The impact of the third fragment features on the healing of femoral shaft fractures managed with intramedullary nailing: a radiological study

Radiographic outcomes and non-union factor analysis in fragmentary segmental femoral shaft fractures (AO/OTA 32C3) treated with reamed antegrade nailing

This study retrospectively assessed radiographic outcomes and risk factors associated with non-union in femoral shaft fragmentary segmental fractures (AO/OTA 32C3) treated with reamed antegrade intra-medullary nailing. Radiological outcomes, including union and alignment, were evaluated. The risk factors for non-union were investigated, including demographics and treatment-related characteristics, such as the number of interlocking screws, segmentation length, main third fragment length, distance of the main third fragment, width ratio and exposed nail length in one cortex from immediate post-operative radiographs. Multivariate logistic regression was used for statistical analysis. Among 2295 femoral shaft fracture patients from three level-1 trauma centers, 51 met the inclusion criteria. The radiological union was achieved in 37 patients (73%) with a mean union time of 10.7 ± 4.8 months. The acceptable axial alignment was observed in 30 patients (59%). Multiple logistic regression analysis identified only exposed nail length as a significant risk factor for non-union (odds ratio: 1.599, p = 0.003) and the cut-off value was 19.1 mm (sensitivity, 0.786; specificity, 0.811). The study revealed high rates of non-union (27%) and malalignment (41%). Therefore, patients who underwent intramedullary nailing with an exposed nail length greater than 19.1 mm or about twice the nail diameter should be cautioned of the potential non-union.

"Fragment Width Ratio" as a Predictor of Nonunion for Femoral Shaft Fracture With Third Fragments

Previous studies have reported that large fracture fragment with displacement might cause nonunion of femoral shaft fractures. We therefore intended to delineate significant risk factors for developing a nonunion predisposed by a major fracture fragment. We analyzed 61 patients who were operated on using interlocking nails for femoral shaft fractures from 2009 to 2018. We classified patients with modified Radiographic Union Scale for Tibia fractures scores of less than 11 or needing reoperations by 1 year postoperatively as nonunion. We thereafter measured parameters of the displaced fracture fragment and fracture site to identify the significant difference between the union and non-union groups. We also applied the receiver operating characteristic curve to demonstrate a threshold value for the fragment width (FW) ratio. Among 61 patients with complete follow-up, no significant difference was found regarding length, displacement, and angulation of fragments between patients with and without union. Except for higher mean FW (P=.03) and the FW ratio (P=.01) in patients with nonunion, the logistic regression analysis demonstrated that FW ratio significantly affected union (P=.018; odds ratio, 0.21; 95% CI, 0.001-0.522). Although a fracture fragment greater than 4 cm with displacement greater than 2 cm was reported to significantly cause nonunions, our study showed that an FW ratio greater than 0.55 instead of fragment size or displacement was predictive for the occurrence of nonunion adjoining to the fracture site. Fixation of the third fracture fragment should not be ignored for preventing a nonunion. More attention should be paid to achieve a better fixation for a major fracture fragment with an FW ratio greater than 0.55 to avoid the development of non-union following the use of interlocking nail for femoral shaft fracture. [Orthopedics. 202x;xx(x):xx-xx.].

Concomitant intramedullary nailing and plate augmentation as a single-stage procedure in treating complicated nonunited femoral shaft fractures

Background and Purpose:

Complicated femur fracture represents a major challenge for the orthopedic surgeon, with failed internal fixation, nonunion with broken intramedullary nail (IMN), and infected nonunion among the complications. Mechanical instability, as well as the poor biological environment, is considered as a concern when treating these cases. The purpose of this study was to evaluate concomitant IMN and plate augmentation as a single-stage procedure for the management of multiply operated nonunited femoral shaft fractures.

Materials and Methods:

Between January 2015 and May 2018, nine patients (eight men) with an average age of 40.8 years (range 25–70) diagnosed as nonunion femoral fractures after an average of four previous surgeries (range 2–6). All patients were available for follow-up with an average of 22 months (range 12–36).

Results:

The average time for fracture union was 6.7 months (range 3–12); five patients needed bone grafting to compensate for the bone defect encountered during the initial procedure, and two patients required secondary bone grafting after 6 months follow-up. Two patients presented with surgical site infection which was treated by antibiotics and daily dressing. The average leg length discrepancy at last follow-up was 1 cm (range 0.5–1.5). No patient had a metalwork failure or needed removal of the implants.

Conclusion:

In treating complicated multiply operated nonunited femoral shaft fractures, we believe that this technique can provide a robust mechanical foundation as well as an improved biological environment for such nonunited fractures to heal.

Effect of the degree of displacement of the third fragment on healing of femoral shaft fracture treated by intramedullary nailing

Objective

To investigate the effect of the degree of displacement of a femoral shaft fracture with the third fragment on fracture healing after intramedullary nailing.

Methods

In total, 216 patients with closed comminuted femoral fracture admitted to Lianyungang Hospital affiliated to Xuzhou Medical University from February 2010 to February 2016 were analyzed retrospectively. Among these patients, 142 were males and 74 were females, the mean age was 38 years (range 17–64 years), and 95 cases were on the right, while 121 cases were on the left. All patients were treated with a femoral interlocking intramedullary nail. Referring to the femoral shaft diameter, the degree of displacement of the third fragment was classified into four grades: grade I (displacement was less than a third of the diameter of the shaft): 121 cases; grade II (greater than a third of the diameter and less than two thirds): 52 cases; grade III (greater than two thirds of the diameter): 28 cases; and grade IV (fracture fragment turnover): 15 cases. According to the modified Radiological Union Scale for Femur (mRUSF), the fracture union rate and the mean union time of the fracture, the effect of the degree of displacement of the third fragment on fracture healing was evaluated.

Results

In total, 216 patients with a mean follow-up of 15.9 months (range 6–31 months) met the inclusion criteria. The best fracture healing was the grade I displacement, with a union rate of 89.2% and a mean union time of 7.7 months. The poorest fracture healing was for the grade IV displacement, with a union rate of 13.3% and a mean union time of 16.5 months. The healing was moderate in the grade II and III displacements, with a union rate of 46.2% and 28.6%, respectively, and a mean union time of 8.6 months and 13.5 months, respectively (P < 0.05).

Conclusions

The third fragment with grade I displacement requires no intervention, whereas fractures with grade IV displacement should be reduced to as near as possible to the diaphyseal bone defect to avoid nonunion. The third fragments with the grade II or III displacement should be treated with closed reduction whenever possible to achieve a displacement within the range of grade I to minimize the incidence of nonunion.

Minimally invasive plate osteosynthesis without floating segment fixation for segmental fracture of femur

Segmental fractures of the femur are technically difficult to manage by intramedullary nailing, the gold standard treatment. We specifically describe minimally invasive plate osteosynthesis (MIPO) without floating segment fixation for this particular fracture pattern. Twenty patients with segmental fractures of the femur were operated on by the MIPO technique. Data were collected on operative time, postoperative complications, union times, and clinical outcomes. The mean operative time was 63.5 minutes (range 50-90). There were no peri-operative complications. All fractures were united with a mean union time of 16.1 weeks (range 12-20). Regarding postoperative malalignment, limb shortening was demonstrated in 4 patients, valgus angulation in 2 and varus angulation in 3. One patient had a bent plate with 7°varus angulation. According to the Thoresen score, 13 were determined to be excellent values, 6 to be good and 1 to be fair. MIPO without floating segment fixation is a safe and effective alternative for segmental fractures of the femur especially in circumstances that are unsuitable or unfeasible for intramedullary nailing.

Bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo as a guide to removing a monolateral external fixator safely

Purpose

As the monolateral external fixator is increasingly used in trauma-control and definitive management for high-energy long bone fractures, timing the fixator removal remains a challenge for surgeons. The purpose of this study was to determine the feasibility and effectiveness of the bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo as a guide to removing a monolateral external fixator safely.

Methods

A total of 131 patients with tibial shaft fractures treated by the monolateral external fixator in our institution were collected from January 2013 to July 2019. In group I, the fixators were removed based on the clinical and radiological assessment only by the treating surgeon. As for group II, the axial load-share (LS) ratio test was accomplished by another medical team without the knowledge of the clinical results. The external fixator was removed when the mechanical test outcome (LS ratio < 10%) was consistent with the conclusion drawn from the clinical and radiological assessment (bone union achieved) by the treating surgeon.

Results

There was no statistical significance in demographic data between the two groups (P > 0.05). In group I, four patients suffered refracture (the refracture rate was 7.7%) after fixator removal and were successfully treated by an intramedullary nail. In group II, 71 patients underwent fixator removal after the first mechanical test, and another eight patients terminated the external fixation after the second test. None of the 79 patients in group II suffered refracture (the refracture rate was 0%). There was statistical significance in the refracture rate between the two groups (P < 0.05).

Conclusion

The bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo using the additional circular frame components is an effectively quantitative indicator to complement the clinical assessment of fracture healing in a monolateral external fixation treatment. Removal of the monolateral external fixator is safe when the axial load-share ratio dropped below 10%.

Internal fixation of acetabular quadrilateral plate fractures in elderly patients: Could the fracture reduction quality affect their functional recovery?

Background

Osteoporotic acetabular fractures frequently involve the quadrilateral plate (QP), a flat and thin bone constituting the medial wall of the acetabulum. This study aims to assess the impact of the quality of osteoporotic QP fractures reduction on the patients’ functional recovery, at 24 months follow-up.

Methods

Patients referring with osteoporotic QP fractures to our Level I trauma centre were prospectively recruited. Inclusion criteria: patients aged 60 years old or older; osteoporosis, defined as Dual-energy X-ray Absorptiometry (DXA) T-score ≤ − 2.5; acute acetabular fracture; anatomic or good fracture reduction according to Matta on postoperative CT. Exclusion criteria: moderate cognitive impairment (defined as Mini-Mental State Examination < 19); a history of malignant neoplasm; concomitant fractures in other sites; traumatic head injury; lower limb joint prostheses; patient not able to walk independently before trauma; poor fracture reduction, according to Matta, on postoperative CT. All the QP fractures were surgically managed. After surgery, the reduction of each QP fracture was classified as anatomical (displacement 0–1 mm), good (displacement 2–3 mm) and poor (displacement > 3 mm) on postoperative CT. Based on this classification: patients with a poor fracture reduction were excluded from this study, patients with an anatomical reduction were recruited in Group-A and patients with a good reduction in Group-B. All the patients underwent a clinical and radiographic 24-months follow-up.

Results

68 patients (males 38; females 30; mean age 68.6 years old; range 60–79) were finally included in in the study. No cases of open fractures or concomitant pelvic ring fractures were observed. Based on the post-operative CT, 39 patients showed an anatomic fracture reduction (Group-A) while the remaining 29 patients revealed a good fracture reduction (Group-B). Complication rates and mean clinical scores showed no significant differences between groups, at 24-months follow-up.

Conclusions

In this study, the functional recovery at 24 months follow-up showed no significant differences in elderly patients with QP fracture undergoing anatomical reconstruction (displacement 0–1 mm) compared to patients receiving a good QP fracture reconstruction (displacement ≤ 3 mm).

The flipped third fragment in femoral shaft fractures: A reason for open reduction?

OBJECTIVES

First introduced by Kuntscher in the 1940s, closed intramedullary nailing of femoral shaft fractures has become the standard of care, with reported union rates up to 99% in some series. However, fractures with large intercalary segments, which are present in 10-34% of femoral shaft fractures, present unique challenges. In particular, how to treat flipped intercalary segments has remained controversial, with some advocating open reduction of these fractures. The purpose of this study was to evaluate the union rates of femoral shaft fractures with flipped intercalary segments treated with closed reduction and intramedullary nail fixation.

METHODS

A retrospective review of patients with femoral shaft fractures and flipped intercalary segments from January 2000 until January 2018 was performed at a single academic level one tertiary care referral center. All patients between the ages of 16-80 with minimum 6-month follow-up were included. Union rates were evaluated using the radiographic union score of the femur (RUSF). Patients with non-diaphyseal femur fractures, pathologic fractures, incomplete radiographic or clinical follow-up, or open reduction at the time of initial surgery were excluded.

RESULTS

Twenty-six patients (18 male and 8 female) with a mean age of 32 years (SD 12.8, range 19-65 years) and mean follow-up of 15.9 months (range, 6-82 months) met inclusion criteria. Seven patients had open fractures. The mean size of the flipped intercalary segments was 71.3 mm (range: 30-174 mm), with mean displacement of 6.6 mm (range: 1-37 mm). The mean radiographic union scale in femoral (RUSF) at 6 months was 9 (standard deviation: 1.35). There were two patients who went on to non-union. The overall union rate was 92% (24 patients); the non-union rate was 8% (2 patients).

CONCLUSIONS

Though uncommon, femoral shaft fractures with flipped intercalary segments present unique challenges to surgical treatment. While previous studies have found the presence of large intercalary segments to be associated with higher rates of non-union, the results of this study challenge prior evidence. In conclusion, the presence of flipped intercalary segments may not require different surgical management than the treatment of conventional femoral shaft fractures.

LEVEL OF EVIDENCE

IV.

Hip hemiarthroplasty with modular neck: is it useful in residents' learning curve? A prospective clinical trial

BACKGROUND

The number of femoral neck fractures (FNFs) worldwide will drastically increase in the next few decades, reaching 6.3 million by 2050. In the future, therefore, newly-qualified orthopaedic surgeons will treat this kind of injury more frequently than in past decades. This prospective observational study aims to assess whether hip hemiarthroplasty with modular neck, performed via the Hardinge approach, can be safely carried out by orthopaedic residents.

METHODS

Patients referred to our Level I trauma centre, between January 2016 and June 2017, with displaced intra-articular femoral fractures, were prospectively recruited. All patients underwent cemented modular bipolar hip hemiarthroplasty (Profemur Z, MicroPort Orthopedics Inc., Arlington, TN, USA) via the Hardinge approach, with the patient positioned in lateral decubitus. The surgical procedures were performed by the same surgical and anesthesiology team, under spinal anaesthesia. All patients underwent clinical and radiographic follow-up up to 24 months. Complications and re-operations were recorded. Clinical evaluation was performed using the Harris Hip Score (HHS), Osteoporosis Quality of Life Questionnaire QUALEFFO-41 and EuroQol-5D (EQ-5D) questionnaire. Anteroposterior pelvis x-rays were performed preoperatively, postoperatively and at 1, 3, 6, 12 and 24 months follow-up.

RESULTS

118 patients met the inclusion criteria (male: 50; female: 68; mean age: 74.3 years; range 65-88 years) and were included in the current study. 67 patients out of 118 (56.8%) were managed by senior orthopaedic surgeons (Group A), whereas the remaining 51 patients out of 118 (43.2%) were treated by orthopaedic residents (Group B). Hip hemiarthroplasties performed by senior surgeons showed the prevalent use of straight (short or long) necks, whereas, in surgical procedures performed by residents, there was a significantly higher use of varus/valgus, anteverted or retroverted necks. The overall complication rate was significantly higher in Group-B patients, compared with Group-A patients (p = 0.002). The length of hospital stay and the mean clinical scores at 24 months follow-up showed no significant differences.

CONCLUSIONS

Hip hemiarthroplasty with modular neck can be safely employed during the learning curve of orthopaedic residents. Great efforts, however, should be made in future to improve residents' training in the management of FNFs.

Periprosthetic femoral re-fractures pathogenesis, classification, and surgical implications

Periprosthetic femoral re-fractures (PFRFs) represent an emerging challenge for orthopaedic surgeons, since their incidence is growing in the last years, but very few experiences about their management have been currently published. The present study aims to (1) introduce, for the first time, an etiologic classification for PRFRs and (2) to provide surgical and pharmacological tips for the correct management of these injuries. Periprosthetic femoral re-fractures (PFRFs) could be classified into traumatic-PFRFs (T-PFRFs) and pathological-PFRFs (P-PFRFs). T-PFRFs, i.e. the "true" periprosthetic re-fractures, present as new fracture lines occurring proximally or distally to a previous periprosthetic fracture, that has correctly healed. They are generally unpredictable injuries but, in selected cases, it is possible to predict them by analyzing the construct used in the treatment of the previous periprosthetic fracture. P-PFRFs, on the other hand, define re-fractures occurring on a previous periprosthetic non-union or delayed union: the new fracture line appears in the same district of the old one. According to the etiologic factors influencing the P-PFRFs pathogenesis, it is possible to define re-fractures caused by mechanical failures, biological failures, septic failures and multifactorial failures, i.e., a combination of the previously mentioned concerns. A successful postoperative outcome, following the surgical management of PFRFs, requires the correct identification of all the underlying causes, which should be promptly and appropriately managed.

Assessment of fracture healing in orthopaedic trauma

Fracture healing is a complex physiologic process, relying on the crucial interplay between biological and mechanical factors. It is generally assessed using imaging modalities, including conventional radiology, CT, MRI and ultrasound (US), based on the fracture and patient features. Although these techniques are routinely used in orthopaedic clinical practice, unfortunately, they do not provide any information about the biomechanical status of the fracture site. Therefore, in recent years, several non-invasive techniques have been proposed to assess bone healing using ultrasonic wave propagation, changes in electrical properties of bones and callus stiffness measurement. Moreover, different research groups are currently developing smart orthopaedic implants (plates, intramedullary nails and external fixators), able to provide information about the fracture healing process. These devices could significantly improve orthopaedic and trauma clinical practice in the future and, at the same time, reduce patients' exposure to X-rays. This study aims to define the role of traditional imaging techniques and emerging technologies in the assessment of the fracture healing process.

Development of the Italian fractures registry (RIFra): A call for action to improve quality and safety

In recent years, there has been an increasing interest in the development of arthroplasty registries, therefore, in our country, the Italian Arthroplasty Registry (RIAP), was issued by the National Law No. 221/2012. In the last decade, however, some European countries -namely Sweden, Denmark, Norway, and Germany (in development)- have introduced another nationwide orthopaedic registry than arthroplasty registers: the fracture registry. The development of this new tool aims to improve quality and safety in fracture management, thus trying to provide a better postoperative quality of life in trauma patients. Based on these findings, the AO-Trauma Italy Council encouraged the development of a national fracture registry in Italy. The present study aims to (1) provide an overview of the fracture registries in Europe and (2) to develop, for the first time, a pilot Italian Fracture Registry (RIFra). Thirteen AO-Trauma Italy members, chairmen of Level-I orthopaedic and trauma centres, diffused throughout Italy, were involved in the RIFra project. The RIFra form, developed between November 2019 and March 2020, consists of 5 main sections, namely: epidemiologic data, previous surgical procedure (if any), patient and fracture features, surgical procedure, surgical implant details. This study constitutes the first step to start, in future years, the bureaucratic procedure leading to the final establishment of a RIAP-like fracture registry in Italy.

[Application of "diamond concept" in treatment of femoral shaft fractures nonunion after intramedullary fixation]

Objective

To investigate the effectiveness of the treatment under the guidance of "diamond concept" for femoral shaft fractures nonunion after intramedullary fixation.

Methods

Between January 2014 and December 2016, 21 cases of femoral shaft fractures nonunion after intramedullary fixation were treated with auxiliary plate fixation combined with autogenous iliac graft, and autologous bone marrow concentrate and platelet-rich plasma (PRP) gel under the guidance of the "diamond concept". There were 13 males and 8 females, with an average age of 32.5 years (range, 17-48 years). All fractures were closed femoral shaft fractures. Four patients underwent internal fixation with plate and resulted in nonunion, then they were fixed with intramedullary nails, but did not heal either. The rest 17 patients were fixed with intramedullary nailing. Fracture nonunion classification: 4 cases of hypertrophic nonunion, 17 cases of atrophic nonunion; the length of bone defect was 1-3 mm; the duration from the last treatment to the current treatment was 10-23 months (mean, 14.3 months). The operation time, intraoperative blood loss, the time between operation and full loading, fracture healing time, and complications were recorded. The visual analogue scale (VAS) score and the imaging system of fracture healing of the extremities (RUST) of patients before operation and at last follow-up were recorded to evaluate the fracture healing; the function of the affected limb was evaluated according to the Schatzker-Lambert efficacy score standard at last follow-up.

Results

The operation time was 105-160 minutes, with an average of 125.6 minutes; the intraoperative blood loss was 160-580 mL, with an average of 370.5 mL. All incisions healed by first intention, without vascular or nerve injury. All patients were followed up 22-46 months (mean, 26.5 months). All the fractures healed, with a fracture healing time of 3-7 months (mean, 4.8 months). During the follow-up, there was no infection, loosening, implant breakage, re-fracture, and other complications. The VAS score at last follow-up was 0.8±0.3, showing significant difference ( t=7.235, P=0.000) when compared with preoperative score (5.2±3.7); the RUST score was 3.4±0.3, which was significantly higher than the preoperative score (1.5±0.7) ( t=8.336, P=0.000). According to the Schatzker-Lambert effectiveness evaluation standard, the limb function was excellent in 16 cases, good in 4 cases, fair in 1 case, and the excellent and good rate was 95.42%.

Conclusion

Nonunion after intramedullary fixation of femoral fracture treated with auxiliary plate combined with autogenous iliac graft, autogenous bone marrow concentration and PRP gel in accordance with the "diamond concept" can not only restore the stability of the fracture ends, but also improves the biological environment of the fracture site, and can improve the rate of fracture healing.

Minimally invasive osteosynthesis technique in the treatment of transverse patellar fractures in the elderly

BACKGROUND

This prospective study aims to describe our experience in the management of transverse patellar fractures in elderly patients with minimally invasive osteosynthesis technique (MIOT), at 12-months follow-up.

METHODS

Patients older than 60, with transverse patellar fracture, type 34-C1 according to the AO/OTA classification system, referred to our trauma centre, between January 2014 and December 2017 were prospectively recruited. All the patients were managed using MIOT surgical procedure and underwent a clinical and radiological follow-up at 2 weeks, 6 weeks and at 3, 6, 12 and 15 months postoperatively. The clinical evaluation was performed using the Lysholm Knee Scoring System (LKSS) and the Visual Analogue Scale (VAS) for pain. The hardware removal was planned at 12-months follow-up. The paired t-test was performed. The test was two-tailed with a confidence level of 5%.

RESULTS

61 patients were recruited. The mean VAS was significantly lower in MIOT group until the 3-months follow-up (p = 0.001). ROM in flexion and LKSS score were significantly better in MIOT-group at all follow-ups, whereas ROM in extension showed no differences, between the two groups, starting from the 6-months follow-up. In the open surgery group, a significantly higher rate of delayed wound healing (p = 0.014), broken wires (p = 0.001) and non-cosmetic scar (p = 0.0221) was observed.

CONCLUSIONS

This prospective study shows that MIOT is a safe option for treatment of patellar transverse fractures in elderly patients, since it reduces the intra-operative blood loss, shortens the operating time, and is endowed with lower rates of postoperative complications.

The use of a gentamicin-coated titanium nail, combined with RIA system, in the management of non-unions of open tibial fractures: A single centre prospective study

BACKGROUND

Nonunion is a quite common complication of open tibial shaft fractures. This prospective case series investigates the use of the gentamicin-coated titanium intramedullary tibial nail, in association with the RIA system, in patients with tibial exposed nonunions.

METHODS

Between January 2015 and January 2018, patients meeting the inclusion and exclusion criteria were recruited.

INCLUSION CRITERIA

patients aged 18 or more; non-union after an open tibial shaft fracture; previous treatment with a circular external fixator.

EXCLUSION CRITERIA

a known allergy to aminoglycosides; pin tract infections; persistent soft-tissues damage; patients pregnant, breastfeeding or planning to become pregnant during the study; history of malignant disease; a life expectancy of fewer than three months; medical illness or cognitive disorders precluding participation in the follow-up examination. All the patients underwent a clinical and radiological follow-up at one-, three-, six- and twelve-months post-operatively. Clinical evaluation was performed using the following validated scores: Euro-Quality 5 D (EQ-5D); American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale and the Visual Analogue Scale (VAS) for pain.

RESULTS

Seventeen patients met the inclusion and exclusion criteria (male: 11; female: 6; mean age: 41.12 ± 11.4). Fracture healing was observed in all the patients; the mean time needed to obtain the fracture healing was 7.18 months. A significant improvement of the quality of life, evaluated with the EQ-5D, and of the mean VAS for pain was observed from the three-months follow-up. The mean AOFAS score showed a significant increase at six-months follow-up.

CONCLUSIONS

The use of gentamicin-coated nails in association with the RIA system demonstrated a safe and effective treatment of tibial non-unions.

The impact of lag screw in the healing time of distal tibia fractures treated with minimally invasive plate osteosynthesis: A randomized clinical trial

BACKGROUND

In recent years, Minimally Invasive Plate Osteosynthesis (MIPO) has been gaining popularity in the treatment of distal tibia fractures, because it is a minimally invasive surgical procedure, thus it limits the soft-tissues damage. This prospective randomized study aims to assess the impact of lag screw in the healing time of distal tibia fractures treated with MIPO technique, in a six-month follow-up.

METHODS

Patients between 20 and 70 years of age with distal tibial fracture, type 43-A according to AO/OTA classification system were included. All the patients were randomized into two groups, to receive MIPO without lag screw (Group-A) or MIPO with percutaneous lag screw (Group-B). Patients were followed clinically and radiographically at 3, 6, 12 and 24 weeks postoperatively. The main outcome measure was the time needed to achieve the painless full weight-bearing (FWB) after surgery. Unpaired t-test after ANOVA (analysis of variance) was performed to assess AOFAS score differences between the 2 groups at each follow-up. Pearson correlation test also was performed. The tests were two-tailed with a confidence level of 5%.

RESULTS

42 patients (24 male and 18 female, mean age 49.54 years old, range 25-80) were recruited. A significant shorter mean time until painless FWB (p = 0.016) was observed in Group-B (11.22 ± 3.06 weeks) compared with Group-A (13.48 ± 2.42 weeks) (Table 2). The mean AOFAS score was comparable in patients treated with (Group-B) and without lag screw (Group-A) at all follow-ups.

CONCLUSIONS

This prospective randomized clinical study has shown that the use of lag screw in distal tibia fractures treated with MIPO technique speeds the fracture healing, thus shortening the time needed to achieve FWB.