[Elastic intramedullary nailing of the tibia with the Marchetti-Vicenzi nail. 43 treated cases]

PURPOSE OF THE STUDY

The purpose of this study was to analyse the results of tibial intramedullary nailing using an unreamed "Universal Elastic Bundle Nail".

MATERIAL AND METHODS

Forty-three intramedullary nailing of tibial shaft were done in 43 patients with recents fractures, from May 1993 and May 1996. There were 36 males and 7 females. The average age was 31.5 years (range 17-68 years). Thirty-three were injured in a traffic accident (20 motorcycles, 5 pedestrians and 8 car passengers), seven were injured in a home accident (fall) and three had a sport injury. There were 13 open fractures according to Gustilo: 5 grade I, 7 grade II and one grade III B. Eight fractures involved the proximal metaphyseal part of the tibia, 16 the distal metaphyseal part and 14 the tibial shaft; in five cases there were segmental fractures. According to AO classification there were: 10 fractures type A, 24 fractures type B and 9 fractures type C (5 segmental fractures). In 5 cases there were associated femoral fractures: three ipsilaterals and two controlaterals. All were treated in the same time: four by UEBN device and one by AO's nail. All the patients with type B and C fractures were positioned on a Maquet table with a boot traction or transcalcaneal pin traction (in the distal fractures). The nail was introduced after closed reduction through a vertical transpatellar tendon incision, without reaming procedure.

RESULTS

Forty one fractures healed after an average time of 96 days (60-120). In 11 open fractures bone union occurred after 98 days (85-120). The distal fractures healed after a mean time of 86 days (60-120), proximal fractures in 123 days and mid shaft fractures in 98 days. In type A fractures bone union occurred after an average time of 68 days, while bone union occurred after a mean time of 100 days in type B and C fractures. Two patients with an open proximal type B fracture, had a delayed union: both healed after proximal screws removal. Two fractures healed with a valgus angulaton 5 degrees and 10 degrees. No infection, no loss of reduction and no bundle migration has been noted.

DISCUSSION

The Marchetti-Vicenzi's nail (UEBN) permitted a stable fixation in tibial fractures. The use of this unreamed nailing coupled with an automatic distal locking in the metaphyseal cancellous bone, reduced operative time and shortened X Ray's radiation exposure. At the follow-up fracture healing occurred in 41 cases 95.3 p. 100 at four months. Two delayed union occurred after four months, the two cases were open fractures grade II. All the two cases healed after secondary procedure without any loss of function. Malunion occurred in two patients (in only one case there was a major valgus angulation 10 degrees), the two cases were related to technical error. We had no cases of infection or leg shortening or bundle migration in the ankle joint.

CONCLUSION

We believe that Universal Elastic Bundle Nail allows a stable and safety fixation in open or closed tibial fractures without pseudarthrosis and without infection (in our series).

Salvage of tibial pilon fractures using fusion of the ankle with a 90 degrees cannulated blade-plate: a preliminary report

Six patients with ankle joint destruction and delayed metaphyseal union after tibial plafond fracture were surgically treated with tibiotalar arthrodesis and metaphyseal reconstruction, using a fixed-angle cannulated blade-plate. The procedure was performed through a posterior approach in five cases and a lateral approach in one case. The subtalar joint was preserved in all cases. Metaphyseal union and a stable arthrodesis were obtained in all cases without loss of fixation and with no mechanical failure of the blade-plate. Union was obtained in an average of 26 weeks. No secondary procedures were required to obtain union. All six patients were ambulatory at last follow-up. Stable internal fixation for simultaneous tibiotalar fusion and metaphyseal reconstruction can be achieved with a cannulated blade-plate while preserving the subtalar joint in complex plafond fractures.

Total knee arthroplasty: periprosthetic tibial fractures

A classification for periprosthetic tibial fractures is presented. It is based on the anatomic location of the fracture in reference to the tibial component; whether the fracture occurred during surgery or in the postoperative period; and whether the prosthesis is radiographically well-fixed or loose. A treatment algorithm is proposed for each fracture type.

Classification of periprosthetic fractures complicating total knee arthroplasty

As the total number of knee arthroplasties increase, the frequency with which periprosthetic fractures will be encountered can be expected to increase as well. The classification of these fractures is an important aspect in the development of an understanding of these problems. Adequate classification systems allow accurate communication between researchers and comparisons to be made between different techniques. Classification systems also allow algorithms to be developed to guide clinicians in the diagnosis, investigation, and treatment of these fractures. The authors present an outline of the classification systems described for fractures occurring in relation to total knee arthroplasty.

Recognition and management of Tillaux fractures in adolescents

Tillaux fractures are relatively uncommon Salter Harris III fractures of the tibia. The importance of recognizing this fracture is that a residual deformity in the joint surface can lead to premature degenerative arthritis. For this reason, it is important that accurate imaging to assess the congruity of the joint, as well as adequate reduction, is obtained. These fractures can occur in adolescents in the 18-month period during which the distal tibial epiphysis is closing. These injuries occur either by lateral rotation of the foot or by medial rotation of the leg on the fixed foot. Closed reduction is sufficient in most cases; however, if a gap of > or = 2 mm of the articular surface remains, open reduction is usually required to adequately reduce the articular surface. Orthopedic injuries are one of the most common reasons children are brought to the emergency department (ED). Most of these injuries are easily managed by splinting, with outpatient orthopedic follow-up. However, certain fractures need closer evaluation and immediate consultation with an orthopedic surgeon. One relatively uncommon fracture that needs special attention is the Tillaux fracture. Paul Jules Tillaux first described this particular fracture in 1892. He performed experiments on cadavers and found that stress to the anterior inferior tibiofibular ligament could lead to this type of avulsion fracture, which today is termed the Tillaux fracture. The distal tibial epiphysis is involved, and the mechanism usually is forced external rotation of the foot in a 12- to 14-year-old adolescent. This fracture only occurs during a certain time of adolescence, owing to the differential growth rate of the epiphysis, and only under certain circumstances. The fracture is of great importance because it involves a major weight-bearing articular surface. A residual deformity of the joint surface can lead to premature degenerative arthritis. We present a patient with a Tillaux fracture to elaborate on the mechanism of injury and to summarize the importance of its recognition and imaging and treatment options.

Tissue perfusion after intramedullary nailing of tibial shaft fracture

BACKGROUNDS AND AIMS

To measure noninvasively the effect of circulative changes caused by fracture and intramedullary nailing on tibialis posterior (TPA), dorsalis pedis (DPA) and sum (TPA + DPA) arterial peak signals, transcutaneous oxygen tension (PtcO2) as well as local skin temperature (T) in patients with tibial shaft fractures.

PATIENTS, MATERIAL AND METHODS

A total of thirty tibias consisting of ten closed, reamed, intramedullary nailed simple tibial shaft fractures (Type AO A), ten contralateral tibias and as controls, ten intact tibias of healthy volunteers. The measurements took place one day before and immediately after nailing, six hours later and during five days postoperatively. The values were compared to those of contralateral legs and to control legs.

RESULTS

In the nailed legs the mean TPA and PtcO2 remained at a significantly lower level compared to the contralateral legs throughout the study (p < 0.003 in both cases). However, the alterations in DPA and TPA + DPA were not statistically significant. Additionally, skin temperature on the fracture site was averagely 3 degrees C warmer than that of the contralaterals (p < 0.001). All the measured parameters were statistically significantly higher in control legs compared to contralateral legs. There were no statistically significant differences between pre- and postoperative values in any measured parameters.

CONCLUSION

The changes in the local tissue perfusion variables measured in the present study reflect rather the injury mechanism itself than the effect of reaming and intramedullary nailing in simple tibial fractures. Additionally, arterial circulation was reduced in the contralateral legs.

Fractures of the tibia. Can their outcome be predicted?

We have carried out a prospective study to determine whether the basic descriptive criteria and classifications of diaphyseal fractures of the tibia determine prognosis, as is widely believed. A number of systems which are readily available were used, with outcome being determined by standard measurements including fracture union, the need for secondary surgery and the incidence of infection. Many validated functional outcomes were also used. The Tscherne classification of closed fractures proved to be slightly more predictive of outcome than the others, but our findings indicate that such systems have little predictive value.

Rank order analysis of tibial plafond fractures: does injury or reduction predict outcome?

We investigated the effects of severity of initial injury pattern and the quality of the articular reduction on outcome of displaced intra-articular distal tibial fractures, using a series of 25 patients who were treated with articulated external fixation and limited internal fixation, which provided a spectrum of reduction quality. Outcome was assessed by clinical ankle scores and radiographic arthrosis. The results demonstrate the rank order method to be a reliable means of stratifying severity of injury and quality of reduction. Neither injury nor reduction correlated with clinical ankle score. Reduction had a significant correlation with radiographic arthrosis. We conclude that the rank order method is useful in stratification of fracture patients, and that factors other than injury pattern and quality of articular reduction are important in determining outcome of patients with this severe articular injury.

Treatment of tibial bone defects with the Ilizarov circular external fixator in high-velocity gunshot wounds

One of the applications for circular external fixators is the treatment of large-bone defects which may be difficult to manage with conventional methods. Successful results have been reported with the use of circular external fixators, particularly in the treatment of infected tibial pseudoarthroses and those with bone loss. In this study, a total of 43 cases with tibial bone defects (18 infected) as a result of high-velocity gun-shot injuries were treated with circular external fixators between January 1, 1988 and December 31, 1995. The mean follow-up period was 50 months (range: 28-98 months) after the removal of the Ilizarov device. Satisfactory union was obtained in 40 cases without any major complication or additional surgical intervention, in spite of the large and in some cases infected defects. We conclude that this is a safe method for the treatment of infected or noninfected tibial bone defects.

[Value of 3D CT in diagnosis and treatment of fractures of the tibial plateau]

A precise classification and an optimal understanding of tibial plateau fractures are the basis of a conservative treatment or adequate surgery. The aim of this prospective study is to determine the contribution of 3D CT to the classification of fractures (comparison with standard X-rays) and as an aid to the surgeon in preoperative planning and surgical reconstruction. Between November 1994 and July 1996, 20 patients presenting 22 tibial plateau fractures were considered in this study. They all underwent surgical treatment. The fractures were classified according to the Müller AO classification. They were all investigated by means of standard X-rays (AP, profile, oblique) and the 3D CT. Analysis of the results has shown the superiority of 3D CT in the planning (easier and more acute), in the classification (more precise), and in the exact assessment of the lesions (quantity of fragments); thereby proving to be of undeniable value of the surgeon.

Concepts of fracture union, delayed union, and nonunion

Laboratory and clinical scientists and practicing clinicians need definitions of union, delayed union, and nonunion. Fracture union is a gradual process, so quantitative measures are the most meaningful. However, end point definitions also are useful, but they need empirical validation. The measure that has received the best validation in human fractures is bending stiffness. Quantitative radiologic assessment of healing is difficult because varying patterns of bone bridging can occur, including periosteal, endosteal, and intercortical patterns. Natural fracture healing was studied in 43 cases of isolated, closed, conservatively treated tibial shaft fracture with serial measurements of bending stiffness and standard radiographs. Three healing groups were defined on the basis of stiffness recovery patterns. Four cases showed delayed union, defined as failure to reach a stiffness of 7 N-m per degree by 20 weeks from fracture. The remaining cases had normal union, but at differing rates. Callus index was used as a measure of periosteal new bone formation. Stiffness measurements correlated more strongly than callus index with injury severity and functional outcome at 6 months. However, the callus index predicted behavior in those fractures that showed no tendency to heal at the 10-week stage. That is, absence of periosteal new bone in these cases presaged delayed union. These delayed union cases all eventually healed, still without producing periosteal callus, but other fractures in the series healed very rapidly, also without periosteal callus. The implication is that endosteal healing is capable of very rapid fracture bridging if conditions are right, but it also can occur late, after the periosteal healing response has ceased. These observations suggest a more rational approach to the definition of union, delayed union, and nonunion than that provided by the selection of arbitrary times. For conservatively treated fractures at least, delayed union can be defined as the cessation of the periosteal response before the fracture successfully has been bridged. Nonunion is the cessation of both the periosteal and endosteal healing responses without bridging.

[Amputation or reconstruction of IIIB and IIIC open tibial fracture. Decision criteria in the acute phase and late functional outcome]

In IIIB and IIIC type open tibial fractures (according to Gustilo) the primary decision that has to be made regarding therapy is wether or not the limb can be salvaged. To standardize the criteria for amputation different salvage scores have been established in recent years. In this study the Hannover Fracture Scale (HFS), the Predictive Salvage Index (PSI), the Mangled Extremity Severity Score (MESS) and the NISSSA score were evaluated regarding their clinical relevance. When ROC Analysis was performed for all these scores in our patients the HFS revealed the highest sensitivity (0.91), but low specificity (0.71). The highest specificity was noted for the MESS (0.97), which in parallel showed the lowest sensitivity (0.59). In general it seems to be essential to make the right decision initially in order to avoid secondary amputation. All the scores mentioned here appear to be helpful in decision making. Salvaged limbs in IIIB and IIIC fractures presented a comparable good outcome, whereas salvaged IIIC injuries with a high score presented an outcome which was as bad as in secondary amputations. Secondary amputated patients required not only significant longer hospitalization but also resulted in poor outcome compared with the patients having received reconstruction or primary amputation.

Juvenile Tillaux fracture simulating syndesmosis separation: a case report

The juvenile Tillaux fracture is an avulsion fracture (Salter-Harris type-3) of the anterolateral comer of the distal tibial epiphysis. We present a case in which the severely displaced Tillaux fragment became incarcerated between the distal tibia and fibula, simulating a syndesmotic separation radiographically. To our knowledge, such a fracture pattern as not been previously described. Preoperative computerized tomography provided accurate imaging of the unusual fracture pattern. Open extrication of the fracture fragment was followed by spontaneous reduction of the syndesmosis. The Tillaux fracture healed following open reduction with pin fixation, and the patient had an excellent functional and radiographic result at 2-year follow-up.

Unreamed intramedullary locking nailing for open tibial fractures

We reviewed the results of the treatment of 24 cases of open tibial fractures using unreamed intramedullary locking nailing. The fractures were classified, following the Gustilo system as grade I-7, grade II-7 and grade III-10. The average time to achieve bony union was 22 weeks with a 26% incidence of pseudoarthrosis. There were no cases of deep infection. Five cases healed with shortening of over 1 cm, but we did not observe angular deformity in any of the patients. In 2 fractures with associated articular lesions, joint motion was limited at final follow up. The nail broke in 2 cases and the screws in 5. The surgical procedure is well tolerated by patients, allows good management of soft tissue lesions and rehabilitation with low rate of infection and malunion. The main disadvantages have been the relative high incidence of nonunion and breakage of metal.

MRI of pediatric growth plate injury: correlation with plain film radiographs and clinical outcome

PURPOSE

To evaluate pediatric growth plate injuries with conventional radiographs and magnetic resonance imaging (MRI). To review potential clinical impact of MRI on subsequent patient management and outcome.

METHODS

Fourteen patients with known or suspected growth plate injury were studied. Each patient underwent imaging by conventional radiography and MRI within 2 weeks of injury. Findings on conventional radiographs and on MR images were compared and then correlated with subsequent management and outcome at a mean of 12 months.

RESULTS

Direct visualization of cartilage afforded by MRI improved evaluation of growth plate injury in each case. MRI changed Salter Harris classification or staging in 2 of 9 patients with fractures visualized on conventional radiographs, allowed the detection of radiographically occult fractures in 5 of 14 cases, and resulted in a physical change in management in 5 of the 14 patients studied.

CONCLUSION

MRI has an important role in the evaluation of acute pediatric growth plate injury, particularly when diagnostic uncertainty persists following the evaluation of conventional radiographs. MRI allows detection of occult fractures, may alter Salter Harris staging, and in the reported study it frequently resulted in a change in patient management.

Treatment of displaced pylon fractures with circular external fixators of Ilizarov

Twenty cases of pylon fractures were treated with IIizarov circular external fixators using the technique of ligamentotaxis. Fourteen men and six women, ranging in age from 20 to 59 years, with open or closed distal tibial fractures were included in this study. The fractures were classified according to the AO system and distributed as seven C1, eight C2, and five C3 fractures. Independent from the type of fracture, six were grade II open according to the Gustilo-Anderson classification. For all fractures, an external fixator was constructed, after reduction by traction and olive wires. Mean follow-up was 29 months. All fractures healed by 14 weeks postreduction. The results were assessed using Weber's criteria: 5 (25%) had excellent results, 10 (50%) good, and 5 (25%) poor results. This technique lowers the rated complications of open reduction and internal fixation, and allows restoration of joint-surfaces, reconstruction of length, and alignment of the extremity while maintaining a sufficient range of motion at the joint. We concluded that use of the Ilizarov circular external fixator enables good results in selected ankle traumas when applied with good indications, planning, and surgical experience.

[Fractures of the tibial pilon. Long-term retrospective study of 51 fractures treated with open reduction and osteosynthesis]

PURPOSE OF THE STUDY

Fracture of the tibial pilon is a rare injury and its treatment remains difficult. The aim of this study was to report the complications and long term results of internal fixation using a technique which respects soft tissues and in which little material was used.

MATERIAL

From 1985 to 1990, 48 patients with 51 fractures of the tibial pilon were treated by open reduction and internal fixation. All patients were submitted to a clinical and radiological review.

METHODS

Both the Rüedi/Allgöwer and the AO-classification were used and determined by standard X-rays. Surgical procedure was performed with a 2 or 3 1/3 tube AO-plates and the peroneus was always fixed if fractured. Intraoperative reconstruction was analyzed. Subjective and objective scoring were used according to Olerud and Molander and the ankle arthritis was scored according to the classification determined by the SOFCOT in 1992.

RESULTS

A minimal follow-up of 1 year for all cases was obtained, based on our own files. Thirty-eight patients (40 fractures) were evaluated after an average period of 88 months (56 to 124 months). Five patients developed cutaneous infection, three developed deep infection and four developed superficial skin necrosis. One aseptic non-union necessitated reoperation after 14 months. Two ankles had joint fusion after 19 and 25 months respectively due to severe arthritis. In six cases infectious and non-infectious complications led to surgical revision. According to the Olerud and Molander score, 15 per cent of the results were excellent, 45 per cent were good, 30 per cent were fair and 10 per cent poor.

DISCUSSION

Literature shows a wide range of results following this surgical procedure. This is due to the difference in the type of trauma, classification system used, material used for the internal fixation and method of evaluation. The classification system of Rüedi and Allgöwer is the most commonly used but has a rather subjective tendency, especially between type II and type III. Treatment is difficult, especially for comminutive fractures associated with soft tissue damage. In this case, open reduction and internal fixation could increase iatrogenic lesions. For this reason surgical procedure can be delayed for several days, little material is used and soft tissue manipulation is reduced to minimum. In other study reports, the use of external fixation with or without minimal internal fixation have produced less complications without improving long term results.

CONCLUSION

Analysis and comparison of study reports are difficult because of the absence of consensus in classification system and evaluation methods. The AO-classification, apparently the most objective, will probably be more and more used in the future. Treatment must be adapted to the bony lesion and soft tissue damage. Open reduction and internal fixation must be reserved for a specific group of lesion.

[Value of external fixation in proximal tibial fractures]

PURPOSE OF THE STUDY

This study was a retrospective analysis of 39 proximal metaphyseal tibial fractures treated by Orthofix fixator in two trauma departments.

MATERIAL AND METHOD

There were 28 men and 10 women with a mean age of 49.5 years. 13 pedestrians were stroked by a car and 18 had a traffic accident on a motorcycle. In 27 cases, the fracture was open with following Cauchoix grading: 15 types 2, 6 types 1 and 6 types 3. All fractures were partially or totally included in the proximal epiphyseal square of the AO system. 14 fractures were metaphyseal, 13 diaphyso-metaphyseal and 12 had an articular irradiation. All external fixations were performed using the Orthofix device, with image intensification. A partial weight bearing was allowed for 2.4 months as an average and full weight bearing at mean 3.7 months. 7 skin grafts, 2 micro surgical (latissimus dorsi) and 2 local flaps were necessary.

RESULTS

In 3 patients this technique failed. 3 patients had an autologous bone graft at the metaphyseal and 2 at the diaphyseal fracture site. 30 patients healed without other procedure after an average delay of 5.5 months. During the healing and weight bearing time, 6 frontal deformities appeared and 5 flexion contractures were not reoperated. With a minimum follow up of one year (mean 3 years) 22 fractures had no deformity, 8 had a valgus deformity (5 degrees to 10 degrees) and 3 a varus deformity (6 to 17 degrees). For the 25 patients with an isolated proximal tibial fracture, 11 (44%) had an excellent functional result (no pain, full range knee motion, normal daily activity); 12 (48%) had a good result (episodic pain, minimally knee discomfort, flexion limitation).

DISCUSSION

Orthofix fixator appear to be a good solution for comminuted fractures. These fractures have anatomical and epidemiological particularities. AO classification system is not useful; a new one is proposed. External fixator must be placed meticulously after closed fracture reduction.

Evaluation of tibial interlocking intramedullary nails

Interlocking intramedullary nailing is currently the leading method of treating a wide assortment of tibial fractures. Satisfactory clinical performance of such a nail is interwoven with the mechanical characteristics (chiefly, static strength, fatigue strength, fatigue life and stiffness) of the nail-contiguous fractured bone construct. The present work reviews the open literature on these nails and the mechanical performance of the constructs. Based on the observations made in the review, areas for future work are identified and expounded upon.

Ankle-joint salvage following a tibial pilon fracture. A case report

This article presents a case of a tibial pilon fracture following a motor-vehicle accident. It discusses the main classification system and mechanism of injury for such fractures and emphasizes an alternative form of treatment of the usually suggested ankle fusion: an arthrectomy, which allows motion, thereby salvaging the ankle joint.

[Primary shortening--secondary lengthening. A new treatment concept for reconstruction of extensive soft tissue and bone injuries after 3rd degree open fracture and amputation of the lower leg]

The main problem in major limb replantation--especially of the lower extremity--is an extensive bone- and soft-tissue loss. The traditional replantation concept tries to preserve the initial limb length; only a small shortening is accepted. To avoid a more extensive shortening, often insufficient debridement at the time of replantation is carried out. After successful revascularisation, bone and soft-tissue defects will be reconstructed according to the principles of staged reconstruction. Especially segmental nerve defects of more than one major peripheral nerve and severe skin and muscle loss necessitate extensive secondary grafting procedures. This often leads to a prolonged hospitalisation and a high complication rate. In 1951, Lorenz Böhler described the deliberate extremity shortening as a method of therapy in segmental combined bone-soft-tissue defects of the extremities. No additional surgical procedure were necessary to treat the soft tissue defect. A functional but shortened extremity was the result. With Ilizarov's principle of callus distraction he proved in an extensive experimental and clinical study the possibility to lengthen extremities without functional damage up to 20 cm. A new reconstruction concept--"concept of primary shortening with secondary limb lengthening"--for the treatment of amputation and/or amputation-like injuries was created by combining both principles mentioned above. At the time of replantation (reconstruction), deliberate shortening is carried out in order to reduce soft-tissue and/or bone defect or to enable primary nerve repair. Moreover, the aggressive debridement leads to a reduction of the local complication risk (wound healing disturbance, infection) and the potential systemic complications (crush-syndrome, ischemia-reperfusion-syndrome) after revascularisation of a large tissue bloc. Six to twelve months after replantation, secondary limb lengthening is started using an external or internal (= programmable intramedullary nail) distraction device. Since 1985, twelve patients (six macroamputations and six third-degree open fractures of the lower leg) have been treated using the "concept of primary shortening with secondary limb lengthening". Indications, operative technique, and results are shown and discussed, comparing this new concept to the traditional "concept of staged length-reconstruction" with extensive free tissue reconstruction and secondary nerve grafting.