Treatment Of Segmental Tibial Fractures Research Articles

Komplikacije u lečenju segmentnih preloma potkolenice

Segmental tibial fractures belong to the group of the most severe fractures of the locomotor system. They are most common in polytraumatized patients. Treatment of segmental tibial fractures can be conservative or operative. Treatment of segmental tibial fractures is accompanied by a number of complications, such as delayed healing, dislocation of fragments in one or the other fracture point, healing of fractures in poor position, non-healing of fractures, aseptic and septic pseudoarthrosis, infection around fixator wedges, wound infection of open segmental tibial fracture, iatrogenic infection, osteomyelitis, and limb amputation. The paper presents a female patient with a severe segmental tibial fracture on two levels, who was treated with external skeletal fixation. Without opening the fracture point, repositioning was performed in the proximal and distal part and the fractures were stabilized with an external skeletal fixator. After the operation, the patient was activated with underarm crutches with relief support on the injured leg. For the purpose of stimulating fracture healing, low molecular weight heparin, Fraxiparine (to prevent thrombosis and pulmonary thromboembolism) and Forticolinn were prescribed. After the fracture healed, the external skeletal fixator was removed and the patient returned to her working and living activities. At the follow-up examination five years after the segmental tibial fracture, the patient had a stable and firm support on the injured leg.

Segmental tibial fractures treated with Ilizarov circular fixator

Background/Aim. Segmental fractures represent complex tibial injuries, featuring a unique fracture type that is most commonly caused by high-energy trauma. These fractures are considered to be a treatment challenge for orthopaedic surgeons due to their sporadic presentation, wide zone of soft tissue injury, and increased rate of complications. They are characterized by a highly unstable intermediary segment and a high rate of open fractures. The method of Ilizarov with its characteristics could offer many advantages over the existing operative techniques. This method, using a percutaneous approach, minimizes the intraoperative trauma and avoids the additional compromising of the biological environment at the fracture site. The aim of this study was to evaluate the results of the Ilizarov fixator in the treatment of segmental tibial fractures. Methods. We analyzed 30 patients treated with the Ilizarov fixator between 2012 and 2017. The average age of patients was 36 years (from 24 to 65). The most common mechanism of injury was a road traffic accident. Open fractures were noted in 22 cases. All fractures were reduced using indirect percutaneous techniques with a great focus on achieving the correct length, rotation, and axial alignment of fragments. All patients were advised to bear weight as tolerated from the second postoperative day. Bone healing and functional results were evaluated according to the criteria established by the Association for the Study and Application of the Method of Ilizarov. Results. Bone healing was achieved in all patients. The average time to union was 25 weeks (19 to 36 weeks). Bone results were excellent in 23 patients, good in five, and fair in two patients. Functional results were excellent in 22 cases, good in 5, and fair in three cases. Eight patients had minor pin-tract infections, successfully treated with oral antibiotics. Patients were without any major complications. Conclusion. The Ilizarov method is a safe and efficient treatment modality for segmental tibial fractures.

Analysis of complications and clinical outcomes in the treatment of segmental tibial fractures according to the method of internal fixation

We compared and analysed not only the clinical and radiological results of surgery but also the complications according to the definitive fixation method. We retrospectively reviewed the medical records and radiographs of all segmental tibial fracture patients treated with either intramedullary nailing or minimally invasive plate osteosynthesis between 2010 and 2017. We enrolled 69 patients. The patients' mean age was 48.6 years (25-74). Forty-nine patients had open fractures (Type I, 20; Type II, 9; Type III, 20) and six had acute compartment syndrome. The initial stabilisation method was intramedullary nailing in 28 patients (40.6%). The time to definitive fixation was longer in the minimally invasive plate osteosynthesis group (mean, 8.8 days; range, 0-27) than that in the intramedullary nailing group (mean, 3.9 days; range, 0-35), with a statistically significant difference (p=0.001). Thirteen patients developed nonunion (five with minimally invasive plate osteosynthesis and eight with intramedullary nailing, p=0.076). Complications were noted in 18 patients (26.1%), including five with infection. There was no significant difference in the clinical and radiological outcomes according to the definitive fixation method. A multivariate logistic regression analysis indicated that age (odds ratio, 1.112; 95% confidence interval, 1.022-1.210; p=0.013) and smoking (odds ratio, 13.976; 95% confidence interval, 1.599-122.150; p=0.017) correlated with the occurrence of complications. The results of our study suggest that if soft-tissue handling and restoration of bony alignment are successful, both intramedullary nailing and minimally invasive plate osteosynthesis will be effective treatment methods for segmental tibial fractures.

Suprapatellar nailing for treatment of segmental tibial fractures

Objective To explore the therapeutic advantages of suprapatellar nailing for treatment of segmental tibial fractures. Methods Twenty-one tibial segmental fractures were managed and followed-up regularly in our hospital from March 2012 to August 2018. They were 15 males and 6 females, with an average age of 46.0 years (range, from 26 to 71 years) . There were 13 cases of type Ⅰ, 4 cases of type Ⅱ, 2 cases of type Ⅲ and 2 cases of type Ⅳ, according to Melis classification. There were totally 10 open fractures (5 cases of type Ⅰ, 2 cases of type Ⅱ, one case of type ⅢA and 2 cases of type ⅢB, according to Gustilo classification) . All the cases received closed reduction and internal fixation with suprapatellar locked tibial nailing of the third generation. Non-weight-bearing exercises of the knee and ankle and muscular strength training for the low extremity commenced 3 days after internal fixation. The knee functions were evaluated postoperatively using the Lysholm knee scoring. Results All the 21 cases were followed up for 10 to 36 months (average, 17.8 months; more than 3 times during at least 10 months) . X-ray revealed occurrence of the callus from 2 to 11 months (average, 7.1 months) after operation.One case of nonunion occurred at the tibial mid-shaft.There was no wound infection, soft tissue necrosis or osteomyelitis. Two cases complained of knee pain and 5 cases of ankle pain, with VAS scores ranging from 2 to 3. After symptomatic management, the knee pain was relieved in 2 cases after 5 months and the ankle pain was relieved in 3 cases. The average Lysholm score 10 months after surgery was 95 points (range, from 87 to 99 points) . Conclusion Suprapatellar nailing is an effective treatment for segmental tibial shaft fractures, especially for those involving injuries to the metaphyseal region and peripatellar soft tissue, because it can provide effective fixation of the multiple metaphyseal fractures and avoid disadvantages of conventional intramedullary nailing, leading to limited postoperative knee pain. Key words: Tibial fractures; Fracture fixation, internal; Bone nailing; Supar-patellar approach

The treatment of segmental tibial fractures: does patient preference differ from surgeon choice?

IntroductionSegmental tibial fractures are complex injuries with a prolonged recovery time. Current definitive treatment options include intramedullary fixation or a circular external fixator. However, there is uncertainty as to which surgical option is preferable and there are no sufficiently rigorous multi-centre trials that have answered this question. The objective of this study was to determine whether patient and surgeon opinion was permissive for a randomised controlled trial (RCT) comparing intramedullary nailing to the application of a circular external fixator. Materials and methodsA convenience questionnaire survey of attending surgeons was conducted during the United Kingdom’s Orthopaedic Trauma Society annual meeting 2017 to determine the treatment modalities used for a segmental tibial fracture (n=63). Patient opinion was obtained from clinical patients who had been treated for a segmental tibial fracture as part of a patient and public involvement focus group with questions covering the domains of surgical preference, treatment expectations, outcome, the consent process and follow-up regime (n=5). ResultsBased on the surgeon survey, 39% routinely use circular frame fixation following segmental tibial fracture compared to 61% who use nail fixation. Nail fixation was reported as the treatment of choice for a closed injury in a healthy patient in 81% of surgeons, and by 86% for a patient with a closed fracture who was obese. Twenty-one percent reported that they would use a nail for an open segmental tibia fracture in diabetics who smoked, whilst 57% would opt for a nail for a closed injury with compartment syndrome, and only 27% would use a nail for an open segmental injury in a young fit sports person. The patient and public preference exercise identified that sleep, early functional outcomes and psychosocial measures of outcomes are important. ConclusionWe concluded that a RCT comparing definitive fixation with an intramedullary nail and a circular external fixator is justified as there remains uncertainty on the optimal surgical management for segmental tibial fractures. Furthermore, psychosocial factors and early post-operative outcomes should be reported as core outcome measures as part of such a trial.

Treatment of segmental tibial fractures with supercutaneous plating.

Segmental tibial fractures usually follow a high-energy trauma and are often associated with many complications. The purpose of this report is to describe the authors' results in the treatment of segmental tibial fractures with supercutaneous locking plates used as external fixators. Between January 2009 and March 2012, a total of 20 patients underwent external plating (supercutaneous plating) of the segmental tibial fractures using a less-invasive stabilization system locking plate (Synthes, Paoli, Pennsylvania). Six fractures were closed and 14 were open (6 grade IIIa, 2 grade IIIb, 4 grade II, and 2 grade I, according to the Gustilo classification). When imaging studies confirmed bone union, the plates and screws were removed in the outpatient clinic. Average time of follow-up was 23 months (range, 12-47 months). All fractures achieved union. Median time to union was 19 weeks (range, 12-40 weeks) for the proximal fractures and 22 weeks (range, 12-42 weeks) for the distal fractures. Functional results were excellent in 17 patients and good in 3. Delayed union of the fracture occurred in 2 patients. All patients' radiographs showed normal alignment. No rotational deformities and leg shortening were seen. No incidences of deep infection or implant failures occurred. Minor screw tract infection occurred in 2 patients. A new 1-stage protocol using supercutaneous plating as a definitive fixator for segmental tibial fractures is less invasive, has a lower cost, and has a shorter hospitalization time. Surgeons can achieve good reduction, soft tissue reconstruction, stable fixation, and high union rates using supercutaneous plating. The current patients obtained excellent knee and ankle joint motion and good functional outcomes and had a comfortable clinical course.

Assessment & Evaluation of the Outcome for Closed and Open Method in Treatment of Segmental Tibial Fracture

Segmental tibial fractures are considered to be a special type of injury associated with high complication rates and are defined by the presence of two or more distinct fracture lines with completely isolating an intermediary segment і.е interruption of bone integrity at two levels(majority) or moreand are usually caused by a high-energy direct trauma with important soft tissue damage effect the both intramedullary and periosteal vascularization, which are predisposed to slow healing with creation of unsuitable biological conditions for fracture union. The aim of our study was to evaluate and assess the outcome of our policy on dealing with closed segmental fracture of the tibia treated by (closed or open) application of external tubular device fixator (AO group of ASIF) .Within the period between October 1, 1998 and September 30, 2010 in Al Nasiriya military hospital, AL Amara military hospital and Al Husain teaching hospital, we collect 38 patients with displaced and minimally displaced closed segmental tibial fractures. We exclude the multiply injured patients died after surgical treatment in the course of further management, open fractures, and all the patients lost for follow up. The minimally or undisplaced fractures were treated by closed application of the external device, while those with significantly displaced fractures, firstly managed by calcaneal continuous traction for a few days as an attempt for reduction, some of them were reduced to minimally displaced or acceptable position which were treated also by closed method, and some are remain significantly displaced, treated by open reposition and external fixation with the help of X-ray control for all cases. A range of motion exercise of ankle and knee joints post operatively were encouraged. The mean age was 38.81 years. We collect and study 38 closed segmental tibial fractures i.e. (two fractures focuses for one bone), so we are dealing with 76 fractures in 38 patients. All the patients were treated by AO unilateral external fixator arranged in multiplanartechnique for more rigid fixation and regarded as a definitive procedure for holding the fractures until clinical& radiological union.Once a considerable callus seen, a loosening of the distal clamps and a very graduated weight bearing started, with the help of the crutches to permit an axial compression on the fractures sites until a secure union of the bone. Then the external fixation was removed and a partial weight bearing was continued with the help of the crutches until consolidation. Healing of the bone occurred in 52 fracture focuses (68.42%) patients, and 24 fractures (31.57%) patients reported significant complications in the course of treatment that required further surgical management, 18 of them delayed union (23.68%) patients and 6 of the fracture focuses(7.89)patients go to nonunion.The delayed union treated simply by dianamyzation with chips bone graft and sometimes rearrangement of the external fixator particularly the loose pines, all of them healed completely, while the nonunited were treated by (Revision procedure):(revision of the external fixator with wider pins and extensive refreshment of the fracture ends and added a considerable amount of bone graft), so all of them were united successfully. We conclude that the external fixation is a suitable method for the treatment of segmental tibial fractures with an acceptable rate of

Using External and Internal Locking Plates in a Two-Stage Protocol for Treatment of Segmental Tibial Fractures

The tibial segmental fractures usually follow high-energy trauma and are often associated with many complications. We designed a two-stage protocol for these complex injuries. The aim of this study was to assess the outcome of tibial segmental fractures treated according to this protocol. A prospective series of 25 consecutive segmental tibial fractures were treated using a two-stage procedure. In the first stage, a low-profile locking plate was applied as an external fixator to temporarily immobilize the fractures after anatomic reduction had been achieved followed by soft-tissue reconstruction. The second stage involved definitive internal fixation with a locking plate using a minimally invasive percutaneous plate osteosynthesis technique. The median follow-up was 32 months (range, 20-44 months). All fractures achieved union. The median time for the proximal fracture union was 23 weeks (range, 12-30 weeks) and that for distal fracture union was 27 weeks (range, 12-46 weeks; p = 0.08). Functional results were excellent in 21 patients and good in 4 patients. There were three cases of delayed union of distal fracture. Valgus malunion >5 degrees occurred in two patients, and length discrepancy >1 cm was observed in two patients. Pin tract infection occurred in three patients. Use of the two-stage procedure for treatment of segmental tibial fractures is recommended. Surgeons can achieve good reduction with stable temporary fixation, soft-tissue reconstruction, ease of subsequent definitive fixation, and high union rates. Our patients obtained excellent knee and ankle joint motion, good functional outcomes, and a comfortable clinical course.

The Ilizarov method for the treatment of segmental tibial fractures

The Ilizarov method for the treatment of segmental tibial fractures

Open acute segmental tibial fracture fixation using the Less Invasive Stabilisation System (LISS): Study of 23 consecutive cases

Aim To evaluate the Less Invasive Stabilisation System (LISS) in the treatment of segmental tibial fractures. Methods A prospective series of 23 consecutive open acute segmental tibial fractures were treated with a long LISS plate, in a university hospital. All but three fractures were temporarily fixed with a unilateral external frame. The minimal follow-up was 2 years. Results Mean age of the casualties was 34 (17–72) years, all but two were male and all were involved in high-energy accidents, had multiple injuries and open fractures. Of the fractures, 4 were grade IIIA, 16 grade IIIB and 3 grade IIIC. It was possible to span the distal fracture with the LISS plate in 20 cases; of these, 3 developed compartment syndrome. Two people with trifocal fractures required additional distal plates, one of which became loose and infected, resulting in a malunion of 8°. Dermatofasciotomy was performed in 13 cases, in 10 of these as a preventive measure and in 3 because of impending compartment syndrome. In five cases a post-fixation neural palsy of the extensor hallucis longus was observed. All except three fractures healed; mean time for union for the proximal fractures was 16 (10–24) weeks and for the distal fractures was 22 (16–44) weeks. Conclusion Use of the LISS plate in fixing these difficult fractures is commended, but immediate fixation should be avoided. A staged sequential procedure with a temporary spanning external fixation and definitive treatment after soft-tissue healing is preferred.

Acute treatment of segmental tibial fractures with the Ilizarov method

Objectives We evaluated the results of acute application of the Ilizarov external fixator for segmental tibial fractures and also examined the experience with these special type fractures. Methods Twenty-four patients (19 males, 5 females) with a mean age of 37.8 years (range 22–66) with segmental tibial fractures were treated with the use of an Ilizarov type circular fixator. According to the categorisation of Melis et al., the fractures were types I, II, III and IV in seven, nine, five and three patients, respectively. Seven fractures were closed and 17 were open (9 grade IIIa, 5 grade IIIb, 2 grade II, 1 grade I according to the Gustilo classification). The mean time from the injury to surgery was 14 h (range 4–36). Eight patients with partial-thickness soft-tissue defects with no bone exposure were managed by split thickness skin grafting. Flap procedures were performed in four patients. All patients had good lower leg viability with a MESS score 6 and below. No patients had bone defects of 3 cm or more at the fracture level. Functional and bone results were made using the criteria proposed by ASAMI. The mean follow-up 28 months (range 12–70). Results We obtained excellent results in 20 and good results in 4 patients in terms of bone assessment. Functional results were excellent in 19 and good in 5 patients. All radiological evaluations showed normal alignment except in two patients. Both united with a residual procurvatum deformity. No rotational deformity was seen. Bone grafting was performed in one patient with a distal fracture. Complete union was achieved in all patients. None of the patients required amputation. There were no refractures after frame removal. Pin-tract infection occurred in 13 of the 24 patients. There were no incidents of chronic osteomyelitis secondary to pin-tract infection. The mean time for proximal fracture union was 36.4 weeks (range 10–78) and 39.8 weeks (range 12–80) for the distal fractures ( p > 0.05). Callus and consolidation occurred earlier posterolaterally. There were no implant failures. Conclusion Ilizarov external fixator is a successful method in the acute management of segmental tibial fractures. This method is particularly effective in the treatment of distal segmental fractures of the tibia when the distal segment is short. This method allows for control of complications by decreasing the need for new operations even in the presence of infection.

Segmental tibial fractures: an assessment of procedures in 27 cases

Twenty-seven patients (two women) with segmental tibial fractures (19 open) were treated in our institution with a mean age of 38.9 years (range 22–67 years) and a mean Injury Severity Score of 11.5 (9–34). Sixteen fractures were stabilised initially with an interlocking nail, seven with an external fixator, one with a hybrid external fixator, two cases were plated and one was treated in plaster. The mean size of the segment was 11.5 cm (range 4–20 cm). Soft tissue coverage was required in 17 cases. There were three cases of compartment syndrome, six cases of superficial infection and four deep infection cases (two of which required amputation). In four cases, excision of the non-viable segment was necessary. Overall, 13 patients were subjected to a second operative procedure (OP) (four external fixators were replaced with the AO solid tibial nail, two Ilizarov bone transports following excision of the dead bone segment, 2 below knee amputations, 3 exchange reamed nailings, 1 LISS plate application for stability and 1 ring fixator for compression of a fracture). Five patients underwent third procedure (two Ilizarov for bone transport, two exchange nailing, and one bone grafting). The mean time to union of the proximal segment was 38.8 weeks (range 10–78 weeks) and 41.4 weeks (range 12–65 weeks) for the distal segment, respectively. The treatment of segmental tibial fractures poses many problems to the surgeon due to the precarious blood supply of the intermediate segment. The risk of non-union delayed union, infection and additional procedures is high as seen in this series of patients.