1
|
Shen M, Tejwani N. Open tibial shaft fracture fixation strategies: intramedullary nailing, external fixation, and plating. OTA Int 2024; 7:e316. [PMID: 38840705 PMCID: PMC11149753 DOI: 10.1097/oi9.0000000000000316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 06/07/2024]
Abstract
Tibial shaft fractures are one of the most common orthopaedic injuries. Open tibial shaft fractures are relatively common because of the paucity of soft tissue surrounding the bone. Despite the prevalence of these injuries, the optimal fixation strategy is still a topic of debate. The purpose of this article was to review the current literature on open tibial shaft fracture fixation strategies including intramedullary nailing, external fixation, and plating.
Collapse
Affiliation(s)
- Michelle Shen
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Nirmal Tejwani
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| |
Collapse
|
2
|
Jang Y, Wilson N, Jones J, Alcaide D, Szatkowski J, Sorkin A, Slaven JE, Natoli R. Plating Versus Intramedullary Nailing of OTA/AO 43C1 and C2 Intra-articular Distal Tibia Fractures: A Propensity Score and Multivariate Analysis. J Orthop Trauma 2024; 38:e9-e14. [PMID: 37735766 DOI: 10.1097/bot.0000000000002697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To compare rates of reduction loss, nonunion, and infection in intra-articular distal tibia fractures (IADTF) treated with limited open reduction internal fixation and intramedullary nailing (IMN) as compared to open reduction internal fixation with plate and screws (plate fixation [PF]). METHODS DESIGN Retrospective review. SETTING Level-I academic trauma center. PATIENT SELECTION CRITERIA Patients age ≥ 18 with OTA/AO 43C1 and C2 IADTF treated with IMN or PF between 2013-2021. OUTCOME MEASURES AND COMPARISONS Loss of reduction, surgical site infection (SSI), nonunion, and patient-reported outcomes (PROs) were compared for IMN versus PF treatments. RESULTS One hundred ten patients met the inclusion criteria (IMN 33 and PF 77). There was no loss of reduction found. Seventeen nonunions (15% overall; IMN 4/33 and PF 13/77) and 13 SSIs (12% overall; IMN 2/33 and PF11/77) were identified. Despite several risk factors being identified for nonunion and SSI in bivariate analysis, only open fracture remained significant as a risk factor for both nonunion (odds ratio 0.09 for closed fracture, 95% confidence interval, 0.02-0.56, P = 0.009) and SSI (odds ratio 0.07 for closed fracture, 95% confidence interval, 0.06-0.26, P = 0.012) in the multivariate model. Propensity scoring based on presurgical variables was significantly different between patients who received IMN versus PF ( P = 0.03); however, logistic regression incorporating the propensity score revealed no significant association with nonunion and SSI. Adjusting for the propensity score, there remained no association comparing IMN versus PF with nonunion and SSI ( P = 0.54 and P = 0.17, respectively). There was also no difference in PROs between IMN and PF (physical function: P = 0.25 and pain interference: P = 0.21). CONCLUSIONS Overall nonunion and SSI prevalence was 15% and 12%, respectively, in operatively treated OTA/AO 43C1 and C2 IADTF. An open fracture was a significant risk factor for nonunion and SSI. Metaphyseal fixation through IMN or PF did not affect loss of reduction, nonunion, SSI, or PROs. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Yohan Jang
- Division of Orthopedic, Trauma, Indiana University, Methodist Hospital, Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN; and
| | | | - Jenna Jones
- Indiana University School of Medicine, Indianapolis, IN; and
| | - Doriann Alcaide
- Indiana University School of Medicine, Indianapolis, IN; and
| | - Jan Szatkowski
- Division of Orthopedic, Trauma, Indiana University, Methodist Hospital, Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN; and
| | - Anthony Sorkin
- Division of Orthopedic, Trauma, Indiana University, Methodist Hospital, Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN; and
| | - James E Slaven
- Indiana University School of Medicine, Indianapolis, IN; and
| | - Roman Natoli
- Division of Orthopedic, Trauma, Indiana University, Methodist Hospital, Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN; and
| |
Collapse
|
3
|
Mortality and morbidity following operative management of tibial shaft fractures in octogenarians. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:299-304. [PMID: 35031851 DOI: 10.1007/s00590-021-03180-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/27/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE As the geriatric population continues to grow, the incidence of tibial shaft fractures in octogenarians is projected to increase. There is significant variation in the functional and physiologic status within the geriatric population. The purpose of this study is to compare the complications following operative treatment of tibial shaft fractures for patients who are 65- to79-year-old compared to patients who are 80- to 89-year-old. METHODS Data were collected through the National Surgical Quality Improvement Program database for the years 2007-2018. All isolated tibial shaft fractures that were treated with open reduction internal fixation (ORIF) or intramedullary nail (IMN) were identified. Patients were divided into a 65- to 79-year-old group and an 80-to 89-year-old group. Primary and secondary outcomes were studied and included 30-day mortality. Univariate and multivariate analyses were performed with a significance set at p < 0.05. RESULTS In total, 434 patients with tibial shaft fractures were included in the study. Of these, 333 were 65- to 79-year-old and 101 were 80- to 89-year-old (Table 1). On multivariate analysis, there was no significant difference in complication rates between the two cohorts. CONCLUSION After controlling for demographics and comorbidities, age was not independently associated with 30-day mortality or any other peri-operative complications between patients aged 80 to 89 and patients aged 65 to 79 following operative management of tibial shaft fractures. In appropriately selected octogenarian patients, operative management of tibial shaft fractures represents a relatively safe treatment modality that may promote early rehabilitation.
Collapse
|
4
|
Preoperative and Intraoperative Considerations Using Intramedullary Nails for the Treatment of Tibial Shaft Fractures Below Total Knee Arthroplasty. J Orthop Trauma 2022; 36:e437-e441. [PMID: 35234734 DOI: 10.1097/bot.0000000000002367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 02/02/2023]
Abstract
SUMMARY Periprosthetic tibial shaft fractures below total knee arthroplasty (TKA) are relatively rare, with an incidence of approximately 1%. However, as the rates of arthroplasty increase, orthopaedic surgeons are likely to see a corresponding increase in these types of fractures. Native tibial shaft fractures are routinely treated with either nails or plates, and the success of intramedullary nailing of tibial shaft fractures has been well described in the literature. In this article, we seek to describe a case series of tibial shaft fractures in patients with ipsilateral TKA treated with infrapatellar intramedullary nailing. We will focus on preoperative considerations including templating and measurement of the anterior cortical implant distance on the lateral radiograph to ensure space for safe nail passage. We will also discuss intraoperative technical tricks, including Kirschner wire insertion for sounding the start point, utilization of the curved awl, use of hand reamers, and rotation of the nail to bypass the implant. Using meticulous preoperative planning and technical intraoperative tricks, patients with tibial shaft fractures below TKA may be successfully treated with intramedullary nailing.
Collapse
|
5
|
Alt V, Pfeifer C, Rupp M, Walter N. Treatment of a Gustilo-Anderson type II open tibia shaft fracture with an ultrathin silver plasma-coated plate: A case report. Trauma Case Rep 2022; 42:100715. [PMID: 36299855 PMCID: PMC9589016 DOI: 10.1016/j.tcr.2022.100715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2022] [Indexed: 10/31/2022] Open
Abstract
The treatment of open tibia fractures with plate fixation bears a high risk for the development of a fracture-related infection. Here we present a case of an 80-year-old female with a Gustilo-Anderson type II open distal tibial shaft fracture with an indwelling knee prosthesis. The case was successfully treated with a 2-stage procedure with initial external fixation and subsequent open reduction and plate fixation with a custom-made ultrathin silver plasma-coated locking plate. Plate fixation was the preferred method as the indwelling knee prosthesis prevented the use of a standard intramedullary tibia nail. The fracture healed uneventfully without any signs of infections and the patient achieved full weight-bearing with a normal gait and without any pain after three months. Radiographical full bridging of the initial fracture area was seen after 5 months without any signs of infection or fracture healing disturbances. After an overall follow-up of 12 months, there were no signs of silver associated or other adverse events. Thus, ultrathin silver plasma coating seems to be helpful in the treatment open fractures with plate fixation to prevent fracture-related infections.
Collapse
Affiliation(s)
- Volker Alt
- Corresponding author at: Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss Allee 11, 93053,Regensburg, Germany.
| | | | | | | |
Collapse
|
6
|
John M, Mir HR. Extreme nailing and immediate weight bearing constructs in fractures of the distal tibia. OTA Int 2022; 5:e180. [PMID: 37781481 PMCID: PMC10538524 DOI: 10.1097/oi9.0000000000000180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/18/2021] [Indexed: 10/03/2023]
Abstract
Extraarticular fractures of the distal tibia can present as difficult but manageable lower extremity injuries. Historically, these injuries have been fixed in a myriad of ways. Early management with intramedullary nailing had higher complication rates due to the unique anatomical and biomechanical features of the distal tibia. Modern improvements in intramedullary nailing surgical techniques and implant design have significantly decreased complication rates and led to improvement in patient outcomes. Many surgeons protect weight bearing postoperatively, but recent literature suggests that patients may safely weight bear immediately following intramedullary fixation. This article reviews technique and implant design changes that have facilitated immediate safe weight bearing following intramedullary nailing of extraarticular distal tibia fractures.
Collapse
Affiliation(s)
- Mitchell John
- University of South Florida, Department of Orthopaedic Surgery
| | - Hassan R Mir
- University of South Florida, Department of Orthopaedic Surgery
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL
| |
Collapse
|
7
|
Tibial Shaft and Pilon Fractures With Associated Syndesmotic Injury: A Matched Cohort Assessment. J Orthop Trauma 2022; 36:157-162. [PMID: 34456310 DOI: 10.1097/bot.0000000000002252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the outcomes of pilon and tibial shaft fractures with syndesmotic injuries compared with similar fractures without syndesmotic injury. DESIGN Retrospective case-control study. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS All patients over a 5-year period (2012-2017) with tibial shaft or pilon fractures with a concomitant syndesmotic injury and a control group without a syndesmotic injury matched for age, OTA/AO fracture classification, and Gustilo-Anderson open fracture classification. INTERVENTION Preoperative or intraoperative diagnosis of syndesmotic injury with reduction and fixation of both fracture and syndesmosis. MAIN OUTCOME MEASUREMENT Rates of deep infection, nonunion, unplanned reoperation, and amputation in patients with a combined syndesmotic injury and tibial shaft or pilon fracture versus those without a syndesmotic injury. RESULTS A total of 30 patients, including 15 tibial shaft and 15 pilon fractures, were found to have associated syndesmotic injuries. The matched control group comprised 60 patients. The incidence of syndesmotic injury in all tibial shaft fractures was 2.3% and in all pilon fractures was 3.4%. The syndesmotic injury group had more neurologic injuries (23.3% vs. 8.3% P = 0.02), more vascular injuries not requiring repair (30% vs. 15%, P = 0.13), and a higher rate compartment syndrome (6.7% vs. 0%, P = 0.063). Segmental fibula fracture was significantly more common in patients with a syndesmotic injury (36.7% vs. 13.3%, P = 0.04). Fifty percent of the syndesmotic injury group underwent an unplanned reoperation with significantly more unplanned reoperations (50% vs. 27.5%, P = 0.04). The syndesmotic group had a significantly higher deep infection rate (26.7% vs. 8.3% P = 0.047) and higher rate of amputation (26.7% vs. 3.3% P = 0.002) while the nonunion rate was similar (17.4% vs. 16.7% P = 0.85). CONCLUSIONS Although syndesmotic injuries with tibial shaft or pilon fractures are rare, they are a marker of a potentially limb-threatening injury. Limbs with this combined injury are at increased risk of deep infection, unplanned reoperation, and amputation. The presence of a segmental fibula fracture should raise clinical suspicion to evaluate for syndesmotic injury. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
8
|
Lu Y, Yang J, Xu Y, Ma T, Li M, Ren C, Huang Q, Zhang C, Wang Q, Li Z, Zhang K. An Approach to Intraoperatively Identify the Coronal Plane Deformities of the Distal Tibia When Treating Tibial Fractures with Intramedullary Nail Fixation: a Retrospective Study. Orthop Surg 2021; 14:365-373. [PMID: 34964267 PMCID: PMC8867441 DOI: 10.1111/os.13194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 11/07/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022] Open
Abstract
Objective To develop a new approach to intraoperatively identify the presence of coronal plane deformities (both valgus and varus) when treating tibial fractures with closed reduction and intramedullary nail fixation. Methods A retrospective analysis was conducted by enrolling 33 consecutive patients with tibial fractures who received closed reduction and intramedullary nail fixation from January 2018 to January 2019 at our trauma center. Out of the 33 patients, 23 were males and 10 were females and the average age was 41 years (ranging 22 to 69 years of age). Standard anteroposterior and lateral preoperative radiographs were routinely performed. After intraoperatively inserting the tibial intramedullary nail through the standard entry point, the parallel relationship between the distal horizontal interlocking screw and the tibiotalar joint surface on the anteroposterior fluoroscopy was used to determine the occurrence of valgus or varus deformities of the distal tibial fragment. Radiographic and clinical outcomes were analyzed using the average interval from injury to surgery, the lateral distal tibial angle (LDTA) of the unaffected and affected sides, complications and the Olerud–Molander ankle score. Results All 33 patients were postoperatively followed for 13 to 25 months (mean 18.7 months). The fractures achieved bone union at an average of 4.3 months (ranging from 3 to 6 months). The total complication rate was 60.6% (20 cases), including four cases that showed deep vein thrombosis, one case showing an infection and delayed union and 15 cases showing slight to moderate anterior knee pain. The postoperative LDTA of the unaffected side measured 87.3° to 89.6 ° (average 88.7° ± 0.8°), and the LDTA of the affected side was 87.5° to 90.4° (average 88.9° ± 1.1°). There was no significant difference between the unaffected and affected sides (t = −1.865, P = 0.068). The intraoperative measurement indicated six cases of valgus angulation and three cases of varus angulation deformities, and all deformities were corrected during surgery. According to the Olerud–Molander ankle score, clinical outcomes demonstrated 22 excellent cases, eight good cases, two fair cases, and one poor case 12 months after surgery. Conclusion The parallel relationship between the distal horizontal interlocking screw and tibiotalar joint surface on intraoperative anteroposterior films were able to determine the onset of valgus or varus angulations of the distal tibial fragment in the fracture zone after the tibial intramedullary nail was inserted through the standard entry point.
Collapse
Affiliation(s)
- Yao Lu
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Jie Yang
- Department of Orthopedics Surgery II, Langfang People's Hospital, Langfang, China
| | - Yibo Xu
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Teng Ma
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Ming Li
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Cheng Ren
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Qiang Huang
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Congming Zhang
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Qian Wang
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Zhong Li
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Kun Zhang
- Department of Orthopedics Trauma, Honghui Hospital Affiliated to School of Medicine, Xi'an Jiaotong University, Xi'an, China
| |
Collapse
|
9
|
Liang H, Li L, Yang J, Du Y, Peng W. Treatment of open and comminuted mid-distal tibial fractures by bilateral external fixation combined with limited-internal fixation. Acta Orthop Belg 2021; 87:745-750. [PMID: 35172442 DOI: 10.52628/87.4.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Open and comminuted mid-distal fractures often result from high-energy trauma, and a concomitant poor blood supply often leads to skin necrosis, infection, and bone union. To circumvent such complications, we used limited-reduction and bilateral-external fixators to treat open and comminuted mid-distal tibial fractures with compromised soft tissue. A retrospective series of 34 patients who had open and comminuted mid-distal tibial fractures and treated by bilateral-external fixators with limited-internal fixation were analyzed. Patients were followed for 10-25 months (mean: 12 months) post-treatment and osseous union was achieved in each case. The average union time was 16.3 weeks. Based on the Johner- Wruhs criteria, the retrospective series consisted of 21 'excellent' cases, 8 'good' cases, 4 'fair' cases, and a 'poor' case. The total percentage of 'excellent' and 'good' cases of fracture recovery was 85.29%. Bilateral-external and limited-internal fixators pro- vided high bone union rate and excellent ankle-joint motion. Hence, it is an appropriate surgical approach for treating open and comminuted mid-distal tibial fractures with compromised soft tissue.
Collapse
|
10
|
Reduction techniques for intramedullary nailing of tibial shaft fractures: a comparative study. OTA Int 2021; 4:e095. [PMID: 33937718 PMCID: PMC8016605 DOI: 10.1097/oi9.0000000000000095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 10/14/2020] [Indexed: 12/04/2022]
Abstract
Objectives: To assess the impact of various reduction techniques on postoperative alignment following intramedullary nail (IMN) fixation of tibial shaft fractures. Design: Retrospective comparative study. Setting: Level I trauma center. Patients: Four hundred twenty-eight adult patients who underwent IMN fixation of a tibial shaft fracture between 2008 and 2017. Intervention: IMN fixation with use of one or more of the following reduction techniques: manual reduction, traveling traction, percutaneous clamps, provisional plating, or blocking screws. Main outcome measures: Immediate postoperative coronal and sagittal plane alignment, measured as deviation from anatomic axis (DFAA); coronal and sagittal plane malalignment (defined as DFAA >5° in either plane). Results: Four hundred twenty-eight patients met inclusion criteria. Manual reduction (MR) alone was used in 11% of fractures, and adjunctive reduction aids were used for the remaining 89%. After controlling for age, BMI, and fracture location, the use of traveling traction (TT) with or without percutaneous clamping (PC) resulted in significantly improved coronal plane alignment compared to MR alone (TT: 3.4°, TT+PC: 3.2°, MR: 4.5°, P = .007 and P = .01, respectively). Using TT+PC resulted in the lowest rate of coronal plane malalignment (13% vs 39% with MR alone, P = .01), and using any adjunctive reduction technique resulted in decreased malalignment rates compared to MR (24% vs 39%, P = .02). No difference was observed in sagittal plane alignment between reduction techniques. Intraclass correlation coefficient (ICC) results indicated excellent intraobserver reliability on both planes (both ICC>0.85), good inter-observer reliability in the coronal plane (ICC = 0.7), and poor inter-observer reliability in the sagittal plane (ICC = 0.05). Conclusions: The use of adjunctive reduction techniques during IMN fixation of tibia fractures is associated with a lower incidence of coronal plane malalignment when compared to manual reduction alone. Level of evidence: Therapeutic Level III.
Collapse
|
11
|
Tian R, Zheng F, Zhao W, Zhang Y, Yuan J, Zhang B, Li L. Prevalence and influencing factors of nonunion in patients with tibial fracture: systematic review and meta-analysis. J Orthop Surg Res 2020; 15:377. [PMID: 32883313 PMCID: PMC7469357 DOI: 10.1186/s13018-020-01904-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 08/20/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The aim of this study is to assess the prevalence of nonunion in patients with tibia fracture and the association between influencing factors and tibia fracture nonunion. METHOD A database searches of PubMed, the Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Weipu database, and Wanfang database from inception until June 2019 was conducted. The pooled prevalence, odds ratio (OR), and 95% confidence intervals (CI) were calculated with Stata software. RESULTS In this study, 111 studies involving 41,429 subjects were included. In the study of the relationship between influencing factors and tibia fracture nonunion, 15 factors significantly influenced the fracture union, including > 60 years old, male, tobacco smoker, body mass index > 40, diabetes, nonsteroidal anti-inflammatory drugs (NSAIDs) user, opioids user, fracture of middle and distal tibia, high-energy fracture, open fracture, Gustilo-Anderson grade IIIB or IIIC, Müller AO Classification of Fractures C, open reduction, fixation model, and infection. CONCLUSION The prevalence of nonunion in patients with tibia fracture was 0.068 and 15 potential factors were associated with the prevalence. Closed reduction and minimally invasive percutaneous plate osteosynthesis (MIPPO) have the low risks of nonunion for the treatment of tibial fractures.
Collapse
Affiliation(s)
- Ruifeng Tian
- Department of Orthopaedics, No.1 Hospital of China Medical University, Shenyang, China
| | - Fang Zheng
- Department of Orthopaedics, No.1 Hospital of China Medical University, Shenyang, China
- Department of Orthopaedics, Shenyang Orthopaedic Hospital, Shenyang, China
| | - Wei Zhao
- Department of Orthopaedics, No.1 Hospital of China Medical University, Shenyang, China
- Department of Orthopaedics, No.4 Hospital of China Medical University, Guangzhou, China
| | - Yuhui Zhang
- Department of Dermatology, No.1 Hospital of China Medical University, Guangzhou, China
| | - Jinping Yuan
- Department of Dermatology, No.1 Hospital of China Medical University, Guangzhou, China
| | - Bowen Zhang
- Department of Orthopaedics, No.1 Hospital of China Medical University, Shenyang, China
| | - Liangman Li
- Department of Orthopaedics, No.1 Hospital of China Medical University, Shenyang, China.
| |
Collapse
|
12
|
Hopf JC, Jähnig A, Jorg T, Westphal RS, Wagner D, Rommens PM. Computer tomographic analysis of anatomic characteristics of the ulna - essential parameters for preshaped implants. PLoS One 2020; 15:e0232988. [PMID: 32437353 PMCID: PMC7241821 DOI: 10.1371/journal.pone.0232988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/24/2020] [Indexed: 11/20/2022] Open
Abstract
Purpose Anatomically preshaped implants are needed for exact restoration of the anatomy after fractures of the proximal ulna and ulnar shaft, which enables a good functional outcome. Aim of this computed tomographic analysis was to identify specific characteristics of the ulna. The data serve for the development of a new intramedullary implant for stabilisation of proximal and diaphyseal ulna fractures. Methods With a standardized research method 100 CT scans of the ulna were evaluated regarding anatomic parameters like width of the medullary canal, proximal ulna dorsal angulation and varus angulation. Also, correlations of these parameters were analyzed statistically. Results The mean proximal ulna dorsal angulation (PUDA) was 6.4° (SD 2.8°), while the mean varus angulation of the proximal ulna was 12.4° (SD 3.3°). The length of the ulna bone was 253.6 mm (SD 19.9 mm) on average. The average minimum diameter of the medullary canal was 4.2 mm (SD 1.1 mm) located at 141.3 mm (SD 19.7 mm) from the olecranon tip. There is a positive correlation between age and minimum diameter in our patient cohort (p< 0.001). Conclusion Our study described the anatomy of the proximal ulna and the ulna shaft with a reproducible research method in a representative patient cohort. The knowledge of the evaluated anatomic parameters can lead to an improvement of any implant design for the fixation of proximal and diaphyseal ulna fractures.
Collapse
Affiliation(s)
- Johannes Christof Hopf
- Department of Orthopedics and Traumatology, University Medical Center, Mainz, Rhineland-Palatinate, Germany
- * E-mail:
| | - Andreas Jähnig
- Department of Orthopedics and Traumatology, University Medical Center, Mainz, Rhineland-Palatinate, Germany
| | - Tobias Jorg
- Department of Radiology, University Medical Center, Mainz, Rhineland-Palatinate, Germany
| | - Ruben Sebastian Westphal
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Mainz, Rhineland-Palatinate, Germany
| | - Daniel Wagner
- Department of Orthopedics and Traumatology, University Medical Center, Mainz, Rhineland-Palatinate, Germany
| | - Pol Maria Rommens
- Department of Orthopedics and Traumatology, University Medical Center, Mainz, Rhineland-Palatinate, Germany
| |
Collapse
|
13
|
Compton J, Wynn M, Willey MC, Sekar P. Escherichia hermannii as the sole cause of osteomyelitis in a patient with an open tibial shaft fracture. BMJ Case Rep 2019; 12:12/11/e231206. [PMID: 31776149 DOI: 10.1136/bcr-2019-231206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Escherichia hermannii is a rare monomicrobial cause of infection in humans. E. hermannii has never before been reported as the sole isolate from an infected open tibia fracture. We present a case of E. hermannii infection after a type III open tibia fracture. The patient was initially treated with irrigation and debridement, open reduction internal fixation and primary wound closure. However, after 8 weeks, he developed a draining wound and infection at the fracture site. He required a repeat debridement, hardware removal, external fixation and 6 weeks of intravenous ceftriaxone for treatment. At 2-year follow-up, he remains infection free, asymptomatic and continues to work with excellent functional outcomes. This case adds to the growing literature that evidences E. hermannii as an organism that can be pathogenic, virulent and cause monomicrobial infection.
Collapse
Affiliation(s)
- Jocelyn Compton
- Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Malynda Wynn
- Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Michael C Willey
- Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Poorani Sekar
- Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| |
Collapse
|
14
|
Intramedullary nailing in opening wedge high tibial osteotomy-in vitro test for validation of a method of fixation. INTERNATIONAL ORTHOPAEDICS 2018; 42:1835-1843. [PMID: 29392383 DOI: 10.1007/s00264-018-3790-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/18/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE Opening wedge high tibial osteotomy (HTO) as a treatment in unicompartimental osteoarthritis of the knee can significantly relieve pain and prevent or at least delay an early joint replacement. The fixation of the osteotomy has undergone development and refinements during the last years. The angle-stable plate fixator is currently one of the most commonly used plates in HTOs. The angular stable fixation between screws and the plate offers a high primary stability to retain the correction with early weight-bearing protocols. This surgical technique is performed as a standard of care and generally well tolerated by the patients. Nevertheless, some studies observed that many patients complained about discomfort related to the implant. METHODS Therefore, the stability of two different intramedullary nails, a short implant used in humeral fractures and a long device used in tibial fractures for stabilization in valgus HTOs, was investigated as an alternative fixation technique. The plate fixator was defined as reference standard. Nine synthetic tibia models were standardly osteotomized and stabilized by one of the fixation devices. Axial compression was realized using a special testing machine and two protocols were performed: a multi-step fatigue test and a load-to-failure test. RESULTS Overall motion, medial, and lateral displacements were documented. Fractures always occurred at the lateral cortex. Axial cyclic loading up to 800 N was tolerated by all implants without failure. The tibia nail provided highest fatigue strength under the load-to-failure conditions. CONCLUSIONS The results suggest that intramedullary nailing might be used as an alternative concept in HTO.
Collapse
|
15
|
Soft tissue complications in distal tibial fractures managed with medial locking plates: A myth or reality? J Clin Orthop Trauma 2017; 8:S90-S95. [PMID: 29158651 PMCID: PMC5681229 DOI: 10.1016/j.jcot.2017.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 06/24/2017] [Accepted: 07/01/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Distal tibial fractures are common injuries that are prone to complications and require careful management. The use of medial periarticular locking plates is an established modality in the treatment if these fractures. These plates are inserted using the minimally invasive plate osteosynthesis (MIPO) or open technique. Our study looks at the soft tissue complications associated with the use of medial locking plates in the management of these fractures. METHODS This was a retrospective study carried out at a tertiary care university hospital in an urban setting. Forty four patients with distal tibia fractures treated with periarticular locking plates during a three year period were included in the study. Both closed and open fractures were included while those with an established non-union were excluded. Patient data related to inpatient stay, outpatient visits as well as readmissions was extracted from hospital records and analysed. Spanning external fixation was done if necessary and definitive fixation was done using medial locking plates with either MIPO technique or open reduction and internal fixation (ORIF) with biological technique. The sub cohort of patients with soft tissue complications was compared to the parent group. RESULTS The study group included 44 patients (28M:16F) with 45 fractures with a median age of 42.6 years (range 18-65 years) followed up for a mean of 9.2 months (range 5-20 months). Domestic falls were the cause of injury in 61.4% (n = 27) of the fractures. The average time to union was 26.2 weeks (range 12-66 weeks). Out of these 45 fractures, soft tissue complications were seen in 22.2% of cases (n = 10) with road side accidents seen in 60% (n = 6) of cases. In four patients, there was difficulty in achieving primary wound closure and in five other cases wound dehiscence with exposure of implant was seen within 12 to 30 days of surgery. One patient required secondary suturing after readjustment for malreduction. No statistically significant difference was found in the parent cohort and the sub cohort with soft tissue complications with respect to the use of spanning external fixator, MIPO/ORIF technique or fibular fixation. CONCLUSION The incidence of soft tissue complications with the use of medial locking plates in distal tibial fractures may be more than what is currently reported in literature and further studies are required to shed more light on this subject.
Collapse
|
16
|
Liu X, Cen S, Xiang Z, Zhong G, Yi M, Fang Y, Liu L, Huang F. [Safety evaluation of secondary conversion from external fixation to internal fixation for open tibia fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2017; 31:665-669. [PMID: 29798646 DOI: 10.7507/1002-1892.201611127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective To evaluate the safety of conversion from external fixation to internal fixation for open tibia fractures. Methods Between January 2010 and December 2014, 94 patients (98 limbs) with open tibia fractures were initially treated with external fixators at the first stage, and the clinical data were retrospectively analyzed. In 29 cases (31 limbs), the external fixators were changed to internal fixation for discomfort, pin tract response, Schantz pin loosening, delayed union or non-union after complete wound healing and normal or close to normal levels of erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and the leucocyte count as well as the neutrophil ratio (trial group); in 65 cases (67 limbs), the external fixators were used as the ultimate treatment in the control group. There was no significant difference in gender, age, side of the limbs, interval from injury to the first debridement, initial pathogenic bacteria, the limbs that skin grafting or flap transferring for skin and soft tissue defect between the two groups ( P>0.05). The incidence of Gustilo type III fractures in the control group was significantly higher than that in the trial group ( P=0.000). The overall incidence of infection was calculated respectively in the two groups. The incidence of infection according to different fracture types and whether skin grafting or flap transferring was compared between the two groups. The information of the pathogenic bacteria was recorded in the infected patients, and it was compared with the results of the initial culture. The incidence of infection in the patients of the trial group using different internal fixation instruments was recorded. Results The overall incidences of infection for the trial and control groups were 9.7% (3/31) and 9.0% (6/67) respectively, showing no significant difference ( χ2=0.013, P=0.909). No infection occurred in Gustilo type I and type II patients. The incidence of infection for Gustilo type IIIA patients in the trial group and the control group were 14.3% (1/7) and 6.3% (2/32) respectively, showing no significant difference ( χ2=0.509, P=0.476); the incidence of infection for type IIIB patients in the two groups were 50.0% (2/4) and 14.3% (2/14) respectively, showing no significant difference ( χ2=2.168, P=0.141); and the incidence of infection for type IIIC patients in the two groups were 0 and 16.7% (2/12) respectively, showing no significant difference ( χ2=0.361, P=0.548). Of all the infected limbs, only 1 limb in the trial group had the same Staphylococcus Aureus as the result of the initial culture. In the patients who underwent skin grafting or flap transferring, the incidence of infection in the trial and control groups were 33.3% (2/6) and 13.3% (2/15) respectively, showing no significant difference ( χ2=1.059, P=0.303). After conversion to internal fixation, no infection occurred in the cases that fixed with nails (11 limbs), and infection occurred in 4 of 20 limbs that fixed with plates, with an incidence of infection of 20%. Conclusion Conversion from external fixation to internal fixation for open tibia fractures is safe in most cases. However, for open tibia fractures with extensive and severe soft tissue injury, especially Gustilo type III patients who achieved wound heal after flap transfer or skin grafting, the choice of secondary conversion to internal fixation should carried out cautiously. Careful pre-operative evaluation of soft tissue status, cautious choice of fixation instrument and meticulous intra-operative soft tissue protection are essential for its safety.
Collapse
Affiliation(s)
- Xi Liu
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Shiqiang Cen
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
| | - Zhou Xiang
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Gang Zhong
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Min Yi
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yue Fang
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Lei Liu
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Fuguo Huang
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| |
Collapse
|
17
|
Ebraheim NA, Evans B, Liu X, Tanios M, Gillette M, Liu J. Comparison of intramedullary nail, plate, and external fixation in the treatment of distal tibia nonunions. INTERNATIONAL ORTHOPAEDICS 2017; 41:1925-1934. [PMID: 28246951 DOI: 10.1007/s00264-017-3432-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 02/14/2017] [Indexed: 12/20/2022]
Abstract
PURPOSE The purpose of this study was to examine time to union of extra-articular distal tibia nonunions based on fracture type and fixation methods: intramedullary nail (IMN), plate osteosynthesis (PO), and external fixation (EF). METHODS This retrospective chart review included all patients who presented at a Level I trauma center with AO/OTA 43A & distal third 42A-C fracture nonunions between 2008 and 2014. Fixation methods were recorded and patient course was followed until nonunion had healed clinically. RESULTS Thirty-three distal tibia nonunions were included, and 29 reached eventual union (88%). Five AO/OTA fracture types were present. Mean times to union from nonunion diagnosis between original fracture types were compared (p = 0.203). Comminuted fracture types had longer times to union from nonunion diagnosis compared to simple fracture types (78 vs. 46 weeks, p = 0.051) and more revision fixations (1.5 vs. 0.5, p = 0.037). Mean time to union from nonunion diagnosis was shorter when no revision fixation was done compared to revisions (15 vs. 42 weeks, p = 0.102). Times to union from nonunion diagnosis without revision fixation were: IMN (12 weeks), PO (27 weeks), and EF (13 weeks) (p = 0.202). Times to union from definitive revision fixation were: IMN (17 weeks), PO (21 weeks), and EF (66 weeks) (p = 0.009), with EF taking significantly longer than both other methods. 21 patients (64%) underwent revision fixation. Revision fail rates were: IMN (0/6, 0%), PO (2/8, 25%), and EF (15/21, 71%). Time to union was longer in revisions that changed fixation method compared to revisions that used the same method (51 vs. 18 weeks, p = 0.030). Deep infections were also associated with longer union times (81 vs. 47 weeks, p = 0.040). CONCLUSIONS In this nonunion population, comminuted fracture types needed more time and revisions to reach union. Time to union was only clinically shorter when revision fixation was not performed, but IMN and PO were both successful fixation options with significantly shorter times to union than EF. Mean time to union increased even more when revision of fixation method was performed vs. exchange revision, as did nonunions with deep infections.
Collapse
Affiliation(s)
| | | | | | | | | | - Jiayong Liu
- Department of Orthopaedic Surgery, University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH, 43614, USA.
| |
Collapse
|
18
|
Current Evidence: Plate Versus Intramedullary Nail for Fixation of Distal Tibia Fractures in 2016. J Orthop Trauma 2016; 30 Suppl 4:S2-S6. [PMID: 27768625 DOI: 10.1097/bot.0000000000000692] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Displaced distal tibia shaft fractures are effectively treated with standard plates and intramedullary nails. Plate fixation performed with meticulous soft tissue handling results in minimal risks of infection and poor wound healing. Standard plates have high rates of primary union, whereas locking plates may delay union because of increased stiffness. Tibial healing may also be delayed after plating of the fibula, although fibula reduction and fixation may aid accuracy of reduction of the tibia. Malalignment occurs more often with infrapatellar intramedullary nailing versus plates, and early results of suprapatellar nailing appear promising in minimizing intraoperative malalignment. Long-term function after fixation of the distal tibia is good for most, with poor outcomes often associated with baseline social and mental health issues.
Collapse
|
19
|
Abstract
OBJECTIVES To report on the immediate postoperative alignment of distal tibia fractures (within 5 cm of the tibial plafond) treated with suprapatellar intramedullary nail (IMN) insertion compared with the infrapatellar technique. Primary outcomes include alignment on both the anteroposterior and lateral radiographic views. DESIGN Retrospective cohort study. SETTING Two urban level I trauma centers. PATIENTS A total of 266 skeletally mature patients with a distal tibia fracture were treated with an IMN. One hundred thirty-two patients underwent this procedure through a suprapatellar technique. INTERVENTION Intramedullary nail placement. MAIN OUTCOME MEASURES Alignment. RESULTS The 2 treatment groups were evenly matched with respect to age, gender, fracture grade, and the presence of open fracture. Within the suprapatellar group, the fibula was intact, fixed, and remained fractured in 6 (4.5%), 22 (16.7%), and 104 (78.8%) cases, respectively. The fibula was intact, repaired, and remained fractured in 9 (6.7%), 32 (23.9%), and 93 (69.4%) cases, respectively, in the infrapatellar group. There was no difference in the rate of fibular fixation between the groups (P = 0.2). Primary angular malalignment of ≥5 degrees occurred in 35 (26.1%) patients with infrapatellar IMN insertion and in 5 (3.8%) patients who underwent suprapatellar IMN insertion (P < 0.0001). CONCLUSIONS This is the largest patient series directly comparing the suprapatellar with infrapatellar IMN insertion technique in the treatment of distal tibia fractures. In the treatment of distal tibia fractures, suprapatellar IMN technique results in a significantly lower rate of malalignment compared with the infrapatellar IMN technique. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
20
|
Dodd AC, Salib CG, Lakomkin N, Obremskey WT, Sethi MK. Increased risk of adverse events in management of femur and tibial shaft fractures with plating: An analysis of NSQIP data. J Clin Orthop Trauma 2016; 7:80-5. [PMID: 27182143 PMCID: PMC4857162 DOI: 10.1016/j.jcot.2016.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 01/10/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND The management of femoral and tibial shaft fractures has long been among the simplest in orthopaedic trauma. Little data exist on the predictors of complications associated with these fractures. The evolving healthcare system is creating a focus on quality metrics and changing payment models. It is critical that traumatologists develop a better understanding of complication rates associated with these injuries so that they may continue to improve patient care while also reducing overall medical costs. METHODS Using the ACS-NSQIP database, we evaluated patient demographics, comorbidities and 30-day complications of femoral and tibial fractures. A bivariate analysis was then used to compare rates of minor and major post-operative complications within 30 days. A multivariate logistic regression was performed, assessing the odds of developing a minor and/or major complication up to 30 days post-surgery. RESULTS 2891 patients were identified. For femoral fractures, intramedullary nailing (IMN) demonstrated an overall complication rate of 14.9% (n = 151) whereas open reduction and internal fixation (ORIF) with plating showed an overall complication rate of 15.6% (n = 70). Patients undergoing plating of the femur or tibia were 2 times more likely than the IMN patients to demonstrate postoperative complications. CONCLUSION Our study is the first to demonstrate that plating of femoral and tibial fractures doubles the odds of developing a complication. As our healthcare system shifts to bundled payment plans, it is impertinent for the orthopaedic surgeon to understand the risk factors associated with fracture treatments in order to assess the best treatment plan.
Collapse
Affiliation(s)
| | | | | | | | - Manish K. Sethi
- Corresponding author. Tel.: +1 615 936 0112; fax: +1 615 936 2667.
| |
Collapse
|
21
|
Breer S, Auerswald M, Fuchs S, Jürgens C, Faschingbauer M, Dannenberg O. Versorgung von Pseudarthrosen der langen Röhrenknochen. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s10039-015-0100-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|