The long-term outcome after treatment for patients with tibial fracture treated with intramedullary nailing is not influenced by time of day of surgery and surgeon experience

INTRODUCTION

The objective of the present study was to evaluate the relationship between clinical outcome and time of day of surgery and experience level of the surgeon. Secondly, we examined the relationship between the length of hospital stay and the time of day of surgery.

METHODS

This retrospective cross-sectional cohort design study included patients treated with intramedullary nailing at Aalborg University Hospital from 1998 to 2008 after tibial shaft fractures (N = 294). At follow-up, the participants completed the Knee Injury and Osteoarthritis Outcome Score (KOOS). Age, sex, complications, length of hospital stay, start time of surgery, and education level of surgeons were recorded.

RESULTS

The long-term analysis of the KOOS assessment shows no significant association between time of day of surgery and the level of surgeon experience. There was no difference in complication rates between time of day of surgery and the level of surgeon experience. The secondary outcome analysis showed an estimated increased risk of 25 % (p = 0.001), for a longer length of hospital stay when operated by a trainee at night-hours compared to day-hours, and an estimated increased risk of 17 % (p = 0.002) for longer length of stay, when operated at day-hours by a trauma surgeon compared to a trainee.

CONCLUSION

Complication rates and KOOS outcome after surgery with intramedullary nailing were not influenced by time of day of surgery and experience level of the surgeon. The lengths of hospital stay increase significantly when surgery is performed at night by trainee surgeons, but not when performed by trauma surgeons.

Population-Based Epidemiology of Tibial Plateau Fractures

Although epidemiologic studies of tibial plateau fractures have been conducted, none have included geographically defined populations or a validated fracture classification based on computed tomography (CT). The goals of this study were to provide up-to-date information on the incidence and basic epidemiology of tibial plateau fractures in a large unselected patient population and to report the mechanisms of injury involved and the distribution of fractures according to a validated CT-based fracture classification. The authors conducted a population-based epidemiologic study of all patients treated for tibial plateau fracture over a 6-year period from 2005 to 2010. The study was based on an average background population of 576,364 citizens. A retrospective review of hospital records was performed. During this time, a total of 355 patients were treated for tibial plateau fracture. This group included 166 men and 189 women, and mean age was 52.6 years (SD, 18.3). The most common fracture type was AO type 41-B3, representing 35% of all tibial plateau fractures. The second most common fracture type was AO type 41-C3, representing 17% of all tibial plateau fractures. The incidence of tibial plateau fractures was 10.3 per 100,000 annually. Compared with women, men younger than 50 years had a higher incidence of fractures. The incidence of fractures increased markedly in women older than 50 years but decreased in men older than 50 years. In both sexes, the highest frequency was between the ages of 40 and 60 years.

[Prevalence of hip, femur and knee fractures at the High Specialty Medical Unit, Hospital de Traumatología y Ortopedia "Lomas Verdes", Instituto Mexicano del Seguro Social]

BACKGROUND

Lower limb fractures are more frequent among older patients with osteopenia after a low energy fall and/or among young patients who sustain a high energy trauma. The prevalence of hip, femur and knee fractures at the High Specialty Medical Unit, Hospital de Traumatología y Ortopedia "Lomas Verdes" is unknown.

MATERIAL AND METHODS

Cross-sectional study, descriptive and retrospective design. Cases with low extremity fractures treated from January 1st, 2012 to December 31st, 2013 at the Hip, Femur and Knee Service, High Specialty Medical Unit, Hospital de Traumatología y Ortopedia "Lomas Verdes", were reviewed.

RESULTS

Most patients (52.2%) were females; 64.1% of patients were over 60 years of age. Fracture distribution according to the segment involved was as follows: 73.4% (n = 1,327) were femur fractures, 13.5% (n = 244) tibial plateau fractures, and 13.2% (n = 238) patellar fractures. 66.8% (n = 1,209) of patients had a long hospital stay (more than 10 days). According to the anatomical location of fractures, transtrochanteric fractures (49.1%) were the most frequent ones, followed by patellar fractures (13.2%), and femur shaft fractures (12.7%).

CONCLUSIONS

The prevalence of lower limb fractures at our hospital corresponds to what has been reported internationally.

Pathoanatomy and incidence of the posterolateral fractures in bicondylar tibial plateau fractures: a clinical computed tomography-based measurement and the associated biomechanical model simulation

OBJECTIVES

The aim of our study is to evaluate the incidence and pathoanatomy of posterolateral fragments and analyze the associated fracture mechanism in bicondylar tibial plateau fractures.

METHODS

From 1.1.2008 to 3.15.2012, all patients suffering bicondylar tibial plateau fractures were identified, scanned and analyzed at the Shanghai Clinical Trauma Center. Furthermore cadaver knees were selected into three groups of 30/60/90 knee flexion to simulate the posterolateral tibial plateau fracture by an impact device.

RESULTS

One hundred and sixty-four (44.32 %) bicondylar tibial plateau fractures finally satisfied our requirements. Fifty-three and ninety-four cases were measured eventually in the groups of posterolateral split and depression. The posterolateral articular fragment proportion was 15.43 %. The posterolateral articular fragment angle showed an average of 12.94°. The posterolateral fragment cortical height was on average 2.96 cm. The posterolateral sagittal fragment angle averaged at 72.06°. Ninety-four cases were measured in the posterolateral depression group. The average posterolateral articular depression proportion was 16.74 %. The average posterolateral articular depression height was 2.47 cm. In the biomechanical modeling of such kinds of fracture patterns, posterolateral split fractures in 30° and 60° flexion are significantly more than those in 90° flexion. Posterolateral splits combined with anterolateral depression fractures in 30° flexion are significantly more than those in 90° flexion.

CONCLUSION

The incidence of posterolateral fractures is 44.32 % in bicondylar tibial plateau fractures. The morphology of posterolateral area can be referenced for the surgeon in the future clinical work. The information is also helpful for the design of locking plate and fracture modeling in biomechanical test. In addition, that posterolateral split and posterolateral depression might be caused by different injury mechanisms. Different angles of knee flexion under the axial impact loading are possibly the interpretations for these two fracture patterns.

Extension of a Cox proportional hazards cure model when cure information is partially known

When there is evidence of long-term survivors, cure models are often used to model the survival curve. A cure model is a mixture model consisting of a cured fraction and an uncured fraction. Traditional cure models assume that the cured or uncured status in the censored set cannot be distinguished. But in many practices, some diagnostic procedures may provide partial information about the cured or uncured status relative to certain sensitivity and specificity. The traditional cure model does not take advantage of this additional information. Motivated by a clinical study on bone injury in pediatric patients, we propose a novel extension of a traditional Cox proportional hazards (PH) cure model that incorporates the additional information about the cured status. This extension can be applied when the latency part of the cure model is modeled by the Cox PH model. Extensive simulations demonstrated that the proposed extension provides more efficient and less biased estimations, and the higher efficiency and smaller bias is associated with higher sensitivity and specificity of diagnostic procedures. When the proposed extended Cox PH cure model was applied to the motivating example, there was a substantial improvement in the estimation.

Morphological characteristics of posterolateral articular fragments in tibial plateau fractures

Treatment of posterolateral tibial plateau fractures is controversial, and information regarding this specific fracture pattern is lacking. The purpose of this study was to elucidate the frequency and morphological features of posterolateral articular fragments in tibial plateau fractures. A retrospective radiographic and chart review was performed on a consecutive series of patients who sustained tibial plateau fractures between May 2008 and August 2012. The articular surface area, maximum posterior cortical height, sagittal fracture angle, and amount of displacement were measured on computed tomography scans using the Picture and Archiving Communication System. Thirty-six (15%) of 242 injuries demonstrated a posterolateral fracture fragment comprising a mean 14.3% of the articular surface of the total tibial plateau (range, 8% to 32%). Mean major articular fragment angle was 23° (range, 62° to -43°), mean maximum posterior cortical height was 29 mm (range, 18 to 42 mm), and mean sagittal fracture angle was 77° (range, 58° to 97°). The posterolateral plateau articular fracture fragment has morphological characteristics of a conically shaped fragment with a relatively small articular surface area and sagittal fracture angle. Recognizing these morphological features will help the clinician formulate an effective surgical plan.

[Fractures in spinal muscular atrophy]

AIM

To determine the frequency of fractures in patients with spinal muscular atrophy, their mechanism of production, age at appearance and functional repercussions.

PATIENTS AND METHODS

Sixty-five patients with spinal muscular atrophy were studied. Cases of fractures diagnosed by means of X-rays were collected and the following parameters were analysed: type of spinal muscular atrophy, gait, age at the time the fracture occurred, mechanism of production, location, treatment applied and functional repercussion.

RESULTS

Thirteen patients (20%) presented a total of 20 fractures (four of them presented two or more fractures). The mean age was 6.35 years. The fractures were mostly located in the femur and the mechanism of production was falls in 12 cases and minor traumatic injury in eight. No vertebral fractures were detected. All of them were treated conservatively. The only patient with a fracture who was able to walk stopped walking after immobilisation.

CONCLUSIONS

The existence of fractures in these patients interferes with their quality of life and their level of functioning. It is important to prevent them from occurring during management of the patient and by ensuring a correct posture in the wheelchair with the use of restraint systems. Further studies are needed on the loss of bone mineral density in these patients and their possible relationship with fractures.

[Methylenetetrahydrofolate reductase polymorphism C677T in patients with consolidated fractures and pseudarthrosis of long bones: relationship with homocystein and inflammatory mediators]

In article described research the results of the prevalence of the genetic polymorphism of the gene Methylentetrahydrofolatereductase C677T (MTHFR) in 130 patients with pseudarthrosis of long bones and in those with consolidated fractures. The incidence of allele-T among patients with pseudarthrosis was 1.4 times higher than among those with consolidated fractures. Pathological genotype MTHFR 677-TT was associated with the development avital types of pseudarthrosis and increase the proportion of people with hyperhomocysteinemia, high content of inflammatory mediators and development refracture.

Risk factors associated with infection in tibial open fractures

BACKGROUND

The objective of the treatment of open fracture is to prevent infection, stabilize the bones, and restore function. However, infection is the most important step in achieving the latter aims.

OBJECTIVE

The objective of the current paper is to find risk factors associated with infection in a sample of tibial open fractures.

PATIENTS AND METHODS

A retrospective analysis was carried out. The study included all patients who underwent to tibial open fracture treatment in the Hospital Geral Roberto Santos-HGRS, Salvador, Bahia, Brasil, from March to October, 2009. Patients under the age of eight, with multiple fractures or suffering from systemic or bone disease were excluded. Clinical and demographic data were collected and Patient outcomes were divided into two groups: Group 1 comprises those without infection whereas group 2 comprises those with lesions which became infected. The two groups were evaluated in search for associated factors that could lead to infection.

RESULTS

We studied 50 patients. Our overall infection rate was 14 (28%; CI95%=15.5-40.5). Infection was significantly associated with place of trauma (OR 3.78; CI95%=1.4-5.5; p=0.02), and time delay superior to 24 hours (OR 3.4; CI95%=1.4-20.8; p=0.03). Fractures graded as Gustilo I, II and IIIA had a lower chance for infection compared to Gustilo IIIB and IIIC (OR 4.32; CI95%=1.3-19.1; p=0.01). Fractures graded Tscherne III and IV had a higher chance for infection, and it was the most significant isolated factor (OR 8.07; CI95%=2.4-47.1; pp<0.00).

CONCLUSIONS

We confirmed the relationships between infection with Gustilo classification and as well as between infection and trauma from the countryside of Bahia State. We also presented a new relationship between soft tissue and infection, and another relating time delay of more than 12 hours with infection.

Epidemiological analysis of outcomes in 323 open tibial diaphyseal fractures: a nine-year experience

INTRODUCTION

Open fractures of the tibia pose a challenge to orthopaedic and plastic surgeons. A retrospective observational review was conducted to evaluate the epidemiological factors and fracture outcomes in the Singapore context.

METHODS

A nine-year period of open tibial shaft fractures presenting to our institution was reviewed. Demographic and management data were recorded. Statistical analysis was performed on the outcomes of length of hospital stay, number of operations, time to union and infection rates.

RESULTS

323 fractures met our inclusion criteria (Gustilo [G] 1=53, G2=100, G3=170). Mean age of patients was 36.5 years, 91.3% were male and 40.9% were non-Singaporeans. 69.3% of fractures occurred from road traffic accidents and 21.7% from industrial accidents. Mean length of hospital stay was 28.7 days and number of operations was 4.29. Time to union was 10.7 months and overall infection rate was 20.7%. Infection rates were significantly higher in G3b/G3c compared to G3a (45.7% vs. 21.1%) patients. There was no significant reduction in infection rates when open tibial fractures were operated on within six hours of admission. Multiple injured patients required a longer time to union and hospital stay. There was an exponential cost increase with greater severity of fracture.

CONCLUSION

High Gustilo and AO classification injuries positively correlate with high non-union and infection rates, requiring multiple operations and long hospital stay. There is no benefit in performing surgery on open tibial fractures within six hours of presentation. A significant proportion of these patients would be polytraumatised, indirectly affecting fracture union.

Fuzzy approach for reducing subjectivity in estimating occupational accident severity

Quantifying or, more generally, estimating the severity of the possible consequences of occupational accidents is a decisive step in any occupational risk assessment process. Because of the lack of historic information (accident data collection and recording are incipient and insufficient, particularly in construction) and the lack of practical tools in the construction industry, the estimation/quantification of occupational accident severity is a notably arbitrary process rather than a systematic and rigorous assessment. This work proposes several severity functions (based on a safety risk assessment) to represent biomechanical knowledge with the aim of determining the severity level of occupational accidents in the construction industry and, consequently, improving occupational risk assessment quality. We follow a fuzzy approach because it makes it possible to capture and represent imprecise knowledge in a simple and understandable way for users and specialists.

Displaced tibial intercondylar eminence fractures

PURPOSE

To review outcomes of 19 patients with tibial eminence fractures.

METHODS

Records of 10 female and 9 male patients with type II (n=3) and type III (n=16) displaced tibial intercondylar eminence fractures were reviewed. Nine of whom were skeletally immature aged 6 to 15 (mean, 12) years; the remaining 10 patients were aged 19 to 55 (mean, 32) years. 14 involved the left knee. All patients presented with a painful haemarthrosis and reduced range of movement.

RESULTS

The most common activity causing this injury was skiing (n=7, primarily in adult females [n=5]), followed by cycling or motocrossing (n=6) and falling or other sporting activities (n=6). The injury mechanisms entailed forced flexion with rotation (n=7), hyperextension with rotation (n=7, primarily in skeletally immature males [n=4]), and direct trauma (n=5, primarily in adult males [n=4]). Eight patients (60% of adults and 22% of children) had associated injuries of the knee, which commonly occurred after direct trauma. Two patients were treated in a cast or brace after closed or open reduction without fixation. Two patients underwent arthroscopic reduction and internal fixation, and 15 underwent open reduction and internal fixation (2 after failed arthroscopic reduction and 11 proceeded directly). Postoperatively, 7 patients had a positive Lachman test, but none complained of subjective instability. Ten patients had knee stiffness; all except one had been immobilised for 4 to 6 weeks. Seven patients had extension impingement; 6 of them had been treated with open reduction and internal fixation. Two patients underwent further surgery for debridement and screw removal at years 1 and 3. One patient developed arthrofibrosis and underwent arthrolysis at month 6, but knee stiffness remained. No patient underwent subsequent anterior cruciate ligament reconstruction.

CONCLUSION

Tibial eminence fractures are as common in adults as in children. Female skiers are at higher risk. Stiffness is a more common complication than laxity. Early range-of-motion exercise may reduce stiffness and extension impingement.

The anterolateral incision for pilon fracture surgery: an anatomic study of cutaneous blood supply

The purpose of this study was to examine the blood supply to the adjacent skin and its vulnerability to anterolateral tibial plating performed with fibular plating through a single surgical incision. Ten lightly embalmed cadaver legs without a history of lower extremity trauma or surgery with a mean age of 71 years (range, 57 to 87 years) were used for this investigation. Each specimen was injected with a commercially available silicone compound through the popliteal artery. The left leg was plated through a modified extensile Böhler approach and the right leg served as the control. Each leg was anatomically dissected. All measurements were taken using a digital caliper by a single investigator. A mean of 93 (range, 4 to 17) perforating arteries were present and in the proximity of the fibula plate. Our findings suggest the potential for iatrogenic soft tissue breakdown along the posterior border of the anterolateral surgical incision in this procedure as a result of compromised blood supply to the skin.

Indirect reduction and hybrid external fixation in management of comminuted tibial plateau fractures

The aim of the present study is to assess the results of indirect reduction and hybrid external fixation in management of comminuted tibial plateau fractures. The study included 28 patients with high-energy tibial plateau fractures (Schatzker type V and VI). The ages ranged from 22 to 58 years with an average of 35 years. The trauma was a road traffic accident in 16 cases and a fall from a height in 12 cases. Concomitant soft tissue injuries were present in 18 cases such as skin wounds in 6 cases, excessive swelling with skin blisters in 9 cases, and compartment syndrome in 3 cases. After clinical and radiological evaluation all the patients were treated by indirect reduction using a traction table and a hybrid external fixator. The average time to healing was 3.2 months. At the final follow-up the range of knee movement ranged from 0 degrees-140 degrees with an average of 110 degrees. The results were satisfactory in 23 cases and unsatisfactory in 5 cases according to the Rasmussen knee functional score. Complications included pin tract infection in 12 cases, an extension lag in 2 cases, varus deformity of about 15 degrees in one case, deep infection in one case and early osteoarthritic changes in 2 cases. Hybrid external fixation is a good method for treatment of comminuted tibial plateau fractures. It allows for early joint movement and reduces the risk of serious complications.

Early primary total knee replacement for complex proximal tibia fractures in elderly and osteoarthritic patients

Complex intra-articular fractures of the proximal tibia are difficult to treat, especially in the elderly osteoporotic patient. Pre-existing osteoarthritis, cartilage damage during trauma, suboptimal reduction and fixation due to poor bone stock and/or secondary displacement frequently lead to poor outcome. After osteosynthesis rehabilitation is cumbersome as patients have been non-weight bearing for long periods of time and secondary total knee arthroplasty can be challenging. For these reasons, we investigated the possibility to perform a total knee arthroplasty with or without adjuvant osteosynthesis as a primary treatment in elderly and/or osteoarthritic patients with complex tibial plateau fractures. Between 2002 and 2009, 12 patients (mean age: 73 years (58-81)) with an AO-41 fracture type B1 (1), B3 (8) and C3 (3) were treated with a primary total knee arthroplasty within three weeks from their trauma. Most patients (7/12) were allowed early full-weight bearing. One patient died due to an unrelated cause; the remaining eleven were reviewed at a mean follow-up period of 31 months (5 w-81 m). At final follow-up the median knee score was 78 (50-100) and the function score 58 (0-100): 7/11 patients had an excellent result, while 1/11 had a fair and 3/11 a poor result. Fair and poor results were mostly related to pre-existing poor general condition and/or concomitant disease. Most patients were satisfied and only minor short- and long-term complications were noted. There was no need for revision surgery. Our limited series of well-selected elderly and/or osteoarthritic patients with a complex tibial plateau fracture treated with primary total knee arthroplasty yielded encouraging results.

Patterns of lower limb fractures sustained during snowsports in Otago, New Zealand

AIMS

The aim of this study was to determine the nature and circumstances of lower limb fractures caused by skiing and snowboarding at the Otago skifields that required operative treatment at Dunedin Hospital from 2002 to 2008.

METHODS

Patients were retrospectively identified from clinical records.

RESULTS

108 cases were included in the study; 28 snowboarders and 80 skiers. Snowboarders had more fractures involving the ankle whereas skiers had more fractures of the proximal third of the tibia and fibula. Snowboarders were more likely to fracture the fibula compared to skiers. Nearly two-thirds of fractures in snowboarders were to the left limb whereas in skiers a laterality was not demonstrated. Most fractures were the result of falls but a greater proportion of snowboarders had jump-related injuries.

CONCLUSIONS

Snowboarding related lower limb fractures are more likely to involve the ankle and be left sided. Skiing related lower limb fractures are more proximal with no laterality.

Epidemiology of adult tibial shaft fractures: a 7-year study in a major referral orthopedic center in Iran

BACKGROUND

Epidemiologic differences among various fracture sites and within different populations are important as they imply different cultures and lifestyles in each region. One of these fractures is the tibial shaft fracture. Rather few epidemiological studies have been undertaken on this injury. This study was designed to provide an update on various aspects of tibial shaft fractures during 1999-2006 in a referral educational orthopedic center in Iran.

MATERIAL/METHODS

The charts of 854 adult patients were evaluated in a cross-sectional study. All the patients were examined and the results were registered. The collated information was classified along with descriptive statistical analysis.

RESULTS

The highest frequency of these fractures was seen in the 20-30 year age group in both genders, and women had a higher rate than men in people aged > or =50 years old. The most common cause of fractures was road traffic accidents; 54% of all injuries were closed fractures and 46% were open. The most frequent fracture pattern was comminuted and the fewest were segmented and with butterfly fractures. The most noticeable complication early after treatment was infection and those during at least one year follow-up were pain, nonunion, and delayed union.

CONCLUSIONS

The peak frequency of tibial shaft fractures in Iran was one decade higher than in European populations and in those > or =50 years old the rate was higher in women, which was two decades lower than the mentioned populations. Furthermore, in this study in addition to high-energy trauma, low-energy trauma also had a great role.

Persistent knee complaints after retrograde unreamed nailing of femoral shaft fractures

Retrograde nailing is an attractive method for stabilisation of femoral shaft fractures in cases of polytrauma, ipsilateral pelvic, acetabular, tibial and femoral neck fractures, bilateral femoral fractures, obese and pregnant patients. However, retrograde nailing may result in complaints about the knee. The purpose of this study was to evaluate the incidence and risk factors of lasting knee pain, and its relation to knee function deficits. We conducted a retrospective study of 75 patients in whom 82 femoral shaft fractures were treated with retrograde intramedullary nailing. Complaints of pain about the knee during follow-up were present in 17 patients (23%). The mean age of patients with knee pain was significantly lower (26 years) than the age of those without knee pain (41 years) (p = 0.0002). Both groups, with and without pain about the knee, were not significantly different according to gender, injury severity score, AO type of fracture, associated ipsilateral injuries, open fractures, or type of nail used. In addition, the range of motion did not differ. Although 49% of all patients had also presented ipsilateral pelvis, acetabulum or lower leg fractures, the majority (89%) had a knee flexion > or = 120 degrees. Complaints of knee pain after retrograde intramedullary nailing of femoral fractures were found to be rather common. Younger age appeared to be a risk factor for knee pain. Nevertheless, the majority of patients had excellent knee function.

Horse-level risk factors for fatal distal limb fracture in racing Thoroughbreds in the UK

REASONS FOR PERFORMING STUDY

Fractures below the level of the radius or tibia (distal limb fractures) are the most common cause of equine fatality on UK racecourses; however, little is known about their epidemiology or aetiology. Identification of risk factors could enable intervention strategies to be designed to reduce the number of fatalities.

OBJECTIVES

To identify horse-level risk factors for fatal distal limb fracture in Thoroughbreds on UK racecourses.

METHODS

A case-control study design was used. Fractures in case horses were confirmed by post mortem examination and 3 matched uninjured controls were selected from the race in which the case horse was running. One hundred and nine cases were included and information was collected about previous racing history, horse characteristics and training schedules. Conditional logistic regression was used to identify the relationship between a number of independent variables and the likelihood of fracture.

RESULTS

Horses doing no gallop work during training and those in their first year of racing were at significantly increased risk of fracture on the racecourse. Case horses were also more likely to have trained on a sand gallop, i.e. a gallop described by trainers as being primarily composed of sand.

CONCLUSIONS

Modifications to training schedules, specifically within the first year of racing, may have a large impact on the risk of fatal distal limb fracture on the racecourse. Horses should do some gallop work in training and our results suggest that the minimum distance galloped should be between 805-2012 m (4-10 furlongs)/week.

POTENTIAL RELEVANCE

The information from this study can be used to alter training schedules in an attempt to reduce the incidence of fatal distal limb fracture in Thoroughbred racehorses. Training should include some gallop work, and further studies, recording the exact level of work, will help to identify an optimum range of training speeds and distances which will reduce the liklihood of catastrophic fracture on the racecourse.

Intraoperative fracture during primary total knee arthroplasty

While the occurrence of periprosthetic fractures around total knee arthroplasties (TKAs) is well know, little is known about intraoperative fractures that occur during TKA. We describe the incidence, location, and outcomes of iatrogenic intraoperative fracture during primary TKA. We reviewed 17,389 primary TKAs performed between 1985 and 2005 and identified 66 patients with 67 intraoperative fractures including 49 femur fractures, 18 tibia fractures, and no patella fractures. There were 12 men and 54 women with a mean age of 65.2 +/- 16 years. Of the 49 femur fractures, locations included medial condyle (20), lateral condyle (11), supracondylar femur (eight), medial epicondyle (seven), lateral epicondyle (two), and posterior cortex (one). Tibia fractures (18) included lateral plateau (six), anterior cortex (four), medial plateau (three), lateral cortex (three), medial cortex (one), and posterior cortex (one). Twenty-six fractures occurred during exposure and preparation, 22 while trialing, 13 during cementation, and three while inserting the polyethylene spacer. The minimum followup was 0.15 years (mean, 5.1 years; range, 0.15-15.4 years). All fractures healed clinically and radiographically. Knee Society scores and function scores improved from 46.4 and 34.6 to 79.5 and 61, respectively. Fourteen of the 66 (21%) patients were revised at an average of 2.8 years. Intraoperative fracture is an uncommon complication of primary TKA with a prevalence of 0.39%. Intraoperative fracture occurred more commonly in women (80.6%) and in the femur (73.1%). The majority of fractures occurred during exposure and bone preparation and trialing of the components.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[Common fractures in a general practice: indication for operations and modern operative technique]

Distal radius, clavicle, malleolar and proximal humerus fractures belong to the most frequent fracture types in every day practice. The initial diagnose with conservative therapy or the postoperative care is often carried out by the general practitioner. In recent years, therapy modality of these fractures changed. With the development of angular stable implants and minimal invasive operations technique, operative treatment is favoured mainly in osteoporotic bone. The mentioned fractures are highlighted.

Aging is not a risk factor for femoral and tibial fractures in motor vehicle crashes

OBJECTIVE

To determine the effect of aging on the occurrence of femoral and tibial fractures during vehicular crashes.

METHODS

The Crash Injury Research and Engineering Network (CIREN), which includes occupants of a vehicle < 8 years old with at least one AIS > or = 3 or two AIS > or = 2 injuries in different body regions, comprised the study population. The occurrence of femoral and tibial fractures during vehicular crashes was analyzed in relation to age and other confounders [gender, BMI, stature, change in velocity (Deltav), restraint use, occupant position (driver vs. passenger) and principal direction of force (PDOF)] using chi2, Mantel-Haenszel chi2 and student t test. Multiple logistic regression (MLR) models were built for the prediction of femoral and tibial fractures with age as the independent variable and possible confounders as co-variates. An alpha = 0.05 was used for all statistics.

RESULTS

The incidence of femoral and tibial fractures in the study population (N=1,418) was 23% and 27%, respectively. Univariate analyses revealed a negative association between increasing age and femoral fractures and no association between age and tibial fractures. MLR models revealed no clear effect of increasing age on the occurrence of either femoral or tibial fractures. Obesity, frontal PDOF, and high Deltav affected the occurrence of femoral fractures. Tibial fractures were influenced by occupant position (driver), frontal PDOF, high Deltav and shorter stature.

CONCLUSION

Despite the known changes in bone composition and strength with aging, elderly vehicular occupants do not experience higher odds of incurring femoral and tibial fractures during crashes.

[Clinical epidemiological analysis of adult spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture]

OBJECTIVE

To investigate the clinical epidemiological features of adult spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture, a special kind of fracture.

METHODS

The clinical data of 1685 cases of adult tibial and fibular shaft fracture were analyzed retrospectively. The cause and mechanism of spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture were studied in detail.

RESULTS

The male and female ratio in adult tibial and fibular shaft fracture was 4.52:1. Most of adult tibial and fibular shaft fracture occurred in the persons aged 31 - 40 (26.0%) and type A fracture accounted for 57.7% of the cases. The male and female ratio in adult spiral tibial fracture was 2.95:1. Most of the adult spiral tibial fracture occurred in those aged 41 - 50 (32.6%). With a male and female ratio of 6:1 (24:4) and mostly occurring in the persons aged 41 - 50, spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture composed 9.7% (28/288) of total tibial fractures and 1.7% (28/1685) of total spiral tibial and fibular fractures. Missed diagnosis rate of spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture was 67.9% (19/28) in the Department of Radiology and 53.6% in the Department of Orthopedics.

CONCLUSION

With a high incidence, spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture was caused by a low energy but not an iatrogenic damage. With a high rate of missed diagnosis, the spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture should be paid more attention to clinically.

[Pathologics fractures of the members: about 43 cases collected in Niamey]

This retrospective and prospective study over 49 months has permitted us to count 43 cases of pathologic fractures: the population concerned is a population of adults whose average age is 43.5 years old. The social groups, which are more affected, are these having poor economical revenue. The male sex is predominating lightly with 22 cases (51.2%). Within 16 cases (37.2%) the pathologic fracture has revealed the causal affection and 27 cases (62.8%) where the affection was already known before the occurrence of pathologic fracture. Pain, tumefaction and functional impotence constitute the main reason (motive) for consultation. Femur is the most affected bone with 26 cases over 43 cases. The principal etiologies are represented by malignant bone tumors 37.2%, osteoporosis 23.2%, and osteomyelitis 23.2%. Imperfect osteogenosa 6.9%, ricket 6.2%. The standard face and profile radiography and biopsy are the principal complementary exams. The treatment is surgical in 81.4% of cases and orthopedic in 18.6% of cases.

Tibia fractures. An overview of evaluation and treatment

The purpose of this article is to increase the reader's knowledge of tibial fractures, which are infrequently life threatening but are often life changing. The focus is on the continuum of care, starting with the mechanism of injury, classification of the tibial fracture and soft tissue involvement, approaches to stabilization and treatment options, postoperative care, potential complications, and considerations to discharge preparation. The parameters of nursing care extend to pain relief and positioning, nerve and vascular assessments, safe mobility, self-care, and prevention of complications.

MRI Follow-Up of Posttraumatic Bone Bruises of the Knee in General Practice

OBJECTIVE

Our purpose was to study the natural course of bone bruises in posttraumatic knees and to describe possible determinants of this course.

SUBJECTS AND METHODS

Prospective MRI follow-up data were gathered for patients with bone bruises after sustained knee trauma. Follow-up ceased when the bone bruise could no longer be discerned or after 1 year of follow-up. For each patient we studied the relationships between time to healing of all bone bruises and the explanatory variables age, sex, obesity, workload, sports load, number of bone bruises, osteoarthritis, and concomitant knee lesions using survival analyses. We also investigated the relationships between resolution of individual bone bruises and lesion type, size and location, and the explanatory variables at 6 months and at 12 months separately, using logistic regression analyses for repeated measurements and generalized estimating equations.

RESULTS

In 80 patients, 157 bone bruises were found. The estimated median healing time was 42.1 weeks. Healing was prolonged in patients having a higher number of bone bruises and in the presence of osteoarthritis. Resolution of individual bone bruises was prolonged in the presence of osteoarthritis and greater age. Reticular lesions were less likely to be present after 6 months than other bone bruise types. None of the remaining tested variables had prognostic value.

CONCLUSION

Median healing time of bone bruises is 42.1 weeks. Prognosis is particularly influenced by the presence of osteoarthritis. Age, type of bone bruise, and number of bruises also have prognostic value.

Social deprivation and adult tibial diaphyseal fractures

We present an analysis of the relationship between social deprivation and tibial diaphyseal fractures. We reviewed 1331 patients and have demonstrated a clear relationship between social deprivation and tibial fractures. Deprivation was also associated with male gender and with age, there being significantly less deprivation in older patients. The effect of deprivation on fracture outcome was assessed in 910 patients in whom the tibial fractures were treated by reamed intramedullary nailing. There was no association with non-union or infection, but there was a trend towards increased deprivation in patients who had an amputation which related to a trend for socially deprived patients to have more severe fractures. We believe that the main reason why the effects of deprivation decrease with age relates to the different modes of injury at different ages.

The Fate of Lower Extremities With Failed Free Flaps

BACKGROUND

Lower-extremity reconstruction with microvascular free flap coverage is often the only option for limb salvage. Flap failure rates, however, continue to have higher complication rates than those to other anatomic sites; a significant number of flaps that fail result in amputation. This study retrospectively analyzed patients treated at a single institution who underwent attempted lower-extremity limb salvage with microsurgical techniques over a 25-year period. Of particular interest are the outcome data for patients who had initial free flap failure.

PATIENTS AND METHODS

A prospectively maintained database was used to identify patients who satisfy criteria. Every patient who was treated with a microvascular free flap to their lower extremities was identified and included in this analysis. All records were reviewed from 1980 through 2004. Patients who had free flaps to the lower extremity fail after the initial operation were identified and selected for further analysis.

RESULTS

Five hundred eighty-eight patients who underwent microsurgical reconstruction of lower extremity wounds had a failure rate of 8.5%. Trauma patients (83%) had a failure rate of 9%. On subset analysis, the failure rate for trauma patients decreased from 11% (1980-1992) to 3.7% (1993-2004). Of patients who had a failed free flap, 18% went on to limb amputation; the remainder was salvaged with secondary free flaps, local flaps, or skin grafting.

CONCLUSION

This single institutional experience spanning 25 years represents the longest continual series of lower-extremity free flaps reported in the literature. The improved success rate seen in the second half of the study period is attributed to a more critical selection of free-flap candidates, improved understanding of the physiology surrounding acute trauma and a more sophisticated multidisciplinary team organization.

[Fracture due to bilateral avulsion of the tuberosity of the shin bone (tibia). A case report]

INTRODUCTION

The avultion-fracture of the tibial tuberosity is a rare injury, one which appears in adolescents, predominantly male and happens in a zone in which the conditions of bone immaturity are favorable, so that an abrupt traction of the patellar tendon generates the injury. The reports of simultaneous fractures in both knees are rare.

CLINICAL CASE

A 14-year-old masculine patient, who had suffered indirect trauma in both knees while playing soccer. The injuries correspond to a 3-A and one 3-B of Ogden's classification for the right and left knee respectively. Both injuries were treated in the same surgical act using screws and wire. The recovery of the patient was satisfactory.

CONCLUSION

The avultion-fracture of the tibial tuberosity is a rare injury. The bilateral presentation in simultaneous form is even rarer. Generally they are injuries of type 3 that require surgical handling. Preexisting conditions such as Osgood-Schlatter disease and the type of athletic training must be considered.

Age-related factors affecting the postyield energy dissipation of human cortical bone

The risk of bone fracture depends in part on tissue quality, not just the size and mass. This study assessed the postyield energy dissipation of cortical bone in tension as a function of age and composition. Specimens were prepared from tibiae of human cadavers in which male and female donors were divided into two age groups: middle aged (51 to 56 years, n = 9) and elderly (72 to 90 years, n = 8). By loading, unloading, and reloading a specimen with rest periods inserted in between, tensile properties at incremental strain levels were assessed. In addition, postyield toughness was estimated and partitioned as plastic strain energy related to permanent deformation, released elastic strain energy related to stiffness loss, and hysteresis energy related to viscous behavior. Porosity, mineral and collagen content, and collagen crosslinks of each specimen were also measured to determine the micro- and ultrastructural properties of the tissue. Age affected all the energy terms plus strength but not elastic stiffness. The postyield energy terms were correlated with porosity, pentosidine (a marker of nonenzymatic crosslinks), and collagen content, all of which varied significantly with age. General linear models suggested that pentosidine concentration and collagen content provided the best explanation of the age-related decrease in the postyield energy dissipation. Among them, pentosidine concentration had the greatest contribution to plastic strain energy and was the best explanatory variable of damage accumulation.

The risk for fractures after curettage and cryosurgery around the knee

Curettage and cryosurgery have been used successfully for treatment of benign locally aggressive and some low-grade malignant bone tumors. After treating these lesions, we reconstruct residual bone defects around the knee with cement, intramedullary pins, and autogenous bone graft for subchondral augmentation and closure of cortical windows. We questioned the incidence of fractures and the rates of nonunion and malunion and asked whether patients at risk for fractures can be identified. We conducted chart and radio-graphic reviews of 60 consecutive patients who had curettage and cryosurgery of primary bone lesions in the distal femur or proximal tibia. Ten of the 60 patients (17%) sustained postoperative intraarticular fractures. Patients who sustained fractures had (1) more freeze-thaw cycles; (2) metaphyseal defect ratios greater than 0.6 and 0.8 on the anteroposterior and lateral projections, respectively; and (3) 4 mm or less proximity of the defect to the joint. Only one fracture united in good alignment. Radiographic measurements can assist in identifying patients at risk for fractures after curettage and cryosurgery around the knee. We expect the fracture rate to decline by reducing the number of freeze-thaw cycles and improving our reconstruction method.

Computerized tomography evaluation of cortical bone properties in the tibia

BACKGROUND

Tibia shaft fractures are among the most common fractures. However, the incidence of tibia fractures does not increase in the elderly. Osteoporotic bone resorption is possibly compensated for by periosteal apposition, which improves the mechanical properties of the bone. The purpose of this study was to identify a correlation between geometric indices of transverse bone scans and radiologic bone density based in CT studies.

MATERIAL AND METHODS

12 human cadaver tibiae were CT examined. Radiological density in Hounsfield units was evaluated in transverse bone scans taken at the junction of the distal and middle third of the tibial shaft. The average and maximum radiological density and area of cortical bone were evaluated.

RESULTS

Average radiological bone density decreased with age. This was not accompanied by a corresponding increase in cortical bone area.

CONCLUSION

The study did not provide direct confirmation that age-related osteoporotic bone resorption is compensated for by periosteal apposition.

Fractures of the tibial plafond

Tibial plafond fractures comprise a diverse group of articular, metaphyseal, and occasionally diaphyseal injuries and have in common injury to the articular surface of the distal tibia and significant associated soft-tissue injury. Injury to the soft tissues combined with the complex fracture patterns has led to high complication rates from surgical attempts to reduce and stabilize these fractures. Currently, there is a wide range of treatment techniques available for a wide spectrum of injury severity, surgeon experience, and surgeon preferences. Patient outcomes vary widely. Because these injuries are relatively uncommon, the amount of clinical data available to guide treatment decisions is limited. Careful classification and assessment of the fracture pattern and associated soft-tissue injury and an understanding of the principles of modern concepts of treatment should allow the surgeon to choose from among several treatment protocols, all of which emphasize minimizing complications to optimize patient outcomes.

Salter-Harris I and II fractures of the distal tibia: does mechanism of injury relate to premature physeal closure?

INTRODUCTION

The distal tibial physis is the second most commonly injured physis in long bones. Recent reports demonstrate a high rate of premature physeal closure (PPC) in Salter-Harris (SH) type I or II fractures of the distal tibia.

METHODS

At our institution, 137 distal tibial SH type I or II fractures were treated from 1994 to 2002. Reviews were performed on all patients and 91 fractures met inclusion criteria. Patients were categorized according to treatment.

RESULTS

We report a PPC rate of 39.6% in SH type I or II fractures of the distal tibial physis. We found a difference in PPC based on injury mechanism. The rate of PPC in patients with a supination-external-rotation-type injury was 35%, whereas patients with pronation-abduction-type injuries developed PPC in 54% of cases. Type of treatment may prevent PPC in some fractures. The most important determinant of PPC is the fracture displacement following reduction.

DISCUSSION AND CONCLUSION

PPC is a common problem following SH type I or II fractures of the distal tibia. Operative treatment may decrease the frequency of PPC in some fractures. Regardless of treatment method, we recommend anatomic reduction to decrease the risk of PPC.

Posterior Malleolar Fracture is Often Associated with Spiral Tibial Diaphyseal Fracture: A Retrospective Study

BACKGROUND

It is known that posterior malleolar fracture is often associated with tibial diaphyseal fractures. However, in literature there are very few studies on tibial shaft fractures with respect to posterior malleolus fragment. We hypothesized that the incidence of posterior malleolar fracture is higher than in previous studies.

METHODS

A total of 74 closed tibial shaft fractures were treated with intramedullary nailing in Turku University Central Hospital between January 1994 and December 1998. There were 55 men and 19 women, with a mean age of 39 years (range, 16 to 58 years). Two cases were excluded and 72 tibial shaft fractures were analyzed retrospectively.

RESULTS

Posterior malleolar fracture was observed in 18 cases (25.0%). Only 10 were observed preoperatively in plain films, seven were detected postoperatively and one was not detected at all during the treatment. Retrospectively, all 18 posterior malleolar fractures were detectable in preoperative plain films.

CONCLUSION

A fracture of the posterior malleolus was involved in every fourth tibial diaphyseal fracture. The fractures of the posterior malleolus were always detected in preoperative plain films and should be suspected, especially in cases of low-energy spiral distal tibial diaphyseal fractures. We recommend additional plain films to be taken at the ankle region to better visualize these fractures.

Fractures of the distal tibial metaphysis in children: patterns of injury and results of treatment

BACKGROUND

Fractures of the tibia are common in children. Fractures of the distal tibial metaphysis have been only described in fracture texts without reference to a peer-reviewed study. The purpose of the present study was to review this fracture pattern and report the results of treatment.

METHODS

The medical records and radiographs of children seen at our institution with a fracture of the tibia were reviewed. The patients with fractures of the distal tibial metaphysis who had been followed until healing were included. Fractures of the distal tibial diaphysis, toddler's fractures, and pathologic fractures were excluded.

RESULTS

Twenty-six children met these criteria and were included in the study. The mechanism of injury was indirect in 13 fractures and direct in 12 fractures. In 1 patient, the mechanism of injury was unknown. The main cause of indirect injury was fall (11 cases). The most common was the transverse type of fracture (14 patients) followed by the oblique type (11 patients). Only 8 cases were nondisplaced. Valgus angulation was usually associated with a recurvatum deformation, whereas varus angulation was associated with procurvatum angulation. These patterns were present in 14 patients. We observed shorter healing time when the fracture was oblique than transverse. Children with the oblique pattern of injury were younger than children with a transverse fracture.

CONCLUSIONS

The patterns of displacement of the distal tibial metaphyseal fractures reported in our study vary from those presented in textbooks. Distal tibial metaphyseal fractures can present with 2 types of displacement: valgus recurvatum and varus procurvatum. Fractures of the fibula always present with the same pattern as the tibia. Primary union of the distal tibial metaphyseal fracture may be expected in all cases regardless of the type of fracture, age, and gender.

A case-control study of factors associated with pelvic and tibial stress fractures in Thoroughbred racehorses in training in the UK

Few epidemiological studies have investigated risk factors for musculoskeletal injury occurring in Thoroughbred racehorses during training, although it is the major cause of wastage in the racing industry. We recently conducted a large-scale epidemiological study to estimate the incidence of fracture in racehorses in training in the UK and to identify associated risk factors. Thirteen racehorse trainers provided data on horses in their care, with daily recording of training information and provision of details on any fractures incurred. Data were collected for 2 years, including two consecutive flat racing seasons (1999 and 2000). This paper describes findings from a nested case-control study investigating factors associated with the occurrence of pelvic and tibial stress fractures in our study population. Cases were identified from the main study and defined as horses with a pelvic or tibial stress fracture, confirmed through routine diagnostic imaging. Randomly selected controls were matched on date of fracture in the case. Age and gender of the horse, its exercise history and training surfaces were examined as explanatory variables. Exercise was quantified as cumulative distances cantered and worked at high speed in 30- and 60-day periods prior to date of fracture in the case. Conditional logistic regression was used to construct multivariable models for the 30- and 60-day periods, respectively. We hypothesised that larger cumulative exercise distances would be associated with an increased risk of pelvic or tibial stress fracture and that different training surfaces would be associated with differences in fracture risk. In the 30-day period, when adjusting for trainer, the risk of pelvic or tibial stress fracture increased with increasing distance cantered, reaching a peak at around 50 km, after which the risk reduced. This trend was not obvious in the 60-day period, with no significant association between exercise distances and risk of stress fracture. Predominant use of one particular sand-based all-weather surface was related to an increased risk of pelvic or tibial stress injury, although this finding should be interpreted with caution. Surface maintenance and construction may play a role; variables that were not considered in the current analyses, which were based on a relatively small number of cases. Trainer was associated with differences in stress fracture risk after adjusting for exercise distances and surface but age and gender were not.

Fatigue bone injuries causing anterior lower leg pain

Shin splints, or stress-related anterior lower leg pain, seem to arise from numerous causes, including stress fractures. We retrospectively reviewed 154 consecutive military patients who had magnetic resonance imaging during a 5-year period for stress-related anterior lower leg pain. Using magnetic resonance imaging, 143 bone stress injuries were diagnosed in 86 of the 154 (56%) patients. The incidence of bone stress injury requiring orthopaedic consultation and magnetic resonance imaging among recruits during the 5 years was 117 per 100,000 person years in military service. The bone stress injury was located in the tibia in 141 (99%) patients. Of these injuries, 80 (57%) were located in the distal (1/3) of the tibial shaft, 42 (30%) in the middle (1/3), 14 (10%) in the proximal (1/3), and five (3%) in the medial condyle. The locations of tibial stress injuries related to the magnetic resonance imaging grades. Almost all lower leg fatigue bone stress injuries were located in the tibia, and the distal lateral shaft was affected most often. When used early after onset of symptoms, magnetic resonance imaging provides accurate diagnosis to ensure appropriate treatment, especially when dealing with exercise-induced lower leg pain in physically active patients.

LEVEL OF EVIDENCE

Diagnostic study, Level II (development of diagnostic criteria on consecutive patients [with universally applied reference "gold" standard]). See the Guidelines for Authors for a complete description of levels of evidence.

Prediction of Soft-Tissue Injuries in Schatzker II Tibial Plateau Fractures based on Measurements of Plain Radiographs

BACKGROUND

Split-depression fractures of the lateral tibial plateau (Schatzker II) are associated with a significant risk of capsuloligamentous and meniscal injury. We hypothesized that the amount of fracture depression and widening on anteroposterior (AP) plain radiographs would correlate with the incidence of injury to these structures on magnetic resonance imaging (MRI).

METHODS

Sixty-two consecutive patients with Schatzker II tibial plateau fractures had a knee x-ray series and MRI preoperatively. AP plain radiographs were measured for lateral joint line depression and condylar widening, and MRIs were evaluated for injury to soft-tissue structures around the knee. For each structure, the threshold of depression and widening that led to the greatest disparity in soft-tissue injury was determined. Multiple logistic regressions were applied to calculate whether depression and/or widening above the thresholds were predictive for injury to individual soft-tissue structures.

RESULTS

When depression was greater than 6 mm and widening was greater than 5 mm, lateral meniscal injury occurred in 83% of fractures, compared with 50% of fractures with less displacement (p < 0.05). When either depression or widening was at least 8 mm, medial meniscal injury occurred more frequently (depression 53%, p < 0.05; widening 78%, p < 0.05; versus neither 15%). Lateral collateral ligament and posterior cruciate ligament tears were not seen with minimally displaced fractures (< 4 mm), but the incidence of injury approached 30% with increasing displacement.

CONCLUSIONS

Due to the limited availability of MRI in some centers, correlation of lateral condylar depression and widening, as measured on plain radiographs, to injury of various soft-tissue structures may be extremely helpful in planning open or arthroscopic treatment methods. Using these guidelines, Schatzker II fractures with depression or widening approaching 5 mm deserve heightened vigilance in diagnosing and treating these concomitant soft-tissue injuries.

Is the absence of an ipsilateral fibular fracture predictive of increased radiographic tibial pilon fracture severity?

OBJECTIVE

Despite their frequent occurrence, there is little clinical or biomechanical data associating the status of the fibula with any injury pattern of the tibial plafond. Similarly, the integrity of the fibula is not assessed in the commonly used tibial pilon fracture classification schemes. The purpose of this study was to determine whether there is a difference in the radiographic severity of tibial pilon injuries with fibular fractures compared with those without fibular fractures by using a rank-order method.

DESIGN

Case-control, radiographic review.

SETTING

Urban level-1, university trauma center.

PATIENTS

During a 36-month period, 20 consecutive tibial pilon injuries without associated fibular fractures were retrospectively identified by using a prospectively gathered trauma database (group 1). During the same time period, an additional 197 tibial pilon injuries with fibula fractures were identified and classified according to the AO/OTA System. This included 48 AO/OTA 43B-type (24.4%) and 149 AO/OTA 43C-type (75.6%) fractures. From this larger group of patients, an age- (+/-5 years) and gender- matched cohort of 20 tibial pilon injuries with fibular fractures were randomly selected electronically (group 2).

INTERVENTION

Digital concealment of the fibula on the anteroposterior and lateral injury radiographs.

MAIN OUTCOME MEASURE

Before definitive fixation, 3 orthopaedic traumatologists independently ranked the digitized anteroposterior and lateral radiographs of all 40 patients according to severity with 40 representing the most severe injury.

RESULTS

Interobserver agreement between the 3 evaluators showed a significant positive association (Kendall's concordance coefficient = 0.87; P = 0.0001). The overall mean rank score for tibial pilon injuries with fibula fractures was 24.4, whereas those without fibula fractures was 16.7 (t test = 0.02). When evaluated within the AO/OTA classification system, the mean rank score for C-type tibial pilon fracture patterns was 10.3 in group 1 and 8.7 in group 2 (P = 0.5). AO/OTA C-type tibial pilon fracture patterns were observed more commonly in group 2 than in group 1 (P = 0.006).

CONCLUSIONS

This study demonstrates that, overall, tibial pilon injuries with fibular fractures were statistically ranked as more radiographically severe than those without fibular fractures. Fibular fractures are more commonly associated with C-type injuries than B-type injuries. There was no difference in severity in C-type injuries with or without fibular fractures; however, C-type injuries were ranked, as a group, significantly more radiographically severe than B-type injuries.

Path analysis of factors for delayed healing and nonunion in 416 operatively treated tibial shaft fractures

A prospective observational study was done in 41 trauma centers. Four hundred sixteen patients with tibial shaft fractures were treated operatively and followed up for at least 6 months. Fifty-two (13%) cases of delayed healing or nonunion were reported. In such nonrandomized observational studies, multiple interrelationships exist between prognostic factors and patient outcomes. We used path analyses to investigate prognostic factors associated with the occurrence of delayed healing or nonunion. The most important factors were identified using multivariate regression analyses, and interrelationships between factors were illustrated using a path diagram. Fractures with open injuries less than and greater than 5 cm were 3.6 and 5.7 times as likely, respectively, to have delayed healing or nonunion as fractures with no skin injuries. The Müller-AO classification of fractures did not provide additional prognostic information. The risk of healing problems was doubled for fractures of the distal shaft and for fractures showing a postoperative diastasis. Treatment options showed an indirect effect on outcome with the occurrence of diastasis. A model for predicting delayed healing or nonunion is proposed. We encourage the use of path analysis in orthopaedics as a powerful visual technique to interpret data from observational studies.

LEVEL OF EVIDENCE

Prognostic study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Outcome and risk factors after anterior cruciate ligament reconstruction: a follow-up study of 948 patients

PURPOSE

The aim of the study was to assess the outcome and risk factors after anterior cruciate ligament (ACL) reconstruction in a large group of patients.

TYPE OF STUDY

Case series.

METHODS

Included in this retrospective study were 948 patients (323 female, 625 male) with a symptomatic unilateral ACL rupture, who underwent arthroscopic reconstruction using patellar tendon autograft and interference screw fixation at 3 Swedish hospitals. The median age of the patients at the time of the index operation was 26 years (range, 14 to 53 years). The patients underwent surgery at a median of 12 months (range, 0.5 to 360 months) after their injury. Independent physiotherapists performed the follow-up examinations at a median of 32 months (range, 21 to 117 months) postoperatively.

RESULTS

Of the 948 patients, 550 (58%) underwent meniscal surgery before, during, or after the ACL reconstruction. The median Tegner activity level was 8 (range, 2-10) before injury, 3 (range, 0-9) preoperatively, and 6 (range, 1-10) at follow-up (P < .0001 preoperative v follow-up). At follow-up, the median Lysholm score was 90 points (range, 14-100), the median KT-1000 anterior side-to-side laxity difference was 1.5 mm (range, -6 to 13 mm), and the median 1-leg hop test quotient was 95% (0% to 167%) compared with the contralateral normal side. At follow-up, 69.3% of the patients were classified as normal or nearly normal according to the International Knee Documentation Committee evaluation system. However, 36% of the patients were unable to or had severe problems performing the knee-walking test. Inferior results correlated with increased time period between the index injury and reconstruction and concomitant joint damage found at the index operation.

CONCLUSIONS

Overall, the results were good after ACL reconstruction using patellar tendon autograft and interference screw fixation. Concomitant joint damage and a long time period between the injury and reconstruction are major risk factors for inferior outcome after ACL reconstruction.

LEVEL OF EVIDENCE

Level IV, case series.