Tibial Shaft Research Articles

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

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

Ultrashort echo time MRI detects significantly lower collagen but higher pore water in the tibial cortex of female patients with osteopenia and osteoporosis.

Ultrashort echo time (UTE) MRI can quantify the major proton pool densities in cortical bone, including total (TWPD), bound (BWPD), and pore water (PWPD) proton densities, as well as the macromolecular proton density (MMPD), associated with the collagen content, which is calculated using macromolecular fraction (MMF) from UTE magnetization transfer (UTE-MT) modeling. This study aimed to investigate the differences in water and collagen contents in tibial cortical bone, between female osteopenia (OPe) patients, osteoporosis (OPo) patients, and young participants (Young). Being postmenopausal and above 55yr old were the inclusion criteria for OPe and OPo groups. The tibial shaft of 14 OPe (72.5 ± 6.8yr old), 31 OPo (72.0 ± 6.4yr old), and 31 young subjects (28.0 ± 6.1yr old) were scanned using a knee coil on a clinical 3T scanner. Basic UTE, inversion recovery UTE, and UTE-MT sequences were performed. Investigated biomarkers were compared between groups using Kruskal-Wallis test. Spearman's correlation coefficients were calculated between the TH DXA T-score and UTE-MRI results. MMF, BWPD, and MMPD were significantly lower in OPo patients than in the young group, whereas T1, TWPD, and PWPD were significantly higher in OPo patients. The largest OPo/Young average percentage differences were found in MMF (41.9%), PWPD (103.5%), and MMPD (64.0%). PWPD was significantly higher (50.7%), while BWPD was significantly lower (16.4%) in OPe than the Young group on average. MMF was found to be significantly lower (27%) in OPo patients compared with OPe group. T1, MMF, TWPD, PWPD, and MMPD values significantly correlated with the TH DXA T-scores (provided by the patients and only available for OPe and OPo patients). DXA T-score showed the highest correlations with PWPD (R = 0.55) and MMF (R = 0.56) values. TWPD, PWPD, and MMF estimated using the UTE-MRI sequences were recommended to evaluate individuals with OPe and OPo.

Clinical efficacy and complications of blocking screw in the treatment of lower limb long bone fracture: An updated systematic review and meta-analysis.

Blocking screw technique has been widely applied in the treatment of long shaft fractures. However, the evidence with regard to whether intramedullary nail combined with blocking screw technique has better clinical efficacy over other is not clear. The aim of the study was to explore the clinical efficacy and complications of intramedullary nail combined with blocking screw technique in the treatment of femoral or tibial shaft fractures. The PuMed, Embase, OVID, Cochrane library, Web of Science, Wanfang, CNKI and Weipu data were searched for studies of intramedullary nail combined with blocking screw in treatment of femoral or tibial shaft fracture published up to Aug 31 2023. Methodological quality of the trials was assessed, relevant data were extracted, and RevMan 5.3 and Stata 15.0 software were used to perform the meta-analysis of parameters related to the consequences. Twenty articles were included, including 1267 patients. Meta-analysis results showed that compared with the non-blocking screw group, the blocking screw group had longer operation time (WMD = 13.24; 95% CI = 5.68-20.79, P = .0006) and more intraoperative fluoroscopy times (WMD = 57.62; 95% CI = 25.82-89.42, P = .0002). However, the postoperative therapeutic response rate was higher (OR = 5.60; 95% CI = 2.10-14.93, P = .0006), postoperative ankle joint function was better (OR = 3.48; 95% CI = 1.20-10.13, P = .02), and fracture healing rate was higher (OR = 3.56; 95% CI = 1.43-8.89, P = .006), fracture healing time was shorter (WMD = -3.59; 95% CI = -4.96 to -2.22, P < .00001), intraoperative blood loss was less (WMD = -54.80; 95% CI = -88.77 to -20.83, P = .002), hospitalization time was shorter (WMD = -1.66; 95% CI = -2.08 to -1.24, P < .00001), and complications were less (OR = 0.38; 95% CI = 0.16-0.89, P = .01). There was no statistical significance in the range of motion of knee joint between the 2 groups (WMD = 10.04; 95% CI = -1.51 to 21.59, P = .09). Current evidence shows that intramedullary nail combined with blocking screw technique in the treatment of lower limb long bone fracture has the advantages of good clinical efficacy, high fracture healing rate, short fracture healing time, good joint function, less complications and so on, which is worthy of clinical recommendation.

Opioid-Sparing Nonsteroid Anti-inflammatory Drugs Protocol in Patients Undergoing Intramedullary Nailing of Tibial Shaft Fractures: A Randomized Control Trial.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective analgesics commonly used in fracture management. Although previously associated with delayed fracture healing, multiple studies have demonstrated their safety, with minimal risks of fracture healing. Given the current opioid crisis in the United States, alternate pain control modalities are essential to reduce opioid consumption. This study aims to determine whether the combination of oral acetaminophen and intravenous ketorolac is a viable alternative to opioid-based pain management in closed tibial shaft fractures treated with intramedullary nailing. We conducted a randomized controlled trial evaluating postoperative pain control and opioid consumption in patients with closed tibial shaft fractures who underwent intramedullary nailing. Patients were randomized into an NSAID-based pain control group (52 patients) and an opioid-based pain control group (44 patients). Visual analog scale (VAS) scores and morphine milligram equivalents (MMEs) were evaluated at 12-hour postoperative intervals during the first 48 hours after surgery. Nonunion and delayed healing rates were recorded for both groups. A statistically significant decrease in MMEs was noted at every measured interval (12, 24, 36, and 48 hours) in the NSAID group compared with the opioid group ( P -value 0.001, 0.001, 0.040, 0.024, respectively). No significant change in visual analog scale scores was observed at 12, 36, and 48 hours between both groups ( P -value 0.215, 0.12, and 0.083, respectively). A significant decrease in VAS scores was observed at the 24-hour interval in the NSAID group compared with the opioid group ( P -value 0.041). No significant differences in union rates were observed between groups ( P -value 0.820). Using an NSAID-based postoperative pain protocol led to a decrease in opioid consumption without affecting pain scores or union rates. Owing to the minimal risk of short-term NSAID use, their role in the perioperative management of tibia shaft fractures is justified, especially when they reduce opioid consumption markedly. Therapeutic Level I.

Prevalence of Rotational Malalignment After Infrapatellar Versus Suprapatellar Intramedullary Nailing of Tibial Shaft Fractures.

Up to 30% of patients with a tibial shaft fracture sustain iatrogenic rotational malalignment (RM) after infrapatellar (IP) nailing. Although IP nailing remains the management of choice for most patients, suprapatellar (SP) nailing has been gaining popularity. It is currently unknown whether SP nailing can provide superior outcomes with regard to tibial RM. The aim of this study was to compare the differences in the prevalence of RM following IP versus SP nailing. This retrospective study included 253 patients with a unilateral, closed tibial shaft fracture treated with either an IP or SP approach between January 2009 and April 2023 in a Level-I trauma center. All patients underwent a postoperative, protocolized, bilateral computed tomography (CT) scan for RM assessment. RM was observed in 30% and 33% of patients treated with IP and SP nailing, respectively. These results indicate no significant difference (p = 0.639) in the prevalence of RM between approaches. Furthermore, there were no significant differences in the distribution (p = 0.553) and direction of RM (p = 0.771) between the 2 approaches. With the IP and SP approaches, nailing of left-sided tibial shaft fractures resulted in predominantly internal RM (85% and 73%, respectively), while nailing of right-sided tibial shaft fractures resulted in predominantly external RM (90% and 80%, respectively). The intraobserver reliability for the CT measurements was 0.95. The prevalence of RM was not influenced by the entry point of tibial nailing (i.e., IP versus SP). Hence, the choice of surgical approach should rely on factors other than the risk of RM. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Antimicrobial resistance in surgical infections: experience from open tibia fracture-related infection intraoperative tissue specimens

Background Antimicrobial resistance in surgical infections is known to have significant morbidity and mortality in extreme cases on top of increased costs in medical expenditure. This study aimed to analyze antimicrobial resistance patterns of microbes in open tibia fracture-related infection (FRI) using intraoperative tissue samples. Methods Between January and June 2022, a descriptive cross-sectional observational study was conducted involving patients aged 18 and above with open tibial shaft fractures. Microbiological culture and sensitivity of three intraoperative deep tissue and bone samples taken by sterile techniques using separate instruments in patients with infection. Antimicrobial susceptibility testing was performed using the Kirby-Bauer disk diffusion method along with biomechanical tests for microbial identification. Results Fifty-seven deep tissue samples were taken from 19 patients with FRI who underwent surgery during the study period were analyzed. Almost all (96.5%) intraoperative tissue samples were culture-positive identifying 73 bacterial isolates out of which 57.9% were polymicrobial. The most frequent isolated bacteria were Gram-negative bacteria 56 (76.7%) with a predominance of Proteus spp 13 (17.8%). Methicilin Resistance Staphyaureus comprised 12 (16.4%) of the isolates whereas Inducible Clindamycin resistance was identified in 8 (57.1%) of Staphyloccus aureus isolates. More than half of the isolates 30 (53.6%) comprised of Extended Spectrum Beta Lactamase producing bacteria. There was high resistance to Cephalosporins and Amoxyclavulanic acid as the efficacy was low ranging from 28.2, 27.8, and 30.0% for cefotaxime, ceftazidime and amoxicillin/clavulanic acid, respectively. Almost all Gram-negative bacteria 47 (83.9%) had multidrug resistance pattern except for Pseudomonas aureginosa that had 77.8 to 88.9% susceptibility to all tested antibiotics. Conclusion High resistance to cephalosporins in patients with delayed or late infection in open tibia FRI is alarming and further studies to establish causes are indicated.

Comparative Analysis of Complication Rates in Tibial Shaft Fractures: Intramedullary Nail vs. Ilizarov External Fixation Method.

Background: The external fixation (EF) Ilizarov method, shown to offer efficacy and relative safety, has unique biomechanical properties. Intramedullary nail fixation (IMN) is an advantageous alternative, offering biomechanical stability and a minimally invasive procedure. The aim of this study was to assess outcomes in patients undergoing tibia fracture fixation, comparing the Ilizarov EF and IMN methods in an early phase of IMN implementation in Serbia. Methods: This was a retrospective study including patients with radiologically confirmed closed and open (Gustilo and Anderson type I) tibial diaphysis fractures treated at the Institute for Orthopedic Surgery "Banjica'' from January 2013 to June 2017. The following demographic and clinical data were retrieved: age, sex, chronic disease diagnoses, length of hospital stay, surgical wait times, surgery length, type of anesthesia used, fracture, prophylaxis, mechanism of injury, postsurgical complications, time to recovery, and pain reduction. Pain intensity was measured by the Visual Analog Scale (VAS), a self-reported scale ranging from 0 to 100 mm. Results: A total of 58 IMN patients were compared to 74 patients who underwent Ilizarov EF. Study groups differed in time to recovery (p < 0.001), length of hospitalization (p = 0.007), pain intensity at the fracture site (p < 0.001), and frequency of general anesthesia in favor of intramedullary fixation (p < 0.001). A shorter surgery time (p < 0.001) and less antibiotic use (p < 0.001) were observed when EF was used. Additionally, we identified that the intramedullary fixation was a significant predictor of pain intensity. Conclusions: The IMN method offers faster recovery and reduced pain intensity in comparison to EF, while the length of surgery predicted the occurrence of any complication.

Evaluation of the treatment outcome of tibia shaft fracture by close reduction and internal fixation with interlocking intramedullary nail, Freetown, Sierra Leone, 2023

Introduction: The tibia shaft is a common site for bone fractures and open fractures. Tibia shaft fracture is mostly caused by high-energy trauma such as a fall from a height or a road traffic accident. The objective of this study was to evaluate the treatment outcome of tibia shaft fracture managed by close reduction and internal fixation with interlocking Intramedullary Nails (IMN) and to determine factors that are associated with tibia fracture infection. Methods: This retrospective study was conducted at the Emergency Trauma Hospital, Freetown, Sierra Leone. We analyzed the medical records of a mixed cohort of patients who were treated for, tibia shaft fracture by closed reduction and internal fixation with interlocking intramedullary nails for the period January 2020 to January 2022; with at least 15 months of follow-up. We later used both bivariate and multivariate logistic regressions to determine the factors that are associated with wound infection post-internal fixation. Results: A total of Ninety (n = 90) patients’ medical records were reviewed of which 79 were included for analysis. The median age was 30 years (Inter Quartile Range: 16-67 years). The average hospital stay was 20 days (Inter Quartile Range: 6-156 days). The mean fracture nailing time was 11 days. Infection and non-union rates were at 18.99% and 3.8% respectively. Type of tibia shaft fracture (AOR = 25.51, 95% CI = 2.06-422.75,) and characteristics of wound (AOR = 29.51, 95% CI = 2.06-422.75) were significantly associated with wound infection. The treatment outcome categorization of IMN was successful in 88.61% of the patients. Conclusion: This study concludes that the type of tibia shaft fracture and characteristics of the wound are major predictors of wound infection. The findings of this study suggest that IMN fixation of closed and Gustilo type 1 Tibia shaft fracture led to successful healing in the majority of the cases with a low non-union rate.

Eldecalcitol protected osteocytes against ferroptosis of D-gal-induced senescent MLO-Y4 cells and ovariectomized mice

BackgroundActive vitamin D analog eldecalcitol is clinically applied in treatment of postmenopausal osteoporosis. This study aims to determine the role of eldecalcitol in the protection of osteocytes from senescence and the associated ferroptosis. MethodsThe MLO-Y4 osteocytes were exposed to D-gal inducing senescence. The ovariectomized (OVX) mice treated with D-gal using as an aging inducer were intraperitoneally injected with eldecalcitol. The multiplexed confocal imaging, fluorescence in situ hybridization and transmission electron microscopy were applied in assessing osteocytic properties. Immunochemical staining and immunoblotting were carried out to detect abundance and expression of molecules. ResultsThe ablation of vitamin D receptor led to a reduction in amounts of osteocytes, a loss of dendrites, an increase in mRNA expression of SASP factors and in protein expression of senescent factors, as well as changes in mRNA expression of ferroptosis-related genes (PTGS2 & RGS4). Eldecalcitol reversed senescent phenotypes of MLO-Y4 cells shown by improving cell morphology and density, decreasing β-gal-positive cell accumulation, and down-regulating protein expression (P16, P21 & P53). Eldecalcitol reduced intracellular ROS and MDA productions, elevated JC-1 aggregates, and up-regulated expression of Nrf2 and GPX4. Eldecalcitol exhibited osteopreserve effects in D-gal-induced aging OVX mice. The confocal imaging displayed its improvement on osteocytic network organization. Eldecalcitol decreased the numbers of senescent osteocytes at tibial diaphysis by SADS assay and attenuated mRNA expression of SASP factors as well as down-regulated protein expression of senescence-related factors and restored levels of ferroptotic biomarkers in osteocytes-enriched bone fraction. It reduced 4-HNE staining area, stimulated Nrf2-positive staining, and promoted nuclear translocation of Nrf2 in osteocytes of mice as well as inhibited and promoted protein expression of 4-HNE and Nrf2, respectively, in osteocytes-enriched bone fraction. ConclusionsThe present study revealed the ameliorative effects of eldecalcitol on senescence and the associated ferroptosis of osteocytes, contributing to its preservation against osteoporosis of D-gal-induced senescent ovariectomized mice.

Constitutional varus knee due to tibial deformity is common and represents a good indication for high tibial osteotomy in Japanese population: Consideration of 1010 knees.

This study aimed to elucidate the characteristics of varus knee deformities in the Japanese population, prevalence of various around knee osteotomy proceduresand influence of femoral and tibial bowing. Varus knee deformity was defined as a weight-bearing line ratio of <50%. A total of 1010 varus knees were selected from 1814 varus knees with weight-bearing full-length radiographs, obtained at two facilities, based on exclusion criteria. Various parameters were measured, and around knee osteotomy simulations based on the deformity centre were conducted using digital planning tools. Bowing of the femoral and tibial shafts was measured, with bowing defined as follows: ≤ -0.6° indicating lateral bowing and ≥ 0.6° indicating medial bowing. Statistical analysis was performed to investigate age-related correlations and their impact on surgical techniques. The study revealed that the proximal tibia was the centre of deformity in Japanese varus knees (42.8%), and high tibial osteotomy was frequently indicated (81.6%). Age demonstrated a mild correlation with femoral shaft bowing (r = -0.29), leading to an increase in the mechanical lateral distal femoral angle and to a decrease in the hip-knee-ankle angle and weight-bearing line ratio (r = -0.29, 0.221, 0.219). The tibial shaft bowing was unaffected by age (r = -0.022). A significant proportion of Japanese individuals with varus knees exhibit a deformity centre located in the proximal tibia, making them suitable candidates for high tibial osteotomy. No age-related alterations were discerned in tibial morphology, indicating that the occurrence of constitutional varus knees is attributable to tibial deformities in the Japanese patient cohort. Level IV.

Effect of Denosumab Injection in Early Union and Consolidation o f Callus in Aseptic Tibial Shaft Non-union

Fractures of the tibial shaft is one of the most common fractures than any other long bone fractures in the human body. Surgical treatment offers better functional outcome than a conservative management. Reamed intramedullary interlocking (IMIL) nailing is the treatment of choice for most of the closed tibial shaft fractures. Despite after a good surgical fixation non-union still persists after reamed IMIL nailing. Plate augmentation and bone grafting with nail in situ was found to have superior results and union rates than any other methods, but the average union time was almost 3 to 5 months. To enhance faster union and recovery here we have used Injection Denosumab 60 mg Sc post operatively during follow up. So, the aim of the study is to find the efficacy of injection Denosumab in enhancing early union and consolidation of callus. It is a comparative prospective study involving 43 patients treated for aseptic non-union of tibial shaft fractures following reamed intramedullary interlocking nailing between 2020 and 2023. All the patients treated by reamed intramedullary interlocking nailing who met the inclusion and exclusion criteria were included in the study. Group A was managed with plate augmentation and bone grafting following non-union IMIL nailing and Group B was managed with Plate augmentation bone grafting with Injection Denosumab Sc post operatively. Both the groups were followed up post operatively for period of one year. Total of 43 patients were included in the study. The average duration of union in GROUP A -14.82 weeks and in GROUP B- 9.45 weeks. Excellent results were obtained in both the groups. There was no complication such as malunion, non-union, implant loosening, nerve palsy, infection and plate/IMIL nail breakage. Augmentation plating, decortication and autogenous iliac crest bone grating is a better treatment option compared to exchange nailing in case of tibial shaft aseptic non-union following IMIL nailing. Using injection denosumab 60mg Sc postoperatively after plate augmentation and bone grafting offers early union and early consolidation of callus. Keywords Tibial Shaft Fractures, Intramedullary Interlocking Nailing, Plate Augmentation, Bone Grafting

Flexible nailing: Pushing the indications for diametaphyseal lower-extremity fractures.

Elastic stable intramedullary nailing (ESIN) has been shown to be an effective form of surgical management for lower-extremity diametaphyseal fractures in pediatric patients, but studies are limited because ESIN treatment for these fractures is relatively uncommon. We sought to determine whether ESIN can be used effectively in the most distal or proximal short-segment forms of these fractures. We queried the electronic medical record system at Johns Hopkins Hospital using Current Procedural Terminology codes for femur and tibia fractures treated with ESIN in patients under 18 years old between January 2015 and October 2022. Preoperative and postoperative radiographs were subsequently reviewed to identify patients with a proximal or distal third femoral or tibial shaft fracture treated with ESIN and to define criteria for short-segment diametaphyseal fractures. We used Beaty radiological criteria to evaluate radiographic outcomes and Flynn titanium elastic nails (TENs) outcome scale to assess clinical recovery after radiographic evidence of union. There were 43 children who met the inclusion criteria. Among them, 10 patients had short-segment diametaphyseal fractures. There were 22 (51.2%) who sustained femur fractures and 21 (48.8%) who sustained tibia fractures. Using Beaty radiologic criteria, ESIN was associated with more satisfactory outcomes in patients with distal or proximal third shaft fractures (32/33) than in patients with short-segment diametaphyseal fractures (7/10) (P = .03). Using the TENs outcome scale, 21 (63.4%) patients with distal or proximal third shaft fractures had excellent results, 11 (33.3%) had satisfactory results, and 1 (3%) had a poor result. Among patients with short-segment diametaphyseal fractures, 4 (40%) had excellent results, 5 (50%) had satisfactory results, and 1 (10%) had a poor result. There were no differences in TENs outcomes between the groups (P = .24). Patients with short-segment lower-extremity diametaphyseal fractures treated with ESIN had worse radiographic outcomes but did no worse clinically than patients with distal or proximal third shaft fractures. Consequently, ESIN should be considered a safe and effective surgical management option for pediatric patients with even the most distal or proximal forms of these fractures.

Patient-Reported Outcome Measurement Information Systems Physical Function and Pain Interference Scores Are Correlated With Tibial Shaft Fracture Nonunion Following Intramedullary Nailing.

To assess trends in Patient-Reported Outcome Measurement Information Systems (PROMIS) Physical Function (PF) and Pain Interference (PI) in surgically treated tibial shaft fracture patients progressing to union versus nonunion. Retrospective cohort study. Level 1 trauma center. Patients with operatively treated tibial shaft fractures (AO/OTA 42-A, B, C) using an intramedullary nail. PROMIS PF and PI were compared between patients progressing to union and patients requiring nonunion repair. A total of 234 patients (196 union, 38 nonunion) were included consisting 144 men and 90 women. The mean age of included patients was 40.8 years. A significant difference in mean PROMIS PF between union and nonunion patients was observed at 1-3 months ( P = 0.005), 3-6 months ( P < 0.001), 6-9 months ( P = 0.003), and 6-12 months ( P = 0.018). The odds of developing nonunion for every unit decrease in PROMIS PF was significant at 3-6 months (OR 1.07, P = 0.028) and 6-9 months (OR 1.17, P = 0.015). A significant difference in mean PROMIS PI between union and nonunion patients was observed at 1-3 months ( P = 0.001), 3-6 months ( P = 0.005), and 6-9 months ( P = 0.005). The odds of developing nonunion for every unit increase in PROMIS PI was significant at 1-3 months (OR 1.11, P = 0.005), 3-6 months (OR 1.10, P = 0.011), and 6-9 months (OR 1.23, P = 0.011). Poorly trending PROMIS PF and PI in the clinical setting is a factor that can be used to evaluate progression to nonunion following tibial shaft repair where imaging studies may lag behind. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rotational Malalignment After Intramedullary Nailing of Tibial Shaft Fractures Is Predictable.

Intramedullary nailing is the treatment of choice for most tibial shaft fractures (TSF). However, an iatrogenic pitfall may be rotational malalignment. The aim of this retrospective analysis was to determine predictors of rotational malalignment following intramedullary nailing of TSF. Retrospective study. Single level 1 trauma center. Patients who had a unilateral intramedullary nailing for TSF with a low-dose bilateral postoperative CT to assess rotational malalignment. Bivariable analysis followed by multivariable analysis was then undertaken to assess for any independent predictors, such as fracture type/sight, surgeon experience, and side of fracture, predictive of rotational malalignment. In total, 154 patients (71% male, median age 37 years) were included in this study. Thirty-nine percent of variability in postoperative rotational malalignment could be explained using a model including (increased) tibial torsion of the noninjured side (mean [38.9 degrees ± 9.02 degrees] considered normal tibial torsion), side of tibial fracture, and spiral-type tibial fracture (R2 = 0.39, P ≤ 0.001, F = 31.40). In this model, there was a negative linear association between degrees of torsion on the noninjured side and rotational malalignment (-0.45, P < 0.001)-as baseline torsion increased from mean by 1 degree, malrotation in the opposite direction of 0.54 degrees seen. Positive linear associations between right-sided TSF and rotational malalignment (8.59 P < 0.001) as well as spiral fractures and rotational malalignment (5.03, P < 0.01) were seen. This study demonstrates that baseline reduced (internal) tibial torsion of the noninjured limb, spiral fractures, and right-sided TSF are predictive of postoperative external rotational malalignment. Conversely, increased baseline (external) tibial torsion of the noninjured limb and left-sided TSF are predictive of postoperative internal rotational malalignment. Surgeons may use this regression model preoperatively to predict what sort of postoperative rotational difference their patient may be prone to. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Feline tibial osteosynthesis

Diaphyseal fractures of the tibia occur as a result of trauma to the pelvic limb and are a rupture in the continuity of the diaphyseal corticosteroid bone. Animals with this type of fracture must be evaluated to determine whether it is the result of contusion or pathology, such as neoplasms. The study reports the case of a three-year-old mixed-breed feline, weighing three and a half kilos, with non-weight-bearing lameness on the right pelvic limb. The patient was attacked by a dog five days before the appointment. Upon physical examination, it was possible to observe loss of bone continuity in the right pelvic limb in the tibia region. There was an increase in volume, without apparent skin lesions. Radiographic, blood count and biochemical exams were performed. Based on clinical presentation, physical examination, imaging diagnosis and laboratory results, it was concluded that the animal had a fracture of the distal third diaphyseal tibia. Osteosynthesis of the tibia was indicated as treatment, in addition to prescription analgesics to alleviate the patient's pain.

Which surgical technique may yield the best results in large, infected, segmental non-unions of the tibial shaft? A scoping review

PurposeInfected nonunion of the tibia with a large segmental bone defect is a complex and challenging condition for the patient and surgeon. This scoping review was conducted to identify existing evidence and knowledge gaps regarding this clinical scenario. Secondly, the objective of this study was to search for a valid recommendation on the optimal treatment.MethodsA comprehensive search was conducted in the bibliographic databases: PubMed, Embase.com, and Web of Science Core Collection. Studies reporting on bone transport techniques, the Masquelet technique, and vascularized fibular grafts in bone defects greater than 5 cm were included. Bone healing results and functional results were compared according to duration of nonunion, infection recurrence, bone consolidation, complication rate, external fixation time, and time until full weight-bearing.ResultsOf the 2753 articles retrieved, 37 studies could be included on bone transport techniques (n = 23), the Masquelet technique (n = 7), and vascularized fibular grafts (n = 7). Respective bone union percentages were 94.3%, 89.5%, and 96.5%. The percentages of infection recurrence respectively were 1.6%, 14.4% and 7.0%, followed by respectively 1.58, 0.78, and 0.73 complications per patient.ConclusionBone transport was found to be the most widely studied technique in the literature. Depending on the surgeon’s expertise, vascularized fibular grafts may be held as a favourable alternative. This review indicates that further high-quality research on large bone defects (≥\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\ge$$\\end{document} 5 cm) in patients with infected tibial nonunions is necessary to gain more insight into the potentially beneficial results of vascularized fibular grafts and the Masquelet technique.

Suprapatellar Nail Insertion for Tibial Shaft Fractures: Better Radiographic Results, But Are They Clinically Relevant?: Commentary on an article by Navnit S. Makaram, MSc, MRCS(Ed), et al.: "Outcome Following Intramedullary Nailing of Tibial Diaphyseal Fractures. Suprapatellar Nail Insertion Results in Superior Radiographic Parameters But No Difference in Mid-Term Function".

Suprapatellar Nail Insertion for Tibial Shaft Fractures: Better Radiographic Results, But Are They Clinically Relevant?: Commentary on an article by Navnit S. Makaram, MSc, MRCS(Ed), et al.: "Outcome Following Intramedullary Nailing of Tibial Diaphyseal Fractures. Suprapatellar Nail Insertion Results in Superior Radiographic Parameters But No Difference in Mid-Term Function".

Optimal hip capsular release for joint exposure in hip resurfacing via the direct anterior approach.

Surgical approaches that claim to be minimally invasive, such as the direct anterior approach (DAA), are reported to have a clinical advantage, but are technically challenging and may create more injury to the soft-tissues during joint exposure. Our aim was to quantify the effect of soft-tissue releases on the joint torque and femoral mobility during joint exposure for hip resurfacing performed via the DAA. Nine fresh-frozen hip joints from five pelvis to mid-tibia cadaveric specimens were approached using the DAA. A custom fixture consisting of a six-axis force/torque sensor and motion sensor was attached to tibial diaphysis to measure manually applied torques and joint angles by the surgeon. Following dislocation, the torques generated to visualize the acetabulum and proximal femur were assessed after sequential release of the joint capsule and short external rotators. Following initial exposure, the ischiofemoral ligament (7 to 8 o'clock) was the largest restrictor of exposure of the acetabulum, contributing to a mean 25% of overall external rotational restraint. The ischiofemoral ligament (10 to 12 o'clock) was the largest restrictor of exposure of the proximal femur, contributing to 25% of overall extension restraint. Releasing the short external rotators had minimal contribution in torque generated during joint exposure (≤ 5%). Adequate exposure of both proximal femur and acetabulum may be achieved with minimal torque by performing a full proximal circumferential capsulotomy while preserving short external rotators. The joint torque generated and exposure achieved is dependent on patient factors; therefore, some cases may necessitate further releases.

Biplanar Anterior Opening Wedge Proximal Tibial Osteotomy to Correct Reverse Tibial Slope

Background: Anatomically, native posterior tibial slope (PTS) ranges from 6° to 10° and have significant effects on cruciate ligament stability. PTS &lt;6° is correlated with increased posterior tibial translation (PTT) and force on the posterior cruciate ligament (PCL), predisposing individuals to PCL injuries and an increased risk of PCL graft attenuation. In rare cases, a reverse tibial slope can occur (&lt;0°) as a result of trauma, physeal arrest, or abnormal development. This results in increased PTT and can lead to posterior tibial subluxation. Reverse tibial slopes in patients can be treated with an anterior opening wedge proximal tibial osteotomy, which increases the PTS to a more anatomic position. Indications: Biplanar anterior opening wedge proximal tibial osteotomies are indicated in patients with a reverse tibial slope both with the absence of PCL insufficiency or in conjunction with PCL reconstruction. Technique Description: Under fluoroscopic imaging, 2 guide pins were placed perpendicular to the tibial shaft. An oscillating saw and osteotomes completed the osteotomy in line with the guide pins with the posterior cortex remaining intact. The osteotomy site was slowly opened with a spreader device to 9 mm until the posterior drawer was such that the palpable step-off between the anterior aspect of the medial femoral condyle and the medial tibial plateau was comparable to the contralateral knee. Due to the patient having slight valgus coronal plane alignment, an opening-wedge posteriorly sloped plate was then placed anterolaterally and fixed while wedges held the osteotomy open. Results: Biplanar anterior opening wedge osteotomies correct a flattened PTS and reverse tibial slope, and coronal malalignment, and has been shown to decrease PCL laxity, preventing future PCL failure. Discussion: Biomechanical studies have shown that decreased tibial slope is correlated with an increased risk of PCL injury and PCL graft failure. In patients with reverse tibial slope, experienced instability can mimic PCL insufficiency despite there being no ligamentous damage. We describe a technique that corrects reverse tibial slope and with a discussion of surgical pearls and pitfalls. This technique restores anatomic position and normal function of the knee while correcting the sagittal malalignment that could lead to future injuries. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Estimating the economic impact of complications after open tibial fracture: A secondary analysis of the pilot Gentamicin Open Tibia trial (pGO-Tibia).

To estimate the indirect economic impact of tibial fractures and their associated adverse events (AEs) in Tanzania. A secondary analysis of the pilot Gentamicin Open (pGO)-Tibia randomized control trial estimating the indirect economic impact of suffering an AE, defined as a fracture-related infection (FRI) and/or nonunion, after an open tibial fracture in Tanzania. The pGO-Tibia trial was conducted from November 2019 to August 2021 at the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania. One hundred adults with open tibial shaft fractures participated in this study. Work hours were compared between AE groups. Cost data were analyzed using a weighted-average hourly wage and converted into purchasing power parity-adjusted USD. Indirect economic impact was analyzed from the perspective of return to work (RTW), lost productivity, and other indirect economic and household costs. RTW was analyzed using a survival analysis. Half of patients returned to work at 1-year follow-up, with those experiencing an AE having a significantly lower rate of RTW. Lost productivity was nearly double for those experiencing an AE. There was a significant difference in the mean outside health care costs between groups. The total mean indirect cost was $2385 with an AE, representing 92% of mean annual income and an increase of $1195 compared with no AE. There were significantly more patients with an AE who endorsed difficulty affording household expenses postinjury and who borrowed money to pay for their medical expenses. This study identified serious economic burden after tibial fractures, with significant differences in total indirect cost between those with and without an AE. II.