higher than forearm fractures (p&amp;lt;0.05). The hospital stay was 3.50 ± 0.79 / 4.29 ± 1.54 / 3.33 ± 0.49 days in femur/tibia/forearm fractures, respectively, and was the highest in tibia fractures (p&amp;lt;0.05).Conclusions: TEN is an effective and safe method for long bone diaphyseal fractures in children aged 5-15 years, with low complication rates and positive effects on the patient and the health system.

Injury-mechanism directness as a key factor for fracture laterality in pediatric extremity fractures

BackgroundAssociations between certain extremity fracture sites and laterality in pediatric trauma are well known, whereas the rationale for such laterality tendencies are unclear. We hypothesized that the laterality tendency of a specific fracture would be affected by directness of injury mechanism and not by the fracture site itself. MethodsWe retrospectively enrolled 1382 children (aged 2–16 years) who were diagnosed with extremity fractures sustained during loss-of-balance situations and investigated the laterality tendencies (dominant vs. non-dominant extremity) of specific fracture sites. Multivariate analyses were sequentially performed to adjust for potential confounding variables-with and without injury-mechanism directness as a covariate. ResultsIn the upper extremities, the non-dominant side was more prone to fractures (p < 0.001), especially of the distal supracondylar humerus, radial and/or ulnar shaft, and distal radius. In the lower extremities, the dominant side was more frequently fractured (p < 0.001), especially at the tibial shaft and distal tibia. However, the predisposing effects of specific fracture sites on fracture laterality were not statistically significant when in analysis adjusted for injury-mechanism directness as a covariate. Fracture laterality was affected by whether the injury mechanism was direct or indirect. Indirect injury to the upper extremity was strongly associated with non-dominant arm injury (odds ratio 0.686 [95% CI 0.517–0.991]; p = 0.009), whereas indirect injury to the lower extremity was strongly associated with dominant leg injury (odds ratio 2.138 [95% CI 1.444–3.165]; p < 0.001). ConclusionsInjury-mechanism directness, rather than fracture site itself, is a key factor that affects fracture laterality in pediatric extremity fractures. These findings are helpful for improving our understanding of which factors may affect fracture laterality among children.

If Socioeconomic Stress Is a Relevant Factor in Fracture-Healing Outcomes, Should It Also Merit Intervention?: Commentary on an article by Zachery Hong, MPHS, et al.: "The Effect of Social Deprivation on Fracture-Healing and Patient-Reported Outcomes Following Intramedullary Nailing of Tibial Shaft Fractures".

If Socioeconomic Stress Is a Relevant Factor in Fracture-Healing Outcomes, Should It Also Merit Intervention?: Commentary on an article by Zachery Hong, MPHS, et al.: "The Effect of Social Deprivation on Fracture-Healing and Patient-Reported Outcomes Following Intramedullary Nailing of Tibial Shaft Fractures".

Pediatric distal third tibial shaft fractures: a comparison of surgical fixation methods and incidence of concomitant physeal fractures.

The purposeof this study was to compare outcomes of operatively treated pediatric distal third tibial shaft fractures fixed with elastic nailing or plate fixation and to evaluate the incidence of concurrent distal tibia physeal fractures. Retrospective review identified skeletally immature patients that underwent operative fixation of distal third tibia fractures at a level 1 children's hospital from 2010 to 2020. Patient and fracture characteristics were recorded. Analysis of treatment outcomes was performed and rates of concurrent distal tibia physeal fractures were evaluated. Of the 214 surgically treated tibial shaft fractures, 43 were distal third fractures. A concurrent distal tibia physeal fracture was present in 32.6% of patients. These were significantly associated with spiral distal third tibial shaft fractures. The presence of concurrent physeal fractures did not affect patient treatment outcomes. Comparing elastic nailing versus open reduction and plating revealed no difference with time to fracture union, time of postoperative immobilization, or time to full weight-bearing. While elastic nailing was associated with increased coronal angulation, translation, and shortening of fractures on initial postoperative imaging, there was no difference in rates of malunion at final follow-up. In our series, there were no differences in treatment outcomes based on fixation method. Our operatively treated distal third tibial shaft fractures had a higher rate of associated distal tibial physeal fractures than previously published in the pediatric orthopedic literature. We recommend careful evaluation of the ankle for concurrent physeal injuries in patients with distal third tibial shaft fractures indicated for operative treatment. Level of evidence: level III therapeutic study - retrospective comparative study.

Clinical analysis of accelerated rehabilitation surgery for Gustilo type IIIA/B open tibio fibular fracture.

To investigate the clinical efficacy of accelerated rehabilitation surgery for the treatment of Gustilo type IIIA/B open tibiofibular fracture with emergency stage I debridement, internal fracture fixation, bone grafting, coverage of the wound surface with a muscle flap combined with vacuum sealing drainage (VSD), and internal and lateral leg reduction. A retrospective analysis was performed on the clinical data of 15 patients with Gustilo type IIIA/B open tibiofibular fracture who were admitted to the Affiliated Zhongshan Hospital of Dalian University from January 2015 to December 2018. There were 12 males and 3 females. The patients ranged in age from 20 to 62years, with an average of 39.5years. After admission, the patients underwent stage I emergency debridement (including exploration and repair of nerves and tendons), open reduction and internal fixation of the tibia and fibula, iliac bone grafting, muscle flap and VSD coverage of the bone defect, complete tensioning of the calf inside and outside, tibia-sparing incision before healing, and stage II free skin grafting. Patients were followed up periodically to observe muscle flap survival, fracture healing time, length of hospitalization, wound healing time, delayed union, bone nonunion, osteomyelitis and other complications. At the last follow-up, the Johner-Wruhs criteria were used to evaluate the rate of good functional recovery from tibial shaft fracture, fracture healing quality was evaluated by the Merchant score, and limb function was evaluated by the LEFS. All 15 cases were followed up for 12-32months, with an average of 22.8months. All the fractures healed; the range of healing time was 14-30weeks (mean 18.5weeks). The length of hospitalization was 25.1 ± 7.6days, and wound healing took 12.2 ± 2.0days. None of the patients had complications such as osteomyelitis infection. When the Johner-Wruhs evaluation criteria for functional recovery from tibial shaft fracture were applied at the last follow-up, the outcomes were as follows: excellent in 13 cases, good in 1 case and fair in 1 case, for an excellent and good rate of 93.3%. When fracture healing was evaluated according to the Merchant scoring standard, the outcomes were as follows: excellent in 12 cases, good in 1 case, fair in 1 case, and poor in 1 case, for an excellent and good rate of 86.7%. The mean LEFS score of the affected limb at the last follow-up was 70 (59-80). For Gustilotype IIIA/B open tibiofibular fractures, emergency stage I debridement, internal fixation of the fracture, bone grafting, coverage of the wound with a muscle flap, complete tensioning of the calf inside and outside, and application of VSD can improve the repair of leg soft-tissue defects, shorten hospitalization time, promote fracture healing, and effectively reduce infection and complications related to bone exposure. More importantly, this treatment protocol provides effective wound repair, guarantees the recovery of limb function, significantly speeds up recovery, and improve patients' quality of life.

Asthma and Its Impact on Pediatric Patients Undergoing Surgical Management of Tibial Shaft Fractures.

Introduction Tibial shaft fractures are a common presenting injury amongthe pediatric population. Asthma is also a common diagnosis that is frequently encountered in this population and has a significant impact on healthcare utilization, quality of life, and mortality.Given the high prevalence of these conditions and risks of peri-anesthetic respiratory complications, the purpose of this study was to evaluate an association between asthma and the incidence of 30-day postoperative complications following the surgical management of tibial shaft fractures in the pediatric population. Methods The National Surgical Quality Improvement Program-Pediatric database was used to identify pediatric patients who underwent surgical treatment for tibial shaft fractures from 2013-2019. Patients were categorized into two groups: patients with a history of asthma and patients without a history of asthma. Differences in patient demographics, comorbidities, and postoperative complications were assessed using bivariate and multivariate analyses. Results Of the 2,649 patients who underwent surgical treatment for tibial shaft fractures, 115 (4.3%) had asthma. Compared to those without asthma, patients with a history of asthma were more likely to have other medical comorbidities. After controlling for the differences in baseline characteristics between the two groups, patients with asthma had an increased risk of prolonged hospital stay (OR 5.78; 95% CI 1.67 to 20.00; p=0.006). Conclusion Pediatric patients being surgically treated for tibial shaft fractures with asthma had an increased risk of prolonged hospital stay. It is important that proper preoperative workup, perioperative care, and understanding of the implications of asthma on postoperative recovery are appreciated to reduce prolonged hospitalization lengths and minimize hospital costs associated with tibial shaft fracture surgery.

A rare case of intramedullary osteosclerosis and literature review

Intramedullary Osteosclerosis (IMOS) is a rare idiopathic dysplasia of the long bones shafts. IMOS remain an un known diagnosis because of its rarity and the absence of specific features. Indeed, the diagnosis of IMOS can be confirmed only after excluding other differential diagnosis of osteosclerotic lesions. We report here a case of IMOS of the tibia shafts, diagnosed in a 53-year-old man. Medical history did not reveal a history of trauma or infection or familial bone disease and all other causes of osteosclerosis were excluded. The X-Rays showed extensive sclerotic intramedullary lesion of the tibia shafts, cortical bone thickening, and narrowing of the medullary cavity. No periosteal reaction or soft-tissue abnormality or fracture line were noted. The radiological signs were not pathognomonic, but the clinic, biology, histology, as well as the absence of medical or family history strongly suggested the diagnostic.

Severe Zinc Deficiency Impairs Accrual of Bone in Rapidly Growing Rats That Is Partially Corrected Following Short-term Zinc Repletion.

Zinc (Zn) deficiency impairs bone growth. However, the precise skeletal effects of varying levels of Zn deficiency and response to subsequent Zn repletion on the growing skeleton are incompletely understood. To address this gap in knowledge, we investigated the effects of dietary Zn ((severe deficiency (< 0.5mg Zn/kg diet) and short-term Zn repletion (30mg/kg diet), marginal deficiency (6mg Zn/kg diet)) on bone mass, density, and cortical and cancellous bone microarchitecture in growing male Sprague Dawley rats. Marginal Zn intake for 42days had no effect on bone mass or cortical and cancellous bone microarchitecture. Twenty-one days of severe Zn deficiency lowered serum osteocalcin and C terminal telopeptide of type I collagen (CTX-1), decreased tibial bone mineral content and density, and lowered cross-sectional volume, cortical volume, and cortical thickness in tibial diaphysis as compared to both Zn-adequate (30mg/kg diet) and pair-fed controls. Severe Zn deficiency similarly lowered cancellous bone volume in proximal tibial metaphysis. Zn repletion (10days) accelerated weight gain, indicative of catch-up growth, normalized CTX-1 and osteocalcin, but did not normalize bone mass (unadjusted and adjusted for body weight) or cortical and cancellous bone microarchitecture. In summary, severe but not marginal Zn deficiency in rapidly growing rats impaired acquisition of cortical and cancellous bone, resulting in abnormalities in bone microarchitecture. Zn repletion accelerated weight gain compared to Zn-adequate controls but absence of a compensatory increase in serum osteocalcin or bone mass suggests Zn repletion may be insufficient to fully counteract the detrimental effects of prior Zn deficiency on skeletal growth.

Pre-Surgery Hip-Knee-Ankle Angle and Weightbearing Line Percentage Are Nearly Perfectly Correlated to the Miniaci Angle When Planning Open Wedge High Tibial Osteotomies

To investigate the conversion formulas between the Miniaci angle, presurgery parameters, and changes in presurgery parameters in open-wedge high tibial osteotomy (OWHTO), including hip-knee-ankle (HKA) angle, weightbearing line (WBL) percentage, mechanical medial proximal tibial angle (mMPTA), ΔHKA angle, ΔWBL percentage, ΔmMPTA, and other parameters. From January 2012 to December 2019, 247 lower limbs of 144 patients with medial unicompartmental knee osteoarthritis combined with proximal tibia vara were enrolled. Inclusion criteria were adults, medial unicompartmental knee osteoarthritis, Kellgren-Lawrence classification grade ≤ III, mMPTA ≤ 85°, normal mechanical lateral distal femoral angle (85°-90°), and patella facing anterior in the bipedal standing position. Exclusion criteria were history of fracture, trauma, or orthopaedic surgery; developmental dysplasia of the hip or femoral head necrosis; femoral bowing deformity; deformity of the tibial shaft; and leg length discrepancy. Using standing whole-leg radiographs, an OWHTO simulation was performed to determine the Miniaci angle by delivering the WBL to the Fujisawa point. The relationship of the Miniaci angle, the presurgery parameters, and the changes in presurgery parameters were analyzed by Spearman's correlation and linear regression analyses. The relationship between the postsurgery HKA angle and presurgery parameters was analyzed by multiple linear regression model. The Miniaci angle showed a near-perfect correlation with the presurgery HKA angle (y=-1.05x+ 192.10, r2= 0.99), presurgery WBL percentage (y=-0.25x+ 15.14, r2= 0.97), ΔHKA angle (y= 1.04x- 0.03, r2= 1.00), ΔWBL percentage (y= 0.25x- 0.52, r2= 0.97), and ΔmMPTA (y= 1.04x- 0.03, r2= 1.00). The ΔHKA angle showed nearly perfect correlation with the ΔmMPTA (y= 1.00x, r2= 1.00), and ΔWBL percentage (y= 0.24x- 0.47, r2= 0.97). The presurgery HKA angle, presurgery WBL percentage, ΔHKA angle, ΔWBL, and ΔmMPTA percentage are nearly perfectly correlated to the Miniaci angle, whereas the ΔmMPTA and ΔWBL percentage are nearly perfectly correlated to the ΔHKA angle. With the conversion formulas determined in the current study, surgeons can calculate the Miniaci angle based on the presurgery parameters without the assistance of digital software for complex surgical simulation. The Miniaci angle is closely related to the gap of the medial opening wedge. Based on the Miniaci angle and the depth of the osteotomy, surgeons can calculate the gap required before surgery using trigonometric functions and then simply measure the gap during surgery.

Intra-articular fracture patterns associated with tibial shaft fractures: more than just the posterior malleolus.

The association of tibial shaft fractures(TSFs) with posterior malleolarfractures is well described. The purpose of this study was to identify specific radiographic parameters that are predictive of any pattern of associated distalintra-articular fractures in TSFs. All TSFs presenting over a 6-year period were identified. A radiographic review of plain radiographs and CT scans included: identification of any associated ankle fracture, classification using the OTA System, measurements of the TSF obliquity angle (FOA), relative distance from distal extent of the TSF to plafond (DFP%), and presence and level of any associated fibular fractures. Patients with and without associated ankle fractures were statistically compared. Multivariate logistic regression determined independent predictors of associated ankle fractures. 405 TSFs in 397 patients were identified, with 145 TSFs with associated distal intra-articular fractures. There were 94 (23.2%) posterior malleolar fractures, 19 (13.1%) medial malleolar fractures, 42 (29.0%) lateral malleolar fractures involving the syndesmosis and 14 (9.7%) Chaput fragments. Multivariate regression demonstrated AO/OTA classification type 42-A1, 42-B1 or 42-C1 (OR 2.3 [95% CI 1.3-4.0]; p = 0.003), FOA greater than 45° (OR 2.7 [95% CI 1.5-4.8]; p = 0.001) and DFP% less than 33% (OR 4.1 [95% CI 2.0-9.0]; p = 0.005) were independent correlates of associated ankle fractures regardless of mechanism of injury. Different patterns of intra-articular fractures beyond posterior malleolar fractures can occur in TSFs. Fracture angles greater than 45° and extent into the distal 33% of the tibial shaft are independent predictors of distal intra-articular fractures in TSFs regardless of mechanism of injury. Diagnostic Level III.

Preoperative and Intraoperative Considerations Using Intramedullary Nails for the Treatment of Tibial Shaft Fractures Below Total Knee Arthroplasty.

Periprosthetic tibial shaft fractures below total knee arthroplasty (TKA) are relatively rare, with an incidence of approximately 1%. However, as the rates of arthroplasty increase, orthopaedic surgeons are likely to see a corresponding increase in these types of fractures. Native tibial shaft fractures are routinely treated with either nails or plates, and the success of intramedullary nailing of tibial shaft fractures has been well described in the literature. In this article, we seek to describe a case series of tibial shaft fractures in patients with ipsilateral TKA treated with infrapatellar intramedullary nailing. We will focus on preoperative considerations including templating and measurement of the anterior cortical implant distance on the lateral radiograph to ensure space for safe nail passage. We will also discuss intraoperative technical tricks, including Kirschner wire insertion for sounding the start point, utilization of the curved awl, use of hand reamers, and rotation of the nail to bypass the implant. Using meticulous preoperative planning and technical intraoperative tricks, patients with tibial shaft fractures below TKA may be successfully treated with intramedullary nailing.

Outcome of Gustilo Type Iiib Fracture Shaft of Tibia Treated with Definitive Fixation and Flap Coverage within Two Weeks

Background: Traditionally Gustilo III B fractures are treated with external fixators initially, which leads to various complications. Purpose of this study was to evaluate the role of definitive management of Gustilo type III B tibia fractures with intramedullary nailing and flap coverage within two weeks on overall outcome.&#x0D; Materials and methods: This was a single group clinical trial and was conducted in the Department of Orthopedic Surgery and of Burn and Plastic Surgery of CMCH for a period of two years. Twenty two patients were enrolled through inclusion and exclusion criteria. Patients were followed up for 15 months and overall outcomes were measured by Tucker criteria.&#x0D; Results: In this study, Out of 22 patients, male (90.9%) were more than female (9.1%). According to post-operative complications, superficial infection was in 09 (40.9%) patients, deep infection was in 05 (22.7%) patients, 07 (35%) patients had delayed-union, 05 (25%) patients had non union and only 01 (05%) patient had knee stiffness. Mean ± SD time for fracture union was 11.27 ± 2.738 months (Range: 8-15 months). Functional outcome at the final follow-up, 10 (50%) had excellent outcome. Good outcome was in 02 (10%), fair outcome was in 03 (15%) and poor outcome was in 05 (25%) patients respectively according to Tucker et al. criteria, Post-operative infection and non union showed statistical significance according to p value.&#x0D; Conclusion: After 15 months of surgery, intramedullary nailing and flap coverage within two weeks is a feasible treatment option for Gustilo type III B tibia fractures providing excellent to good outcome, minimum fracture union time and low rate of complications.&#x0D; IAHS Medical Journal Vol 4(2), December 2021; 24-27

Functional Outcome of Hybrid Illizarov Technique in patients with Complex Tibial Plateau Fractures

Background:Tibial fractures are the most common long bone fracture, with approximately 25% being open. The majority of open tibial fractures result from a high velocity trauma, such as a motorcycle accident, or a low energy, torsional type injury, such as skiing. They are complex fractures to treat because of the lack of soft tissue coverage and blood supply of the tibial shaft. Aim: To determine the functional outcome of hybridillizarov technique in patients with complex tibial plateau fractures Study Design: Descriptive case series. Place of Study: Orthopedics Surgery Department, Jinnah Hospital, Lahore. Duration of Study: Study was carried out over a period of six months from 28-07-2021 to 28-01-2022 Methods: All the 73 patients fulfilling the selection with complex tibial plateau fractures of Schatzker's type V and VI were enrolled. Informed consent and demographic information were recorded. All the patients were evaluated for injuries, haemodynamically stabilized. Bone grafting and minimal internal fixation with cc screws was done in severely comminuted fractures. The functional results were measured by Rasmussen’s knee functional score (as per operational definition). Results: Distribution of the functional outcome of the patients was done, it showed that out of 73 patients 20(27.4%) were in excellent outcome, 41(56.2%) were in good outcome, 7(9.6%) were in fair outcome, 5(6.8%) were in poor. Conclusion: Based on our results, the use of hybrid illizarov fixation for the treatment of complex tibial plateau fractures is safe and effective in terms of low rates of complication and good functional results. Keywords: Functional outcome, Tibia plateau fracture, Hybrid ilizarov.