Treatment Of Distal Tibial Fractures Research Articles

Complications and functional outcome after fixation of distal tibia fractures with locking plate – A multicentre study

IntroductionThe aim of this study was to evaluate the proportion of complications and the functional outcome following ORIF with low-profile locking plates in patients with distal tibia fractures. MethodRetrospective data was retrieved using county databases, operation books, health record and X-ray images for 6 hospitals (1 level 1, 5 level 2) in the Region of Southern Denmark. Between January 2007 and April 2011 70 consecutive patients with 71 distal tibia fractures were treated with low-profile locking plate were included. The proportion of post-operative complications, classified as minor and major complications, was retrieved from electronic health records and patient interviews. Long-term functional outcome assessed by EuroQol EQ-5D-5L questionnaire, AOFAS Ankle-Hindfoot scale, and return to pre-injury job function through patient interview and examination. ResultsThere were 32 43A, 5 43B and 34 43C-fractures, 12 open and 10 high-energy fractures. Forty-nine cases (69%) experienced complications during the follow-up time, of which 34 were minor complications and 15 were major complications. Median EQ-5D-5L index value was 0.76, median EQ VAS-score was 80, and median AOFAS score was 73. Thirty-three percent of working patients had not returned to work as a result of the fracture. ConclusionsOur study suggest that treatment of distal tibia fractures with low-profile locking plates might have a higher proportion of complications and worse functional outcome than previously reported. Level of evidenceTherapeutic level IV Case Serie.

Functional outcome and general health status after treatment of AO type 43 distal tibial fractures

IntroductionDistal tibial fractures are uncommon, but they result in poor overall outcome. The objective of this study was to assess functional outcome and general health status after the treatment of distal tibial fractures and identify factors that affect these outcome measures. Patients and methodsA retrospective cohort study including 118 AO type 43 distal tibial fractures in 116 patients was conducted. With regard to articular involvement, fractures were classified as either simple (A1–B2, n=70) or complex (B3–C3, n=48). Twenty relevant demographic and operative variables were studied. Functional outcome, quality of life and pain were assessed using the Foot Function Index (FFI) and AOFAS ankle score, physical and mental SF-36, and Visual Analog Scale (VAS) questionnaires, respectively. ResultsOver 75% of patients experienced noteworthy loss of ankle function. The general health status assessment showed markedly affected quality of life with more than two-third of all responding patients suffering from pain every day. In fact, complex fractures and increased complication rate were associated with worse functional outcome, whereas prolonged time to definite surgery affected both functional outcome and general health status significantly. ConclusionsComplex distal tibial fractures were associated with poor functional outcome scores and delayed (-staged) surgery has been shown to prevent postoperative soft tissue problems. However, soft tissue injury associated with distal tibial fractures itself affected both the postoperative functional outcome and general health status as well. This should contribute to the understanding of treatment and outcome of distal tibial fractures. Level of evidence3.

Complications of Minimally Invasive Percutaneous Plating for Distal Tibial Fractures.

BackgroundThe management of distal tibia fractures continues to remain a source of controversy and debate.ObjectivesThe aim of this study was to evaluate the various complications of minimally invasive percutaneous plate osteosynthesis (MIPPO) using a locking plate for closed fractures of distal tibia in a retrospective study.Patients and MethodsTwenty-five patients with distal tibial fractures, treated by minimally invasive percutaneous plate osteosynthesis, were evaluated in a retrospective study. We studied the rate, probable etiological factors and preventive and corrective measures of various complications associated with minimally invasive plating of distal tibia.ResultsMean age of the patients was 41.16 years (range 22 - 65). There were 13 male and 12 female patients. All fractures united at an average duration of 16.8 weeks. There were two cases of superficial and two cases of deep infection, and deep infections required removal of hardware for cure. There were four cases of ankle stiffness, most of them occurring in intra-articular fractures, three cases of palpable implant, three cases of malunion, one case of loss of reduction and one patient required reoperation. The average AO foot and ankle score was 83.6.ConclusionsWe found MIPPO using locking plate to be a safe and effective method for the treatment of distal tibial fractures in properly selected patients yet can result in a variety of complications if proper precautions before, during and after surgery are not taken care of.

Locking Compression Plate for Distal Tibia Fractures

This article represents a multidisciplinary approach to biomechanics (engineering + medicine) in the field of distal tibia fractures. The objective of the present study was to carry out a strength and reliability assessment of a medial plate for the treatment of distal tibia fractures. This was performed via numerical modelling (FEM) and experimental methods (compression test and Electronic Speckle Pattern Interferometry – ESPI method). The plate is used for internal fixation in orthopaedics and traumatology. Analyses were performed for non-fused bone with comminuted fracture in the distal metaphysis (i.e. unsuccessful treatment, where all loads in the metaphysis are carried by the plate). An anatomical tibia model (based on CT images in Mimics software) was used for FE analysis. In the experiments, the bone was replaced with a shaped piece of spruce wood (based on Mimics software) and the plate was loaded until its failure (major plastic deformation). Numerical and experimental results were evaluated and compared.

Evaluation of treatment of distal tibial fractures using the minimally invasive percutaneous plate osteosynthesis technique

Objectives The goal of this study was to report and evaluate the treatment of distal tibial fractures using the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique. Background MIPPO has been used for the management of fractures since a long period of time. Good fixation, mild blood loss, and early mobilization are always the main advantages of this technique. Other advantages include the following: it is simple, quick, and causes minimal surgical trauma. Materials and methods From August 2013 to January 2015, 20 (13 male and seven female) patients with a mean age of 49.5 years suffering from type A distal tibial fracture were treated in the Orthopedic Department, El-Menoufiya University Hospital, and Mansoura New General Hospital with medial distal locked plate using the MIPPO technique and early mobilization. Results Fracture union was achieved within 16-23 weeks. In 16 cases union was achieved within 16-20 weeks and was delayed in three cases and achieved within 23 (mean: 19.2) weeks. There was only one case in which nonunion occurred. Conclusion The MIPPO technique is effective in achieving union and excellent functional outcome in metaphyseal distal tibial fractures.

Distal tibia fractures: when is nailing preferred?

Background The treatment of distal tibia fractures remains controversial. Despite the well-known advantages of nailing, its use in distal tibia fractures has been reported to be associated with technical difficulties and high malalignment rates. Many surgeons are still hesitant to use nailing for distal tibia fractures. Objectives The aims of this prospective study were to evaluate the results of using static-reamed intramedullary nailing in the treatment of distal tibia fractures, and to define the situations in which nailing may be preferred. Patients and methods Between January 2008 and December 2011, 30 patients – 21 men and nine women – were treated in King Fahad Hospital at Al-Baha, KSA. Their mean age was 28.6 years. According to the Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification, 20 cases had type A, eight had type B, and two had type C fractures. Ten fractures were open: four type I, five type II, and one type III-A. The American Orthopedic Foot and Ankle Society ankle–hindfoot scale was used for assessment in this study. Results The mean follow-up time was 26.3 months. Three patients with open fractures got superficial infections. All the fractures united with acceptable alignment in a mean time of 15.74 months with two delayed unions. No difference in alignment was encountered between the immediate postoperative and final radiographs. Limb length discrepancy of 5 mm or less was encountered in one patient. Two (6.66%) patients had less than or equal to 10° reduced range of ankle motion. One (3.33%) patient lost his job, four (13.33%) patients did not return to their preinjury daily activity, and eight (26.66) patients stopped sports-related activities. Implant removal was carried out for three patients with knee pain. The mean American Orthopedic Foot and Ankle Society score was 93 at the end of follow-up. Conclusion Static-reamed nailing is a safe and effective biological stable fixation option in treating distal tibia fractures. Nailing may be preferred in uncontrollable patients, open fractures, osteoporotic bone, pathological fractures, obese patients, and when early weight-bearing is unavoidable. We did not recommend nailing for articular comminution, failure of closed reduction, and types III-B and III-C open fractures.

The Role of Fibular Fixation in Distal Tibial Fractures.

Lower tibial extra-articular fractures of lower tibial extra-articular bone, treated with Minimally Invasive Percutaneous plate osteosynthesis (MIPPO) may have certain advantages, though the modiality is technically demanding. To assess the results of distal tibial fractures treated with minimally invasive plate osteosynthesis utilizing precontoured dital medial tibial locking plates without fibular fracture fixation. The study was conducted during the period from june 2009 to june 2011. A series of 30 patients (22 men and 8 women) with concurrent distal tibia and fibula fractures who underwent minimally plate osteosynthesis utilizing precontoured distal tibial medial locking plates without fibular fracture fixation have been reviewed after surgery. 14 fractures were type A1, 6 type A2, and 4 type A3. Open Grade II fracture were 4 and Open Grade IIIA fracture is2. The mean follow-up duration was 2 years. The mean time to bone union was 20 weeks. No patient had shortening, hardware breakdown, or deep-seated infection. Out of 30 patients, 24 had excellent results, 6 had good results. Four patients had palpable screws, two patient had blisters which subsidized with conservative treatment. This minimally invasive technique for treatment of distal tibial fractures proved to be a feasible and worthwhile method of stabilization. It appears from our study that fibula fixation is not required in non-syndesmotic distal metaphyseal extra articular fractures when fixed by locking plate using minimal invasive techniques.

Time to union and functional outcome following minimally invasive plating of extra-articular fractures of the distal tibia

Background Treatment of distal tibial fractures is often challenging and fraught with complications. Minimally invasive plating is thought to overcome complications associated with open plating and intramedullary fixation in the distal third of the tibia. The aim of this study was to evaluate the use of minimally invasive plating in extra-articular fractures of the distal tibia regarding time to union, functional outcome, and complications. Patients and methods Thirty consecutive patients with extra-articular fractures involving the distal third of the tibia were classified according to the Muller-Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification and treated with minimally invasive plating using the anatomical distal plate. In nine cases, the locked anatomical distal plate was used, whereas in 21 cases the conventional nonlocked anatomical distal plate was used. Patients were followed up at 2 and 6 weeks postoperatively and then every 6 weeks with a mean follow-up time of 30 weeks (range: 18–94 weeks), in which time to union and complications were documented. Functional outcome was assessed using the American Orthopedic Foot and Ankle Society ankle scoring system at a minimum of 12 weeks from the start of weight-bearing. Results All cases showed union at a maximum of 16 weeks, except four cases: two had delayed union, one had plate failure that ended in deep infection, and there was a case of nonunion. Overall, the mean time to union was 17 weeks (range: 6–60 weeks). The American Orthopedic Foot and Ankle Society ankle scoring system scored an average of 92.4 points (range: 72–100 points). Conclusion This technique minimizes the soft-tissue complications and provides a good functional outcome for patients with extra-articular distal tibial fractures within a reasonable period of time. Level of evidence The present study was a level IV case series.

Minimally-invasive plate osteosynthesis in distal tibial fractures: Results and complications.

Distal tibial or pilon fractures are usually the result of combined compressive and shear forces, and may result in instability of the metaphysis, with or without articular depression, and injury to the soft tissue. The complexity of injury, lack of muscle cover and poor vascularity make these fractures difficult to treat. Surgical treatment of distal tibial fractures includes several options: external fixation, IM nailing, ORIF and minimally-invasive plate osteosynthesis (MIPO). Management of distal tibial fractures with MIPO enables preservation of soft tissue and remaining blood supply. This is a report of a series of prospectively studied closed distal tibial and pilon fractures treated with MIPO. A total of 21 patients with closed distal tibial or pilon fractures were enrolled in the study between March 2008 and November 2013 and completed follow-up. Demographic characteristics, mechanism of injury, time required for union, ankle range of motion and complications were recorded. Fractures were classified according to the AO/OTA classification. Nineteen patients were initially managed with an ankle-spanning external fixator. When the status of the soft tissue had improved and swelling had subsided enough, a definitive internal fixation with MIPO was performed. Patients were invited for follow-up examinations at 3 and 6 weeks and then at intervals of 6 to 8 weeks until 12 months. Mean age of the patients was 40.1 years (range 19-67 years). Eighteen cases were the result of high-energy trauma and three were the result of low-energy trauma. According to the AO/OTA classification there were extraarticular and intraarticular fractures, but only simple articular patterns without depression or comminution. The average time for fracture union was 19.7 weeks (range 12-38 weeks). Mean range of motion was 10° of dorsiflexion (range 5-15°) and 28.3° of plantar flexion (range 20-35°). Three cases were metalwork-related complications. Two patients underwent plate removal at 24 weeks because of plate impingement. There was one case of wound breakdown at 11 weeks. One patient had fracture union with tibial recurvatum of approximately 10°, without functional impairment. Two patients had delayed union. MIPO is a reliable method of treatment for distal tibial fractures; it provides a high union rate and good functional outcome with minimal soft tissue complications. Skin impingement remains a common complication with MIPO, but this can be solved by timely plate removal.

External Fixation Using a Locking Plate: A Reliable Way in Treating Distal Tibial Fractures.

The surgical treatment of distal tibial fractures is still challenging. The purpose of this study was to evaluate the clinical and radiographic results associated with the use of a precontoured distal femoral locking plate as an external fixator in treating distal tibial fractures. From August 2011 to October 2012, 28 patients with distal tibial fractures were consecutively enrolled in this study. There were 9 OTA 43.A1, 9 43.A2, and 10 43.A3, including 21 closed and 7 open fractures. The precontoured distal femoral locking plate was placed on the anteromedial aspect of the tibia as an external fixator. All patients were followed for an average of 16 months. The mean surgical duration was 38 (25-60) minutes. The mean time until fracture healing was 16.7 (12-24) weeks. At final follow-up, the mean American Orthopaedic Foot and Ankle Society score was 93 (88-100). There were no nonunions, deep infections, or implant fractures. Three patients had transient superficial pin site infection, but these did not change the clinical outcome. External fixation using a precontoured distal femoral locking plate is a reliable option in treating distal tibial fracture. The procedure is easy to perform, is less invasive, and the low profile plate can be concealed under stockings and can be conveniently removed.

The service impact of failed locking plate fixation of distal tibial fractures: a service and financial evaluation at a major trauma centre

The surgical treatment of distal tibial fractures is challenging and controversial. Recently, locking plate fixation has become popular, but the outcomes of this treatment are mixed with complication rates as high as 50 % in the published literature. There are no reports specifically relating to the financial and resource costs of failed treatment in the literature. Retrospective service analysis of patients who had undergone locking plate fixation of a distal third tibial fracture between 2008 and 2011 with at least 12 months follow-up. Rates of readmission, reoperation, bony union and infection were ascertained. The financial and resource (hospital stay and number of outpatient appointments) implications of failed treatment were calculated. Forty-two patients were identified. There were 31 type A fractures, one type B fracture and 10 type C fractures. Three injuries were open. Twenty patients were treated with minimally invasive percutaneous osteosynthesis (MIPO). The readmission and reoperation rates were 26 % (n = 11) and 19 % (n = 8), respectively. A total of 89 % of readmissions were due to infection. All patients had received appropriate antibiotic regimens. The average costs of successful and failed treatment were £ 5538 and £ 18,335, respectively. The average time to union was 24.5 weeks. The rate of non-union was 21 % (n = 9). The rate of infection was 28 % (n = 12), with all patients with open fracture incurring an infection. Tourniquet time had no effect on the incidence of complications. Smokers were more likely to incur a complication (p < 0.05), and non-union was lower in the MIPO group (p < 0.05). The length and total cost of inpatient care were significantly lower in the MIPO group (p < 0.05). MIPO patients were five times less likely to incur readmission or reoperation. Failed treatment was three times more expensive and four times longer than successful treatment. The study identified a large burden to the service following failure of locking plate treatment of these fractures, but the outcomes were similar to series published in the literature. Readmission rates were high following these injuries, and failed treatment was costly and had a significant impact on hospital resources. The implementation of major trauma networks and centralised subspecialised units should improve quality and value for money.

Outcomes After Intramedullary Nailing of Distal Tibial Fractures.

To determine outcomes in the treatment of distal tibial fractures treated with intramedullary nails. Retrospective analysis. Level I trauma center with follow-up in a private orthopaedic practice. Radiographic determination of alignment, nonunion, and malunion, clinical outcome (range of motion, and implant-associated complaints), wound complications, and fibular fixation. A total of 105 patients with OTA/AO type A and C tibial fractures (<11 cm from the joint line) treated with intramedullary nailing. Distance of the fracture from the joint line averaged 6.1 cm (range, 0-11). Mean follow-up was 25.6 months (range, 12-74). Nonunion occurred in 20 (19%) fractures and were significantly associated with open fractures (P = 0.012), wound complications (P < 0.001), and the need for fibular fixation (P = 0.007). Sagittal plane alignment averaged 2.5 degrees (±4.4) valgus. Malunion occurred in 25 (23.8%) fractures and again were significantly associated with open fractures (P = 0.045). Fifty (47.6%) patients had implant-related pain, which resolved in 27 (54.0%) after removal. Intramedullary nailing of distal tibial fractures is a suitable treatment option. Acceptable alignment and range of motion can be achieved. Both nonunions and malunions were significantly associated with open fractures, wound complications, and fibular fixation. Implant removal was needed in 25% of cases. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Anterolateral Versus Medial Plating of Distal Extra-articular Tibia Fractures: A Biomechanical Model.

Both medial and anterolateral plate applications have been described for the treatment of distal tibia fractures, each with distinct advantages and disadvantages. The objective of this study was to compare the biomechanical properties of medial and anterolateral plating constructs used to stabilize simulated varus and valgus fracture patterns of the distal tibia. In 16 synthetic tibia models, a 45° oblique cut was made to model an Orthopedic Trauma Association type 43-A1.2 distal tibia fracture in either a varus or valgus injury pattern. Each fracture was then reduced and plated with a precontoured medial or anterolateral distal tibia plate. The specimens were biomechanically tested in axial and torsional loading, cyclic axial loading, and load to failure. For the varus fracture pattern, medial plating showed less fracture site displacement and rotation and was stiffer in both axial and torsional loading (P<.05). For the valgus fracture pattern, there was no statistically significant difference between medial and anterolateral plating. There were no significant differences between the 2 constructs for either fracture pattern with respect to ultimate load, displacement, or energy absorption in load to failure testing. When used to stabilize varus fracture patterns, medial plates showed superior biomechanical performance compared with anterolateral plates. In this application, the medial plates functioned in anti-glide mode. For valgus fracture patterns, no biomechanical differences between anterolateral and medial plating were observed. In clinical practice, surgeons should take this biomechanical evidence into account when devising a treatment strategy for fixation of distal tibia fractures.

The role of CT in diagnosis and treatment of distal tibial fractures with intra-articular involvement in children

AimDistal tibial fractures with intra-articular involvement during childhood are injuries with potentially severe complications if not treated promptly. Daily clinical practice indicates that sole use of plain radiographs may lead to misdiagnosis and subsequent erroneous selection of suitable treatment. The role of computed tomography (CT) in the classification and treatment decision of these injuries is unclear. This study aims to determine whether CT evaluation is required in the management of these fractures. Patients and methodsWe assessed 64 distal tibial fractures with intra-articular involvement on two separate occasions in a blinded study, in order to classify the fracture and decide the appropriate treatment approach. In the first part of the study, plain radiographs were evaluated in order to diagnose the type of the fracture and select the appropriate treatment. In the second part, CT scans were performed in the same patients in order to re-evaluate diagnosis and treatment. The study included fractures prior to physeal closure (Salter–Harris III and IV fractures, n=32) as well as transitional fractures (J. Tillaux and triplane fractures, n=32). ResultsAccording to plain radiographs, 31 patients were diagnosed with SH III fracture, 8 with SH IV, 9 with J. Tillaux and 16 with triplane fracture. Surgical treatment was decided in 18 patients and non-surgical in 46. After CT scan evaluation, 20 patients were diagnosed with SH III, 12 with SH IV, 9 with J. Tillaux, and 23 with triplane fracture. In this occasion the number of patients referred for surgical treatment raised to 42 leaving only 22 patients to be treated conservatively. ConclusionsComputed tomography lead to changes in fracture classification and treatment decision. Treatment decision changed for 24 patients after CT evaluation. Treatment decision in patients with SH III and IV did not change significantly opposed to patients with transitional fractures, where CT scan had major impact on treatment decision. Despite the irradiation of immature skeleton and higher cost containment, this study indicates that patients with transitional distal tibial fractures as well as patients with displaced SH III and IV fractures must undergo CT examination in order to make accurate diagnosis and select the appropriate treatment.

Outcome of Distal Both Bone Leg Fractures Fixed by Intramedulary Nail for Fibula & MIPPO in Tibia.

Fractures of the distal third of the tibia are mostly associated with a fibular fracture that often requires fixation. The preferred treatment of distal tibial fracture is the minimally invasive percutaneous plate osteosynthesis (MIPPO) procedure. However, there are no clear cut guidelines on fixation of the fibular fracture and currently most orthopedic surgeons use a plate osteosynthesis for the fibula as well. A common complication associated with dual plating is an increased chance of soft tissue necrosis, infection, and in some cases resulting in an exposed implant. We conducted a prospective study to analyze the results of fractures of the distal in both leg bones managed by the MIPPO procedure for tibial fractures and a rush nail for fibular fractures. The study was conducted in a tertiary care hospital from November 2012 to May 2014, a total of 30 fractures in 30 patients (18 males, 12 females) with a mean age of 42.4 years (26-60 years) were treated in our institution in the aforesaid time period with MIPPO for tibia and rush nail for fibular fractures. All the cases were operated on by a single surgeon in emergency within 24 hours. The patients with skin blistering and compound fractures were excluded from this study. Rehabilitative measures were proceeded as per patient's pain profile, isometric and isotonic exercises were started on the first post-operative day, with full weight bearing at 10-12 weeks after assessing clinical and radiological union. Regular follow up of patients was done, radiographs were taken at the immediate post-operative period and at 3, 6, 12 and 24 weeks. All the patients were available for regular follow up. Radiological and clinical union proceeded normally in all the patients, no patients had signs of any deep infection, delayed union or nonunion, three patients had a superficial infection of the tibial incision that healed with a change in antibiotic. The use of dual plating for fixation of the lower tibia and fibula fractures is often associated with soft tissue complications, exposed implant, and increased risk of infection. We conclude that in fractures of the distal tibia and fibula it is better to use a rush nail for the fibula with a concurrent MIPPO for the tibia for the reasons cited above. Moreover, with the use of rush nail the cost of implant is also reduced, which is a very important factor in developing countries.

Minimally invasive percutaneous plate osteosynthesis does not increase complication rates in extra-articular distal tibial fractures.

Background : Selection of a treatment method in cases of unstable, nonarticular distal tibial fractures is still a matter of discussion. Intramedullary nailing, which is a “gold standard” for tibial shaft fractures, does not always work for this specific transition area between diaphysis and metaphysis. Instead, new minimally invasive techniques with special implants are popular.Aims : To determine the functional and radiological results of distal tibial fractures treated with minimally invasive percutaneous plate osteosynthesis (MIPPO) technique.Study Design : Retrospective cohort analysis.Methods : Thirty distal tibial fractures treated with MIPPO method, between January 2006 and December 2010, were evaluated retrospectively. All patients were classified according to AO/OTA classification. Period of hospital stay, time of fracture union, time to allow full weight bearing, early and late complications were inquired. Functional outcomes were assessed by AOFAS scores.Results : There were 13 male and 17 female patients with an average age of 44.26 (range, 22-77 years). One superficial infection and one malunion were observed. Two patients were revised for the loss of reduction and healed uneventfully. According to the AO/OTA classification, 23 patients were 43-A1 (76.6%), 3 were 43-A2 (10%) and 4 were 43-A3 (13.3%). Post-operative mean stay of patients at the hospital was 2.6 ± 1.42 days (range, 1-7 days). Mean full weight-bearing period of the patients was found out as 13.16 ± 2.6 weeks (range, 10-22 weeks). The mean period of union of fracture for patients was found out as 19.8 ± 2.99 weeks (range, 16-34 weeks).Conclusion : Treatment of distal tibial fractures with MIPPO method provides a successful treatment strategy as long as used as per the technique, and it respects and does not harm soft tissues which allows early callus formation and rapid healing that enable the patient to walk as early as possible after the operation. The overall clinical and functional outcome is still good despite minor complications.

Ionising radiation exposure in patients with circular frame treatment of distal tibial fractures

Total radiation exposure accumulated during circular frame treatment of distal tibial fractures was quantified in 47 patients treated by a single surgeon from February 2007 until Oct 2010. The radiation exposures for all relevant radiology procedures for the distal tibial injury were included to estimate the radiation risk to the patient.The median time of treatment in the frame was 169 days (range 105–368 days). Patients underwent a median of 13 sets of plain radiographs; at least one intra operative exposure and 16 patients underwent CT scanning. The median total effective dose per patient from time of injury to discharge was 0.025mSv (interquartile range 0.013–0.162 and minimum to maximum 0.01–0.53). The only variable shown to be an independent predictor of cumulative radiation dose on multivariate analysis was the use of CT scanning. This was associated with a 13-fold increase in overall exposure.Radiation exposure during treatment of distal tibial fractures with a circular frame in this group was well within accepted safe limits. The fact that use of CT was the only significant predictor of overall exposure serves as a reminder to individually assess the risk and utility of radiological investigations on an individual basis. This is consistent with the UK legal requirements for justification of all X-ray imaging, as set out in the Ionising Radiation (Medical Exposure) Regulations 2000 [1].

Distal tibial fractures: evaluation of different fixation techniques.

The purpose of this study was the comparison of the most commonly used surgical techniques (external fixation, intramedullary nailing, and plate fixation) for the treatment of distal tibial fractures (AO/OTA classification 42-A, B, C or 43-A, B1). A retrospective cohort study of patients who underwent surgical treatment for distal tibial fractures between 1992 and 2011 was performed. A total of 93 patients (52 male/41 female) met inclusion criteria. Statistically significant differences were found regarding the consolidation time of the intramedullary-nailing (147.32±91.16 days) and the plate-fixation group (135.75±110.75 days) versus the external-fixation group (163.12±96.79 days; P=0.001; P=0.01). Significant differences were also observed in the range of motion (ROM) of the ankle joint in the intramedullary-nailing and plate-fixation group versus the ROM in the external-fixation group (P=0.044; P=0.025). The overall complication rate was 13/93 (14%). Out of 66 patients treated with intramedullary nailing, 8 (12%) suffered from complications. Out of the 15 patients treated with plate and 12 patients with external fixation, 2 (13%) and 3 (25%) showed complications, respectively. Our results demonstrate advantages in terms of shorter mobilization time and a better ROM of the ankle joint for intramedullary nailing and plate fixation compared with external fixation. Due to our results, we suggest internal fixation (intramedullary nailing or plate fixation) whenever patient's condition and the local fracture situation allow it.

Intramedullary nail versus plate treatments for distal tibial fractures: A meta-analysis

IntroductionControversy remained on whether the optimal treatment for distal tibial fractures is intramedullary nail (IMN) or plate. MethodsDatabases including PubMed, Embase, Cochrane library, Wanfang and CNKI were retrieved up to May 31, 2014 for eligible studies. Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool was used to evaluate literature qualities. Q and I2 test were applied to estimate heterogeneities. Moreover, subgroup analyses were performed and publication bias was detected. Mean difference (MD) and relative risk (RR), with their corresponding 95% confidence interval (CI) were used to calculate the pooled results. ResultsSixteen studies were included involving 1140 participants (IMN: 599; plate: 541). There were no significant differences between IMN and plate treatments in operation time (OT), hospital time (HT), union time (UT), and incidence of deep infection (DI) and union complications (UC). However, IMN achieved a significant lower superficial infection (SI) incidence (RR, 0.41; 95% CI, 0.23 to 0.71; P = 0.001) and a significant higher malunion incidence (RR, 2.27; 95% CI, 1.56 to 3.31; P < 0.001). In subgroup analyses, IMN had significant shorter OT than plate in randomized controlled trials (RCTs) (MD, -19.04; 95% CI, -24.86 to −13.21; P < 0.0001), but comparable incidence of SI to plate in non-Asia countries. No obvious publication bias was indicated in UT and malunion. ConclusionFor distal tibial fractures treatment, IMN might be advantageous over plate with lower SI incidence, and comparable UT, OT and HT. Meanwhile, IMN was related to higher risk of malunion. However, more RCTs are warranted.

Stromal cells and stem cells in clinical bone regeneration.

Stem-cell-mediated bone repair has been used in clinical trials for the regeneration of large craniomaxillofacial defects, to slow the process of bone degeneration in patients with osteonecrosis of the femoral head and for prophylactic treatment of distal tibial fractures. Successful regenerative outcomes in these investigations have provided a solid foundation for wider use of stromal cells in skeletal repair therapy. However, employing stromal cells to facilitate or enhance bone repair is far from being adopted into clinical practice. Scientific, technical, practical and regulatory obstacles prevent the widespread therapeutic use of stromal cells. Ironically, one of the major challenges lies in the limited understanding of the mechanisms via which transplanted cells mediate regeneration. Animal models have been used to provide insight, but these models largely fail to reproduce the nuances of human diseases and bone defects. Consequently, the development of targeted approaches to optimize cell-mediated outcomes is difficult. In this Review, we highlight the successes and challenges reported in several clinical trials that involved the use of bone-marrow-derived mesenchymal or adipose-tissue-derived stromal cells. We identify several obstacles blocking the mainstream use of stromal cells to enhance skeletal repair and highlight technological innovations or areas in which novel techniques might be particularly fruitful in continuing to advance the field of skeletal regenerative medicine.