Treatment Of Distal Tibial Fractures Research Articles

Risk factors for malalignment after intramedullary nail treatment of distal tibia fractures with associated fibula fractures

PurposeMalalignment of distal tibia fractures can lead to malunion/nonunion or alter the limb mechanical axis which may cause arthritis. Proposed methods to decrease malalignment include fibular fixation or multiplanar interlocking screws, however these remain controversial. This study aimed to identify factors associated with malalignment in distal tibial fractures with associated fibular shaft fractures.MethodsA retrospective review was performed of distal tibia fractures with associated fibular shaft fractures treated with intramedullary nailing at two level one trauma centers between 2015 and 2019. Cases involving malalignment (> 5° of deviation from anatomic axis on either coronal/sagittal axis) on final follow-up (minimum three months postoperatively) were compared to those without malalignment with regard to demographics, fracture characteristics, intraoperative characteristics, and complications.ResultsThe rate of malalignment was 13%. On multivariate analysis, multiplanar distal interlocking screw fixation (odds ratio [OR], 0.18; 95% confidence interval [CI] 0.03–0.92) was associated with a decreased rate of final malalignment, while nail diameter > 10 mm was associated with a higher rate (OR, 4.05; 95% CI 1.25–13.11). Fibular fixation was not associated with malalignment.ConclusionMultiplanar distal interlocking screws may protect against malalignment. Fibula fixation does not appear associated with a decreased rate of malalignment in distal tibia fractures treated with intramedullary nails.Level of EvidenceIII.

How Effective is Fibula Pro Tibia Plating in Treatment of Distal Tibial Fractures: A Pilot Study.

Despite recent advances, management of distal tibial fractures is challenging, with high rate of complications. Fibula pro tibia plating technique fixes fibula and tibia together, via laterally placed fibular plate without disturbing the tibial soft tissue sleeve. We contemplated this pilot study to assess effectiveness of fibula pro tibia plating in management of distal tibia fibula fractures. A total of 30 patients with distal tibia fibula fractures with fracture line extending within 5cm from tibial plafond were managed with fibula pro tibia plating, with or without minimal articular fixation. Outcome evaluation was done by union, union time, alignment and functional outcome as assessed by AOFAS score. Mean age in the series was 39.4 years with male to female ratio of 3:2. Mean duration of surgery, blood loss and C arm exposure were 79 minutes (range 52 to 98min), 80ml (range 62 to 102ml) and 48 shoots (range 36 to 81 shoots), respectively. All fractures united in mean union time of 10.2 weeks (range 9 to 14 weeks) with acceptable alignment in all the patients except one. Mean AOFAS score was 86.3 (range 70 to 93) with 29 patients having good to excellent outcome. One patient had varus malunion and in one case infection was seen. Fibula pro tibia plating can be successfully used to manage complex distal tibia fractures which leaves the soft tissue and periosteal sleeve undisturbed, thus avoiding wound related problems and leading to early union.

Operative Treatment of Distal Tibial Fractures in Children Managed With Epiphyseal Screws: A Comparison of Outcomes When Screws Are Retained Versus Removed Following Fracture Union.

Fractures of the distal tibial epiphysis in children are often accompanied by articular surface disruption. With increased displacement, internal fixation is frequently performed with an epiphyseal screw to close the fracture gap. Despite limited, high-level clinical evidence to support implant removal, epiphyseal screws are commonly removed after fracture healing due to potentially increased contact forces on the tibiotalar joint. The purpose of this study was to investigate and compare outcomes and complications in children that underwent surgical treatment of distal tibial epiphyseal fractures with placement of an epiphyseal screw(s) and had the implant(s) retained versus removed at a minimum of 2-year postoperative follow-up. Children younger than 18 years from two urban tertiary care centers who underwent operative management of distal tibia Salter-Harris III and IV fractures using epiphyseal screws (2013-2020) were divided into two cohorts: retained epiphyseal screws and implant removed. Demographics, intraoperative, postoperative, and radiographic data were collected. Patient-reported outcomes (PROs) using the Foot and Ankle Ability Measure (FAAM) and Single Assessment Numeric Evaluation (SANE) questionnaires were collected at the final follow-up. Statistical analysis, including power analysis, was performed. Fifty-two children were included (30 males, 22 females) with a mean age of 13.3 years at the time of injury (range, 7.7-16.4 years). Thirty-five children retained the implants; seventeen had implants removed. All completed the FAAM questionnaires at a mean follow-up of 4.4 ± 1.9 years, while 29 completed the SANE questionnaire at a mean follow-up of 4.4 ± 1.7 years. No statistically significant difference in patient demographics, surgical variables, or PROs was observed. Six children experienced complications from the initial surgery, including infections and complex regional pain syndrome, with no difference in complication rates between the cohorts ( P =0.08). Furthermore, no complication was observed as a result of implant removal. Children with retained epiphyseal implants have similar functional outcomes as compared with those who had implants removed after distal tibial epiphyseal fracture fixation and union. Level III-Retrospective comparative study.

Lower Limb Malrotation following Minimally Invasive Plating in Distal Tibia Fractures.

Minimally invasive percutaneousosteosynthesis (MIPO) plating techniques havedemonstrated good outcomes in the treatment of distal tibia fractures. Early arthritis and functional impairment mayoccur if length and rotation are not restored. This study aims to determine the incidence and severity of tibia malrotation following MIPO plating of isolated unilateral distal tibia fractures, defined as torsional difference of greater than 10° as compared to the contralateral limb and whether the degree of malrotation affects functional outcomes scores. This was a level 2 prospective cohort study. All patients with fractures of the distal tibia who underwent surgical fixation with the exclusion ofpatients with polytrauma, neurovascular injuries or pre-existing disabilities were recruited. Patients underwent MIPO plating followed by a post-operative ComputedTomography (CT) scan of bilateral lower limbs. AOFAS ankle-hindfoot score was recorded at six months and one year follow-up. A total of 24 patients (28 to 83 years old) were recruited. Nineteen patients obtained CT scans. Nine of the 19 patients (47.3%) had tibia malrotation. The mean tibia malrotation angle was 10.3° (0° - 45°). The average AOFAS scores was 82.4 and 84.3 at 6 months and 1 year follow-up. Degree of CT malrotation was not significantly associated with AOFAS scores at 6 month (spearman rho -0.386) and 1 year (spearman rho -0.343). Tibia malrotation following MIPO plating of distal tibia fractures is common, with an incidence of 47.3% and an average malrotation angle of 10.3°. The degree of malrotation does not appear to have significant mid-term functional impact on the patient.

Comparative experimental study of the biomechanical properties of retrograde tibial nailing and distal tibia plate in distal tibia fracture.

Objective: A biomechanical comparative analysis was conducted to evaluate the retrograde tibial nailing (RTN) and distal tibia plate techniques for the treatment of distal tibia fractures. Methods: Fourteen fresh adult tibia specimens were selected, consisting of seven males and seven females aged 34-55years. The specimens were randomly divided into two groups (Group A and Group B) using a numerical table method, with seven specimens in each group. Group A underwent internal fixation of distal tibial fractures using RTN, while Group B received internal fixation using a plate. The axial compression properties of the specimens were tested in the neutral positions under pressures of 100, 200, 300, 400, and 500N. Additionally, the torsional resistance of the two groups was assessed by subjecting the specimens to torques of 1.0, 2.0, 3.0, 4.0, and 5.0Nm. Results: At pressures of 400 and 500N, the axial compression displacement in Group A (1.11 ± 0.06, 1.24 ± 0.05) mm was significantly smaller than that in Group B (1.21 ± 0.08, 1.37 ± 0.11) mm (p = 0.023, 0.019). Moreover, at a pressure of 500N, the axial compression stiffness in Group A (389.24 ± 17.79) N/mm was significantly higher than that of the control group (362.37 ± 14.44) N/mm (p = 0.010). When subjected to torques of 4 and 5Nm, the torsion angle in Group A (2.97° ± 0.23°, 3.41° ± 0.17°) was significantly smaller compared to Group B (3.31° ± 0.28°, 3.76° ± 0.20°) (p = 0.035, 0.004). Furthermore, at a torque of 5Nm, the torsional stiffness in Group A (1.48 ± 0.07) Nm/° was significantly higher than that in Group B (1.36 ± 0.06) N·m/° (p = 0.003). Conclusion: The results obtained from the study demonstrate that the biomechanical performance of RTN outperforms that of the distal tibial plate, providing valuable biomechanical data to support the clinical implementation of RTN.

Benefits of Poller Screw in Improving Radiological Outcomes after Intra-Medullary Nailing for Distal Tibia Fractures; A Retrospective Cohort Study.

To compare the radiological outcomes after fixation of distal tibia fractures with IM nail between patients in whom poller screw was used vs those in whom it was not used. A retrospective cohort study was conducted between 1st January 2009 to 31st June 2019 including patients treated with IM nail for distal tibial metaphyseal fractures. Patients were divided into 2 groups based on whether a poller screw was placed during surgery or not. The exposed group consisted of patients who underwent augmentation of IM nail with a poller screw, while control group included patients who underwent fixation with nail alone. All adult patients aged ≥18 years were included and patients with pathological fractures, known metabolic bone disease were excluded from the study. Follow-up x-rays were viewed through our hospital database and fracture healing was classified as either union, malunion or non-union based on radiographic parameters. A Radiographic Union Score in Tibia (RUST) score was calculated and a score of ≥9 was considered conclusive for complete union. 93 patients were included in the study with 21 patients in the exposed and 72 in the control group. According to the analysis, there were no significant differences in baseline characteristics of the study participants. The exposed group was found to be associated with increased rates of union and decreased non-union and mal-union rates compared to control group (P-value = 0.003). Mean RUST score was also noted to be significantly higher in exposed group compared to control group with a P-value of 0.025. Use of poller screw with IM nail in treatment of distal tibial fractures is important in improving post-operative outcomes and decreasing mal-union and non-union.

INTRAMEDULLARY NAIL OR LOCKING COMPRESSION PLATE FOR FIXING A FRACTURED DISTAL TIBIA: FINITE ELEMENT ANALYSIS ALONG WITH AN ADAPTATION MODEL

Intramedullary (IM) nailing and plating are two major options for the treatment of distal tibial fractures; each method has its own pros and cons. Bone loss due to IM nailing or plating can be a serious concern, which may lead to the premature failure of the implants. Thus, investigating bone remodeling in response to orthopedic implantation is of paramount importance for the purpose of designing more efficient prostheses. The main goal of this study was to predict the effects of nailing and plating on the bone apparent density distribution in tibia, through use of the finite element method (FEM) along with a bone remodeling model. To this end, three-dimensional geometry of tibia, with properties derived from computer tomography (CT) imaging data, IM nail and locking compression plate (LCP) were created. Then, a bone remodeling model and FEM, with physiological-like loading, were combined and implemented using Python programming language. The results showed that both nailing and plating methods cause a reduction in bone apparent density, but the plate affects just the distal part of the tibia, where the implant is present; whereas the IM nail affects almost the whole tibia. Moreover, in agreement with clinical observations, it was found here that the stress shielding effects of the LCP are less pronounced than that of IM nail, in the long term. Stress analysis revealed that the load, to most extent, transferred to IM nail; whereas it transferred to LCP just in the distal part of tibia. On the basis of the results of this work, it might be concluded that plating is a better choice than nailing for distal tibial fracture, from the bone remodeling point of view.

Functional Outcome of Distal Tibial Fractures Fixed with Distal Tibial Locking Plate using MIPPO Technique

Introduction: Because of the extensive list of potential consequences, treating extra-articular distal tibia fractures is a daunting task for an orthopedic surgeon. This study was designed to evaluate the clinical and functional outcomes of minimally invasive plating for the treatment of distal tibial fractures. Materials and Methods: This prospective study was conducted at the Department of Orthopedic Surgery, Popular Medical College and Hospital, Dhaka during June 2021 to May 2022. A total of 20 patients with distal tibial fracture were selected for surgery and treated with minimally invasive plating. Afterwards, the patients' clinical and radiological outcomes were recorded. The ankle-hindfoot score developed by the American Orthopedic Foot and Ankle Society (AOFAS) was used to assess the functional outcomes. Results: In 15 of the 20 cases, radiological union took place between 18 and 22 weeks (mean 20.5 weeks); however, in 5 cases, union was delayed and required almost 26 weeks to establish. Four of the 20 cases experienced a superficial infection, while the remaining patients showed no further complications. According to the AOFAS score, our research showed that, out of 20 patients, 9 had excellent outcomes, 8 had good results, and 3 had acceptable results. Conclusion: Treatment of distal tibia fractures with locking plates by MIPPO technique is an effective method of therapy to achieve union and excellent functional results since it aids in the early restoration of ankle movement while reducing ankle stiffness. Medicine Today 2023 Vol.35(2): 114-117

Effect of intramedullary nail fixation and internal plate fixation in distal tibia fracture surgery on post-operative wound infection in patients: A meta-analysis.

Distal tibial fracture is the most commonly seen type of fracture of the lower extremities. Both intramedullary nail fixation (INF) and plate fixation (PF) have been used to treat distal tibial fractures, but the best way to treat them is still in dispute. The purpose of this meta-analysis is to compare INF versus PF fixation with respect to the incidence of injury. For studies that have been published between inception and June 2023, a systematic review has been carried out on PubMed, Embase, Cochrane Library and Web of Scientific databases. All of the trials that looked at INF and PF-related complications were enrolled. Data from the 13 primary results were analysed with RevMan 5.3. The meta-analyses comprised 13 randomized controlled trials (RCTs). INF indicates that there is a tendency for patients with distal tibia fractures to reduce the risk of operative site infection (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.40, 3.13; p = 0.0003) after surgery compared with PF. INF resulted in a reduction in total wound complications (OR, 14.20; 95% CI, 1.81, 111.57; p = 0.01) but shortened operation time (mean difference, 13.03; 95% CI, 2.08, 23.99; p = 0.02). In view of these findings, INF seems to be a preferred method of surgery for the treatment of distal tibial fractures with respect to the reduction of post-operative wound complications.

Evaluation of Treatment of Distal Tibia Fracture with an Intramedullary Interlocking Nail and Single Poller Screw

Introduction: Distal tibia fracture tends to angulate while using a standard intramedullary interlocking nail. By using a single Poller screw, the medullary cavity's functional diameter is reduced. This leads to angulation correction and three-point fixations, which improve the mechanical stability of the nail-bone construct.
 Aims: To assess the functional and radiological results of the intramedullary interlocking nail and poller screw in management of adult distal tibia fracture.
 Methods: All patients with distal tibia fractures age more than 18 years, treated with intramedullary interlocking nails and a single poller screw at Nepalgunj Medical College between January 2022 and April 2023 were included in this prospective study. Radiological examination involved measuring sagittal and coronal plane angulation pre and postoperatively, while functional outcome was assessed using the Karlstorm- Olerud score. Ethical clearance was obtained from Institutional Review Committee.
 Results: Total 30 patients, 19 male and 11 females with mean age of 32.37 ± 11.02 (range 18 to 62 years) were treated. Mean difference of diameter between isthmus and fracture site was statistically significant. There was significant reduction in coronal and sagittal plane angulation after surgery which was maintained till union. All fractures united at an average of 17.60 ± 2.25 weeks, with 90% having good to excellent results.
 Conclusion: Using a poller screw with an intramedullary interlocking nail can greatly alleviate the angulation issue with the distal fragment for distal tibia fracture.

Minimally Invasive Percutaneous Plate Osteosynthesis versus Interlocking Intramedullary Nail Fixation in Treating Extra-Articular Distal Tibial Fractures in Adults. A Systematic Review

Background IM nailing and MIPPO fixation remain viable options for management of distal tibia fractures. IM nailing provides superior operation time, union time, and time to full weight-bearing as well as a lower incidence of superficial and deep infection, but may provide inferior alignment and is associated with residual knee pain. MIPPO fixation provides superior alignment and avoids knee pain, but it has a higher rate of soft-tissue complications and hardware irritation. This review revealed that MIPPO has a higher risk of both superficial and deep infection among patients treated with MIPPO compared to IMN. In the MIPPO technique, 15% developed a superficial infection, compared to 7% after IMN, and 14% developed a deep infection, compared to 6.3% after IMN. Aim of the Work to provide a complete overview of the optimal surgical treatment of distal tibia fractures by evaluating and comparing the clinical and functional outcomes of minimally invasive percutaneous plate osteosynthesis (MIPPO) vs Interlocking intramedullary nail (IMN) for treating extra-articular distal tibial fractures. Outcomes of interest include operation time, time to union, non-union, mal-union, infection, secondary operations, and functional outcomes (quality of life scores and ankle scores). Patients and Methods In terms of union complication, IMN has a higher incidence of malunion which occurred in 14.7% of the patients after IMN compared to 8.8% after MIPPO fixation. The incidence of non-union was similar in both treatment methods, it occurred in 3.5% of patients. In addition to union rate, the union time was significantly shorter after IMN fixation compared to the MIPPO technique especially in AO 43A fracture type and the closed fractures. The mean time for union was 18 weeks in IMN compared to 20 weeks in MIPPO. Results Nine studies including 813 patients reported on operation time with an overall weighted mean operation time of 74.1 minutes (range 56.4 – 124 minutes) in IMN and 85.4 minutes (range 51.4 – 124 minutes) in MIPPO. The operation time in the IMN was significantly shorter compared to MIPPO (WMD -11.24 minutes, 95% CI -15.44 to -7.05, P < 0.05) with significant moderate heterogeneity (I2 = 68%). Conclusion Based on this study, both MIPPO and IMN have similar therapeutic efficacy regarding the functional outcome and can be used safely in distal tibial extra-articular fractures. Although IMN is advantageous over MIPPO with a lower incidence of infection and implant irritation symptoms, shorter operation time, earlier weight-bearing, and earlier union, it leads to a higher rate of mal-union and anterior knee pain. Overall, choosing an implant based on the findings of this meta-analysis is difficult and should be done on a caseby-case basis. Patients who have a high risk for infection (due to high age, comorbidities, smoking, or severe soft tissue injury) should preferably be treated with a nail. MIPPO fixation may be more beneficial to young, active, and healthy patients who are less prone to infection because it reduces the risk of knee pain and mal-union.

Tolérance de la position à genoux après enclouage centromédullaire ou fixation par plaque sans complications

IntroductionDistal tibia fractures often occur in younger, high demand patients, though the literature surrounding management remains contentious. This study sought to quantitatively determine differences in kneeling ability and self-reported knee function in patients managed with either intramedullary nailing (IMN) or open reduction internal fixation (ORIF) with compression plating following distal tibia fracture to assist in the pre-operative consent process. HypothesisThere is no difference in kneeling tolerance following either tibial nailing or plate fixation of distal tibia fractures. Material and methodsRetrospective sampling of public hospital data with outpatient prospective functional testing were completed. The primary outcome measure was the Kneeling Test (KT). Secondary outcome measures were The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Forgotten Joint Score (FJS) for the knee joint. There were 28 patients recruited (18 IMN and 10 ORIF) with a mean age of 44 years. Mean overall follow-up was 13.3 months (range 8–25, SD 3.6). All fractures had completely healed without post-operative complication. ResultsThe IMN affected limb had a significantly worse overall kneeling function than their non-affected limb (mean KT: 70.4 vs 94.9 respectively, p<0.005) Additionally, the IMN group performed significantly worse when compared to the ORIF group (mean KT 70.4 vs 92.5 respectively, p<0.005). No significant differences (p>0.05) in kneeling function existed for the ORIF group when comparing affected to non-affected limbs. Secondary outcome analysis showed significantly worse overall WOMAC and FJS in the IMN group compared to the ORIF group (mean WOMAC 19.3 vs 6.9 respectively, p=0.040; mean FJS 38.3 vs 75.9 respectively, p=0.005). DiscussionThe use of intramedullary nailing for the treatment of distal tibia fracture results in a mean reduction of 20% in kneeling tolerance in comparison to ORIF. The resulting kneeling tolerance is comparable to that of patients post-total knee arthroplasty. The present findings should assist in the consent process for patients with high kneeling demands in sportive, professional or cultural pastimes. Level of evidenceIV; retrospective cohort study with quantitative outcome measurement.

In silico biomechanical analysis of poller screw-assisted small-diameter intramedullary nail in the treatment of distal tibial fractures.

Objective: To evaluate the biomechanical effects of Poller screws (PS) combined with small-diameter intramedullary nails in the treatment of distal tibial fractures at different locations and on different planes. Methods: Nine finite element (FE) models were used to simulate the placement of the intramedullary nail (IMN) and the PS for distal tibial fractures. Structural stiffness and interfragmentary motion (IFM) through the fracture were investigated to assess the biomechanical effects of the PS. The allowable stress method was used to evaluate the safety of the construct. Results: With the axial load of 500N, the mean axial stiffness of IMN group was 973.38 ± 95.65N/mm, which was smaller than that at positions A and B of the coronal group and sagittal group (p < 0.05). The shear IFM of the IMN group was 2.10 ± 0.02mm, which were smaller than that at positions A and B of the coronal group and sagittal group (p < 0.05). Under physiological load, the stresses of all internal fixation devices and the nail-bone interface were within a safe range. Conclusion: In the treatment of distal tibial fractures, placing the PS in the proximal fracture block can obtain better biomechanical performance. The IMN fixation system can obtain higher structural stiffness and reduce the IFM of the fracture end by adding PS.

External fixator as a safe method in the treatment of distal tibial fractures in children.

The objective of this study is to evaluate the functional and radiological results of external fixator application in the treatment of distal tibial metaphyseal diaphyseal junction (MDJ) fractures in children and to analyze differences between stable and unstable fractures. Medical records of children with distal tibial MDJ fracture confirmed by imaging from January 2015 to November 2021 were retrospectively analyzed. Patients were divided into stable and unstable groups and parameters, including clinical and imaging data and Tornetta ankle score were compared. Twenty-five children, comprising 13 with stable and 12 with unstable fractures, were included in our study. The mean age was 7 years (range, 2-13.1 years), and there were 17 males and 8 females. All children had closed reduction, and the basic clinical data of the two groups were comparable. Stable fractures showed shorter intraoperative fluoroscopy, operation, and fracture healing times than unstable fractures. No significant difference in Tornetta ankle score was observed. Twenty-two patients had excellent ankle score, and three had a good ankle score, for a combined incidence of 100%. Two patients in the stable fracture group and one in the unstable fracture group developed a pin site infection, and one patient with unstable fracture showed a length discrepancy (discrepancy<1 cm). External fixator is safe and effective for the treatment of distal tibial MDJ fractures, whether the fracture is stable or not. It has the advantages of minimally invasive, excellent ankle function score, few major complications, needless auxiliary cast fixation, and early functional exercise and weight bearing. Level IV.

The application of intramedullary nails and transmedullary support screws in surgical treatment of distal tibia fracture

Introduction. Fractures of the distal tibia are a difficult treatment problem due to the specific anatomy of this area and the soft tissue injuries resulting from trauma. A distal fracture is short, has a wide marrow cavity, and the asymmetric muscle forces acting on it can cause secondary displacements despite the originally correct positioning. Against the background of the problems presented above, the fixation with an intramedullary nail (IMN) with the use of TMS (trans medullary support) screws directional screws seems to be the best alternative for treatment. Aim. The aim of this study was to evaluate the bone fracture repositioning after surgical treatment of tibia fracture, the time of bone healing and the function of the upper ankle joint. Materials and methods. Forty patients treated surgically due to a fracture of the distal tibia with the use of an intramedullary nail and TMS screws were included in this study. The mean follow-up time was 25.3 months. The function of the ankle joint of the injured limb was evaluated using the AOFAS, VAS and SF-36 questionnaires. Radiological documentation was assessed in terms of correct bone fragment repositioning, placement of directional screws and correct union of the fibula. Post-operative X-rays as well as X-rays taken at the end of treatment in AP and lateral projection were also assessed, evaluating LDTA (lateral distal tibial angle) and ADTA (anterior distal tibial angle). Results. The function of the ankle joint after surgical treatment of a distal tibia fracture using the IMN + TMS method is as follows: AOFAS score 91.5, VAS 2.2 / 10 points. The range of motion of the ankle joint: the angles of ankle movement were significantly greater in the case of the uninjured limb compared to the injured one. Bone union was obtained in all patients. In 80% of patients, it was achieved in less than 6 months. Assessment of repositioning after surgery – mean LDTA angle after surgery was 89 and mean ADTA angle after surgery was 86 (standard LDTA 90, ADTA 85). Conclusions. The function of the ankle joint after treatment of a distal tibial fracture with an intramedullary nail and TMS screws according to the AOFAS and VAS scale was very good and allowed for the anatomical bone fragment fixation. The bone healing after fixation of the distal tibial fracture with an intramedullary nail and TMS screws was shorter than 6 month in most cases.

Distal Tibia Fractures: is the Tibia First Technique a Rational Approach?

In this retrospective case-series study we discuss the clinical and radiographic outcomes obtained following the "tibia-first concept" in the treatment of distal tibia fractures, both in patients with fibular comminution and in cases with a simple fibula fracture. We analysed a consecutive series of 64 patients who presented at our emergency department with a distal articular tibial and fibular fracture from January 2015 to September 2020. A total of 22 patients met the inclusion and exclusion criteria and were included in the study. Clinical and radiographic examination were performed at each follow-up. To quantify pain and functional disability, the Foot and Ankle Outcome Score (FAOS) and the American Orthopaedic Foot and Ankle Society's ankle-hindfoot scale (AOFAS) were applied. The overall mean age was 52.8 years, and the mean follow-up was 13.18 months. Multiple scales data from the FAOS were as follows: pain score 80.70; symptoms score 81.69; activities of daily living score 87.22; quality of life 76.05. The mean AOFAS ankle-hindfoot score was 74.36. Even though the principles of Rüedi and Allgöwer are still valid, in specific circumstances, the tibia-first concept could be considered as a valid option for the treatment of these demanding fractures. If a good reduction is obtained intra-operatively by ligamentotaxis, we recommend fixing the tibia first, avoiding surgical stress on tissues derived from a previous fibular fixation.

MIPO Technique for Treatment of Distal Tibial Fractures

Background: Distal tibial fractures are usually associated with significant soft tissue injury caused by high energy trauma, which may result in a series of complications such as fixation failure, skin flap necrosis or deep infection. The aim of this study was to evaluate the result of minimally invasive percutaneous osteosynthesis for treatment of distal tibial fractures associated with soft tissues injuries. including preoperative planning, operative technique, and complication encountered during the study period. Methods: This prospective study included 20 trauma patients with distal tibial fractures. Patient selection was mainly based on the fracture pattern and the severity of soft tissue status. Patients were subjected to history taking, clinical examination and radiological evaluation. Results: All fractures were united in a mean period 9 weeks. According to American Orthopedic Foot and Ankle Society (AOFAS) score, 15 patients (75%) were graded as excellent, good in 3 patients (15%) and fair in 2 patients (10%). Complications: This study had 17 patients (85%) with no complication, 2 patients (10%) with skin infection and one patient (5%) had malunion of fracture. Conclusions: On the basis of the finding of this study it can be concluded that MIPO technique yields good to excellent clinical outcomes with accepted functional outcome for the management of closed distal tibia fractures. Being minimally invasive, it preserves the biological environment by preserving the soft tissue and vascularity and reduces incidence of wound complications.

Expert tibial nail (ETN) versus minimally invasive plate osteosynthesis techniques in the treatment of distal tibia fractures in young adults: A randomized controlled trial

Abstract Purpose To compare anatomical locked plates inserted in a minimally invasive pattern (MIPO) versus expert tibial nailing (ETN) for fixation of extra-articular fractures of the distal tibia in young adults. Patients and methods The study included 120 patients, 84 males and 36 females. The mean follow-up time was 13.5 months, with at least 12 months of follow-up. Cases were equally divided and randomized by the closed-envelope technique into two groups, group A: fixed by anatomical locked plate through a minimally invasive approach, and group B: fixed by ETN. Results The average operative time was significantly higher in the MIPO group (94 min) compared with the ETN group (81.67 mins). Also, the radiological exposure time was also higher (87.6 secs) in group A versus 78.4 in group B. Although there was an incidence of deformity in few cases of the ETN group (eight patients), that was not significant enough to warrant correction by revision surgery. There were no significant differences in the union time (P value: 0.09) and American Orthopedic Foot and Ankle Society (AOFAS) scores (P value: 0.78) between the two groups. Furthermore, the infection and the need for further surgeries did not show significant differences among both groups. Conclusion Both MIPO and ETN are valid treatment options for distal tibia fractures, AO type 43 A. Both methods resulted in acceptable union time, and American Orthopedic Foot and Ankle Society scores, with no reported cases of nonunion. Level of evidence. Therapeutic study, level I

Extra-articular Distal Tibial Fracture: A Comparative Study of the Outcome Between Closed IMLN and MIPO

Background: The treatment of distal tibial fractures (DTF) is still up for debate. For DTF, minimally invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMLN) are potentially effective techniques; however, they have been linked to complications. Thus, this study was aimed to evaluate and compare clinical and functional results in individuals with DTF that were managed with MIPO or IMLN.Patients and Methods: Between August 2020 and February 2022, 31 patients with closed extra-articular distal tibia fractures were enrolled in a comparative study of locking plate by MIPO versus closed IMLN at the Sulaimani Teaching Hospital and Shar Teaching Hospital. The Foot and Ankle Ability Measure (FAAM) and Johner and Wruh's criteria were used to evaluate the results.Results: IMLN was used on 16 individuals, while MIPO was used on 15 patients that underwent surgery. In terms of time, there was no significant difference (p&gt;0.05) in fracture union, malunion, or functional results. However, there was a significant difference in total weight-bearing following surgery, blood loss, and complications in terms of the operation time.Conclusions: Both techniques were effective in treating a distal tibial extra-articular fracture. IMLN had a faster complete weight-bearing time and a shorter operation time. At the same time, MIPO had less blood loss and equal time in complete union. Thus, we recommend using FAAM as a valuable tool in evaluating functional outcomes after distal tibia fracture.

AO distractor and manual traction reduction techniques repair in distal tibial fractures: a comparative study

BackgroundMinimally invasive plate osteosynthesis (MIPO) via percutaneous plate placement on the distal medial tibia can be performed with minimizes soft tissue injury and produces good clinical results. However, the difficulty with MIPO lies in how to achieve satisfactory fracture reduction and maintain that reduction via indirect reduction techniques to facilitate internal fixation. The purpose of this study was to compare the effects of AO distractor and manual traction reduction techniques combined with MIPO in the treatment of distal tibia fractures.MethodsBetween January 2013 and December 2019, 58 patients with a distal tibia fracture were treated using MIPO. Patients were divided into two groups according to the indirect reduction method that was used: 26 patients were reduced with manual traction(group M), and 32 were reduced with an AO distractor (group A).Time until union and clinical outcomes including AOFAS ankle-rating score and ankle range of ankle motion at final follow-up were compared. Mean operative time, incision length, blood loss and postoperative complications were recorded via chart review. Radiographic results at final follow-up were assessed for tibial angulation and shortening by a blinded reader.ResultsMean operative time, incision length, and blood loss in group A were significantly lower than in group M(p = 0.019, 0.018 and 0.016, respectively).Radiographic evidence of bony union was seen in all cases, and mean time until union was equivalent between the two groups (p = 0.384).Skin irritation was noted in one case(3.1%) in group A and three cases(11.5%)in group M, but the symptoms were not severe and the plate was removed after bony union. There was no statistically significant difference in postoperative complications between the two groups(p = 0.461). Mean AOFAS score and range of ankle motion were equivalent between the two groups, as were varus deformity, valgus deformity, anterior angulation and posterior angulation. No patients had gross angular deformity. Mean tibial shortening was not significantly different between the two groups, and no patients had tibial shortening > 10 mm.ConclusionBoth an AO distractor and manual traction reduction techniques prior to MIPO in the treatment of distal tibial fractures permit a high fracture healing rate and satisfying functional outcomes with few wound healing complications. An AO distractor is an excellent indirect reduction method that may improve operative efficiency and reduce the risk of soft tissue injury.