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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.
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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
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Southi BA, Fryer C, Ebert J, Ackland T, Kuster MS, Calvert ND. Kneeling tolerance following intramedullary nailing or plate fixation of uncomplicated distal tibia fractures. Orthop Traumatol Surg Res 2023; 109:103497. [PMID: 36460290 DOI: 10.1016/j.otsr.2022.103497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 10/23/2022] [Accepted: 11/16/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Distal tibia fractures often occur in younger, high demand patients, though the literature surrounding management remains contentious. This study sought to quantitatively determine differences in kneeling ability and self-reported knee function in patients managed with either intramedullary nailing (IMN) or open reduction internal fixation (ORIF) with compression plating following distal tibia fracture to assist in the preoperative consent process. HYPOTHESIS There is no difference in kneeling tolerance following either tibial nailing or plate fixation of distal tibia fractures. MATERIAL AND METHODS Retrospective sampling of public hospital data with outpatient prospective functional testing were completed. The primary outcome measure was the Kneeling Test (KT). Secondary outcome measures were The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Forgotten Joint Score (FJS) for the knee joint. There were 28 patients recruited (18 IMN and 10 ORIF) with a mean age of 44years. Mean overall follow-up was 13.3months (range 8-25, SD 3.6). All fractures had completely healed without postoperative complication. RESULTS The IMN affected limb had a significantly worse overall kneeling function than their non-affected limb (mean KT: 70.4 vs. 94.9 respectively, p<0.005) Additionally, the IMN group performed significantly worse when compared to the ORIF group (mean KT 70.4 vs. 92.5 respectively, p<0.005). No significant differences (p>0.05) in kneeling function existed for the ORIF group when comparing affected to non-affected limbs. Secondary outcome analysis showed significantly worse overall WOMAC and FJS in the IMN group compared to the ORIF group (mean WOMAC 19.3 vs. 6.9 respectively, p=0.040; mean FJS 38.3 vs. 75.9 respectively, p=0.005). DISCUSSION The use of intramedullary nailing for the treatment of distal tibia fracture results in a mean reduction of 20% in kneeling tolerance in comparison to ORIF. The resulting kneeling tolerance is comparable to that of patients post-total knee arthroplasty. The present findings should assist in the consent process for patients with high kneeling demands in sportive, professional or cultural pastimes. LEVEL OF EVIDENCE IV; retrospective cohort study with quantitative outcome measurement.
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Affiliation(s)
- Benjamin A Southi
- Department of Orthopaedics, Royal Perth Hospital, Perth, WA, Australia.
| | - Callum Fryer
- Department of Orthopaedics, Royal Perth Hospital, Perth, WA, Australia
| | - Jay Ebert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, Australia
| | - Tim Ackland
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, Australia
| | - Markus S Kuster
- Department of Orthopaedics, Royal Perth Hospital, Perth, WA, Australia; Department of Orthopaedics, Sir Charles Gairdner Hospital, Perth, WA, Australia
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McGraw-Heinrich JA, Ezeokoli EU, Mitchell P, Silverstein RS, Smith BG. Pediatric distal third tibial shaft fractures: a comparison of surgical fixation methods and incidence of concomitant physeal fractures. J Pediatr Orthop B 2023; 32:393-400. [PMID: 36377938 DOI: 10.1097/bpb.0000000000001038] [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] [Indexed: 11/16/2022]
Abstract
The purposeof this study was to compare outcomes of operatively treated pediatric distal third tibial shaft fractures fixed with elastic nailing or plate fixation and to evaluate the incidence of concurrent distal tibia physeal fractures. Retrospective review identified skeletally immature patients that underwent operative fixation of distal third tibia fractures at a level 1 children's hospital from 2010 to 2020. Patient and fracture characteristics were recorded. Analysis of treatment outcomes was performed and rates of concurrent distal tibia physeal fractures were evaluated. Of the 214 surgically treated tibial shaft fractures, 43 were distal third fractures. A concurrent distal tibia physeal fracture was present in 32.6% of patients. These were significantly associated with spiral distal third tibial shaft fractures. The presence of concurrent physeal fractures did not affect patient treatment outcomes. Comparing elastic nailing versus open reduction and plating revealed no difference with time to fracture union, time of postoperative immobilization, or time to full weight-bearing. While elastic nailing was associated with increased coronal angulation, translation, and shortening of fractures on initial postoperative imaging, there was no difference in rates of malunion at final follow-up. In our series, there were no differences in treatment outcomes based on fixation method. Our operatively treated distal third tibial shaft fractures had a higher rate of associated distal tibial physeal fractures than previously published in the pediatric orthopedic literature. We recommend careful evaluation of the ankle for concurrent physeal injuries in patients with distal third tibial shaft fractures indicated for operative treatment. Level of evidence: level III therapeutic study - retrospective comparative study.
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Affiliation(s)
| | | | | | | | - Brian G Smith
- Baylor College of Medicine, Texas Children's Hospital
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Makelov B, Mischler D, Varga P, Apivatthakakul T, Fletcher JWA, Veselinov D, Berk T, Raykov D, Gueorguiev B. Single-Stage Externalized Locked Plating for Treatment of Unstable Meta-Diaphyseal Tibial Fractures. J Clin Med 2023; 12:jcm12041600. [PMID: 36836132 PMCID: PMC9961641 DOI: 10.3390/jcm12041600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/05/2023] [Accepted: 02/15/2023] [Indexed: 02/19/2023] Open
Abstract
(1) Background: Unstable meta-diaphyseal tibial fractures represent a heterogeneous group of injuries. Recently, good clinical results have been reported when applying a technique of externalized locked plating in appropriate cases, highlighting its advantage in terms of less additional tissue injury compared with conventional methods of fracture fixation. The aims of this prospective clinical cohort study were, firstly, to investigate the biomechanical and clinical feasibility and, secondly, to evaluate the clinical and functional outcomes of single-stage externalized locked plating for treatment of unstable, proximal (intra- and extra-articular) and distal (extra-articular), meta-diaphyseal tibial fractures. (2) Methods: Patients, who matched the inclusion criteria of sustaining a high-energy unstable meta-diaphyseal tibial fracture, were identified prospectively for single-stage externalized locked plating at a single trauma hospital in the period from April 2013 to December 2022. (3) Results: Eighteen patients were included in the study. Average follow-up was 21.4 ± 12.3 months, with 94% of the fractures healing without complications. The healing time was 21.1 ± 4.6 weeks, being significantly shorter for patients with proximal extra- versus intra-articular meta-diaphyseal tibial fractures, p = 0.04. Good and excellent functional outcomes in terms of HSS and AOFAS scores, and knee and ankle joints range of motion were observed among all patients, with no registered implant breakage, deep infection, and non-union. (4) Conclusions: Single-stage externalized locked plating of unstable meta-diaphyseal tibial fractures provides adequate stability of fixation with promising clinical results and represents an attractive alternative to the conventional methods of external fixation when inclusion criteria and rehabilitation protocol are strictly followed. Further experimental studies and randomized multicentric clinical trials with larger series of patients are necessary to pave the way of its use in clinical practice.
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Affiliation(s)
- Biser Makelov
- University Multiprofile Hospital for Active Treatment, Trakia University, 6003 Stara Zagora, Bulgaria
| | | | - Peter Varga
- AO Research Institute Davos, 7270 Davos, Switzerland
| | | | - James W. A. Fletcher
- AO Research Institute Davos, 7270 Davos, Switzerland
- Department for Health, University of Bath, Bath BA2 7AY, UK
| | - Deyan Veselinov
- Bulgarian Academy of Sciences, Institute of Metal Science ‘Acad. A. Balevski’, 1574 Sofia, Bulgaria
| | - Till Berk
- AO Research Institute Davos, 7270 Davos, Switzerland
- University Hospital Zurich, 8091 Zurich, Switzerland
| | - Dimitur Raykov
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Medical University Varna, 9002 Varna, Bulgaria
| | - Boyko Gueorguiev
- AO Research Institute Davos, 7270 Davos, Switzerland
- Correspondence:
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Gao F, Wang XH, Xia SL, Zhou XX, Wang MH, Fu BG, Yi CG, Guo SY. Intramedullary Nail Fixation by Suprapatellar and Infrapatellar Approaches for Treatment of Distal Tibial Fractures. Orthop Surg 2022; 14:2350-2360. [PMID: 35946437 PMCID: PMC9483059 DOI: 10.1111/os.13397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 06/10/2022] [Accepted: 06/17/2022] [Indexed: 11/28/2022] Open
Abstract
Objective To compare the functional and alignment outcomes of intramedullary nail fixation using suprapatellar and infrapatellar approaches in treating distal tibial fractures. Methods In this retrospective study, 132 patients with distal tibial fractures (87 men, 45 women) ranging in age from 20 to 66 years were treated with intramedullary nails using the suprapatellar (69 patients) or infrapatellar (63 patients) approach. The radiographic alignment outcomes and ankle function were compared between the two groups. Multivariate logistic regression analyses were performed to determine which variety influenced ankle functional scores and whether the suprapatellar approach intervention demonstrated a protective effect. Results The mean follow‐up time was 14.22 ± 2.31 months. The mean sagittal section angle of the fracture in the suprapatellar and infrapatellar approach groups was 3.20° ± 1.20° and 5.31° ± 1.23°, respectively (P < 0.001). The mean coronal section angle was 3.51° ± 0.89° and 5.42° ± 1.05°, respectively (P < 0.001). Three patients (4.3%) in the suprapatellar approach group and 15 patients (23.8%) in the infrapatellar approach group had poor fracture reduction (P < 0.001). The mean hind foot functional score and ankle pain score were 95.91 ± 4.70 and 35.91 ± 4.70 points, respectively, in the suprapatellar approach group and 85.20 ± 5.61 and 25.20 ± 5.61 points, respectively, in the infrapatellar approach group (P < 0.001 for both). In the comparison of ankle function, the multivariate logistic regression analyses demonstrated that the odds ratio in the suprapatellar approach group was about 7 times that in the infrapatellar approach group (odds ratio, 7.574; 95% confidence interval, 2.148–28.740; P = 0.002). Of the variants measured, the statistically significant risk factors for poor ankle function were AO type A3 (P = 0.016) and diabetes mellitus (P = 0.006). Sex and the operation interval were not statistically significant risk factors for poor ankle function. Conclusion Intramedullary nailing using the suprapatellar approach facilitates simple fracture reduction, excellent postoperative fracture alignment, and few complications, giving it obvious advantages over the conventional infrapatellar approach. Additionally, the suprapatellar approach is a prognostic factor associated with postoperative ankle joint function.
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Affiliation(s)
- Feng Gao
- Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai Pudong New District Zhoupu Hospital, Shanghai, China
| | - Xiu-Hui Wang
- Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai Pudong New District Zhoupu Hospital, Shanghai, China
| | - Sheng-Li Xia
- Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai Pudong New District Zhoupu Hospital, Shanghai, China
| | - Xiao-Xiao Zhou
- Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai Pudong New District Zhoupu Hospital, Shanghai, China
| | - Ming-Hui Wang
- Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai Pudong New District Zhoupu Hospital, Shanghai, China
| | - Bei-Gang Fu
- Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai Pudong New District Zhoupu Hospital, Shanghai, China
| | - Cun-Guo Yi
- Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai Pudong New District Zhoupu Hospital, Shanghai, China
| | - Sheng-Yang Guo
- Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai Pudong New District Zhoupu Hospital, Shanghai, China
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He M, Liu J, Deng X, He M. Controlling the angle between the distal locking screw and tibiotalar joint tangent helps to reduce the occurrence of misalignment of distal tibial fractures treated with intramedullary nail fixation. BMC Musculoskelet Disord 2022; 23:671. [PMID: 35836214 PMCID: PMC9281126 DOI: 10.1186/s12891-022-05641-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Studies have shown that on the coronal plane, whether the direction of the distal locking screw is parallel to the tangent line of the tibiotalar joint can be used to determine whether there is varus or valgus deformity after the treatment of distal tibial fractures with intramedullary nail (IMN) fixation. However, there has been no statistical analysis of the included angle on the coronal plane, and there have been no reports on whether there is a relationship between the direction of the distal locking screw on the sagittal plane or the included angle of the tangent line of the tibiotalar joint and the postoperative alignment of distal tibial fractures treated with IMN fixation. OBJECTIVE Our aim was to evaluate the relationship between the angles formed by the distal locking screw and the tibiotalar joint tangent (ADTTs) on the sagittal and coronal planes and postoperative alignment in the treatment of distal tibial fractures with IMN fixation. METHODS We performed a retrospective analysis of 100 patients with distal tibial fractures treated with IMN fixation using the suprapatellar approach. On the coronal and sagittal planes, the ADTTs were arranged from small to large and divided into 4 groups, namely, groups A, B, C and D. One-way ANOVA was used to compare the lateral distal tibial angle (LDTA) and anterior distal tibial angle (ADTA) among all groups, and the chi-square test was used to compare the incidence of postoperative tibial misalignment among all groups. Univariate analysis was performed using chi-square tests to identify factors that might be associated with dislocation, including fibular open reduction and internal fixation (ORIF), limited open reduction, ADTT, IMN diameter, injury mechanism, open vs. closed fracture, comminution, and fibular fracture level. Then, the statistically significant variables in the univariate analysis were included in a multivariate logistic regression equation to evaluate the independent factors related to misalignment. RESULTS On the coronal plane, the ADTTs of groups A, B, C and D were < 0°, 0°-1.3°, 1.3°-2.7° and > 2.7°, respectively. The mean LDTAs of groups B and C (0°-1.3° and 1.3°-2.7°), group A (< 0°) and group D (> 2.7°) were 89.5 ± 1.6°, 92.0 ± 3.2° and 85.8 ± 3.5°, respectively (P < 0.01). Deformity greater than 5° were more likely in groups A and D than groups B and C [14 of 50 (28%) vs. 1 of 50 (2%), P < 0.001]. On the sagittal plane, the ADTTs of groups A, B, C and D were < 8.9°, 8.9°-10.4°, 10.4°-11.7° and > 11.8°, respectively. The average ADTAs of groups B and C (8.9°-10.4° and 10.4°-11.7°), group A (< 8.9°) and group D (> 11.8°) were 80.4 ± 1.3°, 83.1 ± 3.7° and 77.9 ± 2.5°, respectively (P < 0.01). Deformity greater than 5° was more likely in groups A and D than groups B and C [13 of 50 (26%) vs. 0 of 50 (0%), P < 0.001]. An ADTT of 0°-2.7° on the coronal plane and 8.9°-11.7° on the sagittal plane (OR: 0.08, P = 0.02) and limited open reduction (OR: 0.21, P < 0.01) were independent factors that reduced the likelihood of misalignment. CONCLUSION The alignment of distal tibial fractures after surgery is sensitive to the ADTT and use of limited open reduction. Controlling the ADTT between 0° and 2.7° on the coronal plane and between 8.9° and 11.7° on the sagittal plane is helpful to reduce the occurrence of misalignment after the treatment of distal tibial fractures by IMN fixation.
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Affiliation(s)
- Miao He
- Department of Orthopaedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), No. 1 Jiankang Road, Chongqing, 400010, China
| | - Jian Liu
- Department of Orthopaedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), No. 1 Jiankang Road, Chongqing, 400010, China
| | - Xu Deng
- Department of Orthopaedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), No. 1 Jiankang Road, Chongqing, 400010, China
| | - Miao He
- Department of Orthopaedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), No. 1 Jiankang Road, Chongqing, 400010, China.
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Effect of Different Reduction Intramedullary Nails on Spiral Fracture of Middle and Lower Tibia. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:4716978. [PMID: 35414802 PMCID: PMC8979711 DOI: 10.1155/2022/4716978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/10/2022] [Accepted: 03/17/2022] [Indexed: 11/17/2022]
Abstract
Objective To compare the efficacy of different reduction and intramedullary nailing in the treatment of spiral fracture of middle and lower tibia. Method A total of 96 patients with spiral fractures of middle and lower tibia treated with intramedullary nails were retrospectively analyzed. The patients were divided into closed functional reduction group, open anatomical reduction group, and closed anatomical reduction group according to different treatment methods. The operation time, intraoperative blood loss, intraoperative fluoroscopy times, fracture healing time, fracture nonunion, wound complications, and healing conditions of the three groups were compared. Results The operation time and intraoperative fluoroscopy times of patients in the closed anatomical reduction group were significantly increased compared with those in the closed functional reduction group, while the fracture healing time was significantly reduced. However, patients in the open reduction group had significantly more intraoperative blood loss than those in the closed reduction group. The mean follow-up duration of patients was 15.81 ± 3.25 months. Open anatomical reduction was found to have a higher complication rate during follow-up. Specifically, a total of 3 cases recovered after 2 times of surgical treatment. 6 cases showed a small gap at the fracture end which did not affect the function. Conclusion In the treatment of middle and lower spiral fracture of tibia, closed anatomical reduction and intramedullary nail internal fixation have shorter fracture healing time, less blood loss, and fewer complications, which can act as the first surgical choice. However, open reduction and intramedullary nailing have a high complication rate, which is not recommended.
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Bleeker NJ, van Veelen NM, van de Wall BJM, Sierevelt IN, Link BC, Babst R, Knobe M, Beeres FJP. MIPO vs. intra-medullary nailing for extra-articular distal tibia fractures and the efficacy of intra-operative alignment control: a retrospective cohort of 135 patients. Eur J Trauma Emerg Surg 2022; 48:3683-3691. [PMID: 34984496 DOI: 10.1007/s00068-021-01836-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/08/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Definitive treatment of distal extra-articular fractures of the tibia is challenging and both minimal invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are considered to be feasible surgical modalities with their own implant-specific merits and demerits. This retrospective study was designed to compare MIPO versus IMN in terms of fracture healing, complications, functional and radiological outcomes and to assess the efficacy of intra-operative alignment control to reduce the rate of malalignment after definitive fixation of distal extra-articular fractures of the tibia. MATERIALS AND METHODS All consecutive adult patients with extra-articular distal meta- or diaphyseal tibia fractures that were treated between January 2012 and September 2019 either with MIPO or IMN were included. Outcome measures included fracture healing, complications (infection, malalignment, subsequent surgeries), functional and radiological outcomes. Intra-operative alignment control encompassed bilateral draping of the lower extremities. RESULTS A total of 135 patients were included out of which 72 patients (53%) were treated with MIPO and 63 patients (47%) underwent IMN. There was a significantly higher incidence of non-union for fractures treated with IMN (13 (22%) vs. 4 (6%), p = 0.04). There was no significant difference between both groups in terms of rotational malalignment (3% vs. 10%) and angular malalignment (4% vs. 5%). A significantly higher rate of infection was found after MIPO after correction of significant differences in baseline characteristics. No differences were found in subsequent surgeries or functional outcomes. CONCLUSION Both MIPO and IMN are reliable surgical techniques. IMN is associated with higher rates of non-union, whereas MIPO results in a higher risk for infection. The incidence of malalignment was surprisingly low endorsing the utility of the intra-operative alignment control.
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Affiliation(s)
- Nils Jan Bleeker
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
| | - Nicole M van Veelen
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
| | - Bryan J M van de Wall
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
| | - Inger N Sierevelt
- Specialized Center of Orthopaedic Research and Education (SCORE), Orthopaedic Department, Xpert Clinics, Amsterdam, The Netherlands
| | - Björn-Christian Link
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland.,Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne (LUKS), Lucerne, Switzerland
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Chen H, Li Z, Yang D, Wang P, Niu J, He X, Wu G. Clinical study of intramedullary nailing fixation for the treatment of Danis-Weber B in lateral malleolus fracture. J Int Med Res 2021; 49:3000605211047371. [PMID: 34713740 PMCID: PMC8645306 DOI: 10.1177/03000605211047371] [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] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To compare the clinical effects between anatomical locking plates and interlocking intramedullary nails in patients with Danis-Weber B lateral malleolus fractures. METHODS This retrospective study enrolled patients with Danis-Weber B fractures of the lateral malleolus. All the operations were completed by the same group of surgeons. The reduction effect, operation time, intraoperative blood loss, hospital stay, fracture healing time and ankle functional outcomes (Olerud-Molander Ankle Score [OMAS]) were compared. Postoperative complications, including incision infections, fixation discomfort and internal fixation loosening, were also compared. RESULTS This study enrolled 73 patients that were treated with either an anatomical locking plate (locking plate group; n = 37) or an interlocking intramedullary nail (intramedullary nail group; n = 36). There was no significant difference between the two groups in terms of reduction effect, hospital stay and OMAS. The intramedullary nail group had significantly lower operation time, intraoperative blood loss and fracture healing time compared with the locking plate group. Postoperative complications in the intramedullary nail group were significantly lower compared with the locking plate group. CONCLUSION Using intramedullary nails resulted in more satisfactory functional outcomes compared with using locking plates in patients with Danis-Weber B fractures of the lateral malleolus.
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Affiliation(s)
- Hongfeng Chen
- Department of Foot and Ankle Surgery, The Second Affiliated Hospital of Luohe Medical College, Luohe, Henan Province, China
| | - Zhen Li
- Department of Foot and Ankle Surgery, The Second Affiliated Hospital of Luohe Medical College, Luohe, Henan Province, China
| | - Dongsong Yang
- Department of Orthopaedics, The Second Affiliated Hospital of Luohe Medical College, Luohe, Henan Province, China
| | - Pengru Wang
- Department of Orthopaedics, The Second Affiliated Hospital of Luohe Medical College, Luohe, Henan Province, China
| | - Junke Niu
- Department of Orthopaedics, The Second Affiliated Hospital of Luohe Medical College, Luohe, Henan Province, China
| | - Xishun He
- Department of Orthopaedics, The Second Affiliated Hospital of Luohe Medical College, Luohe, Henan Province, China
| | - Guangliang Wu
- Department of Orthopaedics, The Second Affiliated Hospital of Luohe Medical College, Luohe, Henan Province, China
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Greenfield J, Appelmann P, Lafon Y, Bruyère-Garnier K, Rommens PM, Kuhn S. A comparative biomechanical study of the Distal Tibia Nail against compression plating for the osteosynthesis of supramalleolar corrective osteotomies. Sci Rep 2021; 11:18834. [PMID: 34552116 PMCID: PMC8458440 DOI: 10.1038/s41598-021-97968-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 07/21/2021] [Indexed: 11/09/2022] Open
Abstract
The Distal Tibia Nail (DTN; Mizuho, Japan) has demonstrated higher biomechanical stiffness to locking plates in previous research for A3 distal tibia fractures. It is here investigated as a fixation option for supramalleolar corrective osteotomies (SMOT). Sixteen Sawbones tibiae were implanted with either a DTN (n = 8) or Medial Distal Tibia Plate (MDTP; n = 8) and a SMOT simulated. Two surgical outcome scenarios were envisaged: "best-case" representing an intact lateral cortex, and "worst-case" representing a fractured lateral cortex. All samples were subjected to compressive (350 N, 700 N) and torsional (± 4 Nm, ± 8 Nm) testing. Samples were evaluated using calculated construct stiffness from force-displacement data, interfragmentary movement and Von Mises' strain distribution. The DTN demonstrated a greater compressive stiffness for the best-case surgical scenario, whereas the MDTP showed higher stiffness (p < 0.05) for the worst-case surgical scenario. In torsional testing, the DTN proved more resistant to torsion in the worst-case surgical setup (p < 0.05) for both ± 4 Nm and ± 8 Nm. The equivalent stiffness of the DTN against the MDTP supports the use of this implant for SMOT fixation and should be considered as a treatment option particularly in patients presenting vascularisation problems where the MDTP is an inappropriate choice.
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Affiliation(s)
- Julia Greenfield
- Univ Gustave Eiffel, IFSTTAR, LBMC, UMR_T9406, Univ Lyon, 25 Avenue François Mitterrand, 69500, Bron, France.,Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Philipp Appelmann
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Yoann Lafon
- Univ Gustave Eiffel, IFSTTAR, LBMC, UMR_T9406, Univ Lyon, 25 Avenue François Mitterrand, 69500, Bron, France
| | - Karine Bruyère-Garnier
- Univ Gustave Eiffel, IFSTTAR, LBMC, UMR_T9406, Univ Lyon, 25 Avenue François Mitterrand, 69500, Bron, France
| | - Pol Maria Rommens
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Sebastian Kuhn
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany. .,Department of Digital Medicine, Medical Faculty OWL, Bielefeld University, Universitätsstr. 25, 33615, Bielefeld, Germany.
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Cho Y, Byun YS, Suh JD, Yoo J. Osteoperiosteal Decortication and Autogenous Cancellous Bone Graft Combined with Bridge Plating for Non-hypertrophic Diaphyseal Nonunion. Clin Orthop Surg 2021; 13:301-306. [PMID: 34484621 PMCID: PMC8380522 DOI: 10.4055/cios20227] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/30/2020] [Accepted: 12/30/2020] [Indexed: 11/17/2022] Open
Abstract
Backgroud The aim of this study was to evaluate results of osteoperiosteal decortication and autogenous cancellous bone graft combined with a bridge plating technique in atrophic and oligotrophic femoral and tibial diaphyseal nonunion. Methods We retrospectively reviewed 31 patients with atrophic or oligotrophic femoral and tibial diaphyseal nonunion treated with osteoperiosteal decortication and autogenous cancellous bone graft between January 2008 and December 2018. Patients with hypertrophic nonunion, infected nonunion, and nonunion treated with autogenous cancellous bone graft alone were excluded. The nonunion site was exposed by using the Judet technique of osteoperiosteal decortication. Nonunion with a lack of stability was stabilized with a new plate using a bridge plating technique or augmented by supplemental fixation with a plate. Nonunion with malalignment was stabilized with a new plate after deformity correction. Autogenous cancellous bone graft was harvested from the posterior iliac crest and placed within the area of decortication. A basic demographic survey was conducted, and the type of existing implants, mechanical stability of the implants, the type of implants used for stabilization, the operation time, the time to bone union, and postoperative complications were investigated. Results The average follow-up period was 33.3 months (range, 8–108 months). The operation time was 207 minutes (range, 100–351 minutes). All but 1 nonunion (96.7%) were healed at an average of 4.2 months (range, 3–8 months). In 1 patient, bone union failed due to implant loosening with absorbed bone graft, and solid union was achieved by an additional surgery for stable fixation with a new plate, osteoperiosteal decortication, and autogenous cancellous bone graft. There were no other major complications such as neurovascular injuries, infection, loss of fixation, and malunion. Conclusions Osteoperiosteal decortication and autogenous cancellous bone graft combined with stable fixation by bridge plating showed reliable outcomes in atrophic and oligotrophic diaphyseal nonunion. This treatment modality can be effective for treating atrophic and oligotrophic diaphyseal nonunion because it is very helpful stimulating bone union.
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Affiliation(s)
- Youngho Cho
- Department of Orthopaedic Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Young-Soo Byun
- Department of Orthopaedic Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Jeong-Duk Suh
- Department of Orthopaedic Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Junhyug Yoo
- Department of Orthopaedic Surgery, Daegu Fatima Hospital, Daegu, Korea
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12
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Bleeker NJ, van de Wall BJM, IJpma FFA, Doornberg JN, Kerkhoffs GMMJ, Jaarsma RL, Knobe M, Link BC, Babst R, Beeres FJP. Plate vs. nail for extra-articular distal tibia fractures: How should we personalize surgical treatment? A meta-analysis of 1332 patients. Injury 2021; 52:345-357. [PMID: 33268081 DOI: 10.1016/j.injury.2020.10.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/06/2020] [Accepted: 10/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Treatment for distal diaphyseal or metaphyseal tibia fractures is challenging and the optimal surgical strategy remains a matter of debate. The purpose of this study was to compare plate fixation with nailing in terms of operation time, non-union, time-to-union, mal-union, infection, subsequent re-interventions and functional outcomes (quality of life scores, knee- and ankle scores). METHODS A search was performed in PubMed/Embase/CINAHL/CENTRAL for all study designs comparing plate fixation with intramedullary nailing (IMN). Data were pooled using RevMan and presented as odds ratios (OR), risk difference (RD), weighted mean difference (WMD) or weighted standardized mean difference (WSMD) with a 95% confidence interval (95%CI). All analyzes were stratified for study design. RESULTS A total of 15 studies with 1332 patients were analyzed, including ten RCTs (n = 873) and five observational studies (n = 459). IMN leads to a shorter time-to-union (WMD: 0.4 months, 95%CI 0.1 - 0.7), shorter time-to-full-weightbearing (WMD: 0.6 months, 95%CI 0.4 - 0.8) and shorter operation duration (WMD: 15.5 min, 95%CI 9.3 - 21.7). Plating leads to a lower risk for mal-union (RD: -10%, OR: 0.4, 95%CI 0.3 - 0.6), but higher risk for infection (RD: 8%, OR: 2.4, 95%CI 1.5 - 3.8). No differences were detected with regard to non-union (RD: 1%, OR: 0.7, 95%CI 0.3 - 1.7), subsequent re-interventions (RD: 4%, OR: 1.3, 95%CI 0.8 - 1.9) and functional outcomes (WSMD: -0.4, 95%CI -0.9 - 0.1). The effect estimates of RCTs and observational studies were equal for all outcomes except for time to union and mal-union. CONCLUSION Satisfactory results can be obtained with both plate fixation and nailing for distal extra-articular tibia fractures. However, nailing is associated with higher rates of mal-union and anterior knee pain while plate fixation results in an increased risk of infection. This study provides a guideline towards a personalized approach and facilitates shared decision-making in surgical treatment of distal extra-articular tibia fractures. The definitive treatment should be case-based and aligned to patient-specific needs in order to minimize the risk of complications.
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Affiliation(s)
- N J Bleeker
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland.
| | - B J M van de Wall
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
| | - F F A IJpma
- Dept. of Trauma Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
| | - J N Doornberg
- Dept. of Orthopaedic Trauma Surgery, Flinders Medical Centre, Adelaide, Australia
| | - G M M J Kerkhoffs
- Dept. of Orthopaedic Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - R L Jaarsma
- Dept. of Orthopaedic Trauma Surgery, Flinders Medical Centre, Adelaide, Australia
| | - M Knobe
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
| | - B C Link
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
| | - R Babst
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
| | - F J P Beeres
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
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13
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Kang H, Song JK, Rho JY, Lee J, Choi J, Choi S. Minimally invasive plate osteosynthesis (MIPO) for mid-shaft fracture of the tibia (AO/OTA classification 42): A retrospective study. Ann Med Surg (Lond) 2020; 60:408-412. [PMID: 33250999 PMCID: PMC7677665 DOI: 10.1016/j.amsu.2020.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/08/2020] [Accepted: 11/08/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND There is abundance of literature regarding the treatment of tibial mid-shaft fracture, and intramedullary nailing (IMN) is described as the treatment of choice. However, problems such as malunion and knee pain are known disadvantages of this approach. Minimally invasive plate osteosynthesis (MIPO) technique is another treatment option for tibial mid-shaft fracture.The purpose of this study is to evaluate the clinical, radiological results, and complication rates of tibial mid-shaft fractures treated with MIPO technique. MATERIALS AND METHOD Thirty-seven skeletally mature patients who underwent MIPO for a mid-shaft fracture of tibia (AO/OTA classification 42) from June 2016 to May 2018 were retrospectively reviewed. A total of 37 patients (12 females, 25 males) with a mean age of 52.7 years (range 28-78 years) were included. The clinical and radiological outcomes, such as the Jeju Lower Extremity Trauma Scale (JLETS), time to callus formation, time to bony union, and complications such as delayed union, malunion, nonunion, and infection were assessed. RESULTS Bony union was achieved in all cases but one (36 cases). Average callus formation was observed in 10.7 (6.5-14.5) weeks. The average time to union was 19.8 (11.5-26.5) weeks. The average JLETS score was 46.9 (40-53) point. Malunion deformities were observed in 3 cases (8.1%). Two superficial infection cases all resolved spontaneously. There was no statistically significant difference in clinical and radiographic outcomes by different AO/OTA fracture types. CONCLUSION The MIPO technique with locking compression plate provides stable fixation and satisfactory clinical and radiological results for mid-shaft fractures of tibia irrespective of the fracture type. Future study should aim to compare MIPO and IMN cases directly to clarify the differences and similarities between the two treatment modalities.
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Affiliation(s)
- Hyunseong Kang
- Department of Orthopedic Surgery, Jeju National University School of Medicine, Jeju, South Korea
| | - Jung-Kook Song
- Department of Preventive Medicine, Jeju National University School of Medicine, Jeju, South Korea
| | - Joseph Y. Rho
- Department of Orthopedic Surgery, Jeju National University School of Medicine, Jeju, South Korea
| | - Jaehwang Lee
- Department of Orthopedic Surgery, Jeju National University School of Medicine, Jeju, South Korea
| | - Jaewon Choi
- Department of Orthopedic Surgery, Jeju National University School of Medicine, Jeju, South Korea
| | - Sungwook Choi
- Department of Orthopedic Surgery, Jeju National University School of Medicine, Jeju, South Korea
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Baseri A, Bagheri MA, Rouhi G, Aghighi MR, Bagheri N. Fixation of distal tibia fracture through plating, nailing, and nailing with Poller screws: A comparative biomechanical-based experimental and numerical investigation. Proc Inst Mech Eng H 2020; 234:1129-1138. [DOI: 10.1177/0954411920941664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The goal of this study was to investigate two commonly used methods of fixation of distal metaphyseal tibia fractures, plating and nailing as well as the less frequently employed nailing with Poller screws, from a biomechanical perspective. Despite numerous studies, the best method to repair fractures of tibia the remains up for of debate. This study includes an in vitro experimental phase on human cadaveric tibias followed by a finite element analysis. In the experimental phase, under partial weight-bearing axial loading, the axial stiffness of the bone-implant construct and interfragmentary movements for each of the fixation methods, bone-plate, bone-nail, and bone-nail-Poller screw, were measured and compared with each other. Shear interfragmentary movement and stress distribution in the bone-implant construct for the three mentioned fixation methods were also determined from FE models and compared with each other. Results of in vitro experiments, i.e., the exertion of axial loading on the tibia-plate, tibia-nail, and tibia-nail-Poller screw, showed that utilization of tibia-nail and tibia-nail-Poller screw led to a stiffer bone-implant construct, and consequently, lower interfragmentary movement, compared to the tibia-plate construct ( p values for tibia-nail and tibia-nail-Poller screw, and for both axial stiffness and interfragmentary movement, compared to those of tibia-plate construct, were less than 0.05). Numerical analyses showed that nailing produced less undesirable shear interfragmentary movement, compared to the plating, and application of a Poller screw decreased the shear movements, compared to tibia-nail. Furthermore, using the finite element analysis, maximum von Mises stress of adding a screw in tibia-nail, tibia-plate, and tibia-nail-Poller screw, was found to be: 51.5, 78.6, and 60.5 MPa, respectively. The results of this study suggested that from a biomechanical standpoint, nailing both with and without a Poller screw is superior to plating for the treatment of distal tibia fractures.
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Affiliation(s)
- Amin Baseri
- Department of Biomedical Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Mohammad Ali Bagheri
- Faculty of Biomedical Engineering, Amirkabir University of Technology, Tehran, Iran
| | - Gholamreza Rouhi
- Faculty of Biomedical Engineering, Amirkabir University of Technology, Tehran, Iran
| | - Mohammad Reza Aghighi
- Iranian Tissue Bank and Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Bagheri
- Department of Orthopedic, Tehran University of Medical Sciences, Tehran, Iran
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Liu XK, Xu WN, Xue QY, Liang QW. Intramedullary Nailing Versus Minimally Invasive Plate Osteosynthesis for Distal Tibial Fractures: A Systematic Review and Meta-Analysis. Orthop Surg 2020; 11:954-965. [PMID: 31823496 PMCID: PMC6904655 DOI: 10.1111/os.12575] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 10/16/2019] [Accepted: 10/16/2019] [Indexed: 12/14/2022] Open
Abstract
To evaluate the application, safety and efficacy of the patients treated with intramedullary nailing (IMN) and minimally invasive plate osteosynthesis (MIPO) in distal tibia fractures. Following the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) guidelines, we searched databases PubMed, Cochrane library, EMBASE and Web of Science from inception of the database up to 10 October 2018, using the keywords "distal tibia fractures", "plate", "intramedullary nailing" and "RCT" to identify randomized clinical trials about distal tibia fractures. The included studies were assessed by two researchers according to the Cochrane risk-of-bias criteria. The primary outcome of measurement included operation time, malunion rate, nonunion/delayed union rate, and wound complication. Data analysis was conducted with Review Manager 5.3 software. A total of 10 RCTs involving 911 patients fulfilled the inclusion criteria with 455 patients in the IMN group and 456 patients in the MIPO group. There were no significant differences in radiation time, nonunion or delayed union rate, union time and operation time between the two groups. Patients treated with MIPO had lower incidence of malunion compared with IMN (RR = 1.85, 95%CI: 1.21 to 2.83, P = 1.00), while IMN seemed to have lower surgical incision complications whether in closed or opening fractures (RR = 0.49, 95%CI 0.33 to 0.73, P = 0.43). But in patients classified as 43A, the result of subgroup analysis suggested that there was no significant inwound complication between the two groups. MIPO was superior in preventing malunion compared with IMN, and intramedullary nailing appeared to have lower wound complications. However, in patients with 43A distal tibial fractures, MIPO was more recommended for its prevention of malunion. No matter which method we choose, we should notice and prevent the associated complications.
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Affiliation(s)
- Xiao-Kai Liu
- Joint Surgery Department, Chaoyang Central Hospital, Chaoyang City, Liaoning Province, China
| | - Wen-Nan Xu
- Department of Orthopaedic, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Qing-Yun Xue
- Department of Orthopaedic, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Qing-Wei Liang
- Department of Orthopaedic, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
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Lin ZQ, Zhang HZ, Luo GG, Yao JC, Xie HF, Zhang X, Zhu YZ. Comparison of 3 Treatment Methods for Distal Tibial Fractures: A Network Meta-Analysis. Med Sci Monit 2019; 25:7480-7487. [PMID: 31587012 PMCID: PMC6792504 DOI: 10.12659/msm.917311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background The choice of optimal internal fixation device for distal tibial fractures remains controversial. The purpose of our study was to evaluate the effectiveness and safety of open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and intramedullary nailing of distal tibial fractures in adults using network meta-analysis of data from clinical trials. Material/Methods The studies were abstracted from MEDLINE, EMBASE, CNKI, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials meeting inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 13.0 (Stata Corporation, College Station, Texas, USA). Results Eleven randomized controlled trials were included. The total number of participants was 710 and the studies were published between 2005 and 2017. There were no significant differences in rates of delayed union, nonunion, or malunion among the various treatments (all p>0.05). The intramedullary nailing group had a lower incidence of wound complications than did the open reduction and internal fixation group and minimally invasive percutaneous osteosynthesis technique group. The SUCRA probabilities were 28.6% for ORIF, 98.4% for IMN, and 22.9% for MIPPO. Conclusions Given the superior results for intramedullary nailing in terms of wound complications, we recommend this procedure for treatment of distal tibial fractures. More RCTs focused on distal tibial fractures are needed to support the current evidence.
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Affiliation(s)
- Zhong-Qin Lin
- Department of Orthopedic Surgery, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, Zhejiang, China (mainland)
| | - Hong-Zhen Zhang
- Department of Orthopedic Surgery, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, Zhejiang, China (mainland)
| | - Guo-Gang Luo
- Department of Orthopedic Surgery, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, Zhejiang, China (mainland)
| | - Jian-Chuan Yao
- Department of Orthopedic Surgery, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, Zhejiang, China (mainland)
| | - Hai-Feng Xie
- Department of Orthopedic Surgery, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, Zhejiang, China (mainland)
| | - Xiang Zhang
- Department of Orthopedic Surgery, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, Zhejiang, China (mainland)
| | - Yi-Zhou Zhu
- Department of Orthopedic Surgery, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, Zhejiang, China (mainland)
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Abstract
OBJECTIVES To assess the relationship between the distal nail target and postoperative alignment for distal tibia fractures treated with intramedullary nailing. DESIGN Retrospective cohort study. SETTING A single level 1 trauma center. PATIENTS/PARTICIPANTS One hundred thirty distal tibia fractures treated with intramedullary nailing over a 10-year period. MAIN OUTCOME MEASUREMENTS Malalignment >5 degrees. RESULTS Thirty-eight cases (29.2%) of malalignment >5 degrees included valgus (19 cases, 14.6%), procurvatum (13 cases, 10.0%), recurvatum (1 case, 0.8%), and combined valgus with procurvatum (5 cases, 3.8%). Medially directed nails demonstrated relative valgus (mean lateral distal tibia angle 86.4 vs. 89.4 degrees, P < 0.01) and more frequent coronal malalignment (24 of 78, 30.8% vs. 0 of 52, 0%, P < 0.01). Anteriorly directed nails demonstrated relative procurvatum (mean anterior distal tibia angle 82.8 vs. 80.9 degrees, P < 0.01) and more frequent sagittal malalignment (15 of 78, 19.2% vs. 3 of 52, 5.8%, P = 0.03). Malalignment was less common for nails targeting the central or slightly posterolateral plafond (0 of 30, 0% vs. 38 of 100, 38%), P < 0.01. Multivariate analysis demonstrated the distal nail target (P = 0.03), fracture within 5 cm of the plafond (P = 0.01), as well as night and weekend surgery (P = 0.03) were all independently associated with malalignment. CONCLUSIONS Alignment of distal tibia fractures is sensitive to both injury and treatment factors. Nails should be targeted centrally or slightly posterolaterally to minimize malalignment. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Toogood P, Huang A, Siebuhr K, Miclau T. Minimally invasive plate osteosynthesis versus conventional open insertion techniques for osteosynthesis. Injury 2018; 49 Suppl 1:S19-S23. [PMID: 29929686 DOI: 10.1016/s0020-1383(18)30297-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Osteosynthesis has evolved theoretically and practically throughout its evolution. Similar to trends in other surgical fields, surgical techniques in fracture fixation, such as minimally invasive plate osteosynthesis (MIPO), have moved from large dissections to more tissue sparing methods. These plating techniques have been developed for a variety of bones, but more universal clinical adoption will rely upon improved clinical outcomes. The current review will describe minimally invasive techniques, evaluate their rationale, and summarize evidence for their efficacy.
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Affiliation(s)
- Paul Toogood
- University of California, San Francisco (UCSF), Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital and Trauma Center, San Francisco, California, USA.
| | - Adrian Huang
- University of California, San Francisco (UCSF), Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Karl Siebuhr
- University of California, San Francisco (UCSF), Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Theodore Miclau
- University of California, San Francisco (UCSF), Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital and Trauma Center, San Francisco, California, USA
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Bisaccia M, Cappiello A, Meccariello L, Rinonapoli G, Falzarano G, Medici A, Vicente CI, Piscitelli L, Stano V, Bisaccia O, Caraffa A. Nail or plate in the management of distal extra-articular tibial fracture, what is better? Valutation of outcomes. SICOT J 2018; 4:2. [PMID: 29469802 PMCID: PMC5822878 DOI: 10.1051/sicotj/2017058] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 11/14/2017] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Distal tibial fractures are the most common long bone fractures. Several studies focusing on the methods of treatment of displaced distal tibial fractures have been published. To date, locked plates, intramedullary nails and external fixation are the three most used techniques. The aim of our study was to compare intramedullary nail (IMN) and locked plate (LP) for treatment of this kind of fracture. MATERIALS AND METHODS We collected data on 81 patients with distal tibial fractures (distance from the joint between 40 and 100 mm) and we divided into two groups: IMN and LP. We compared in the 2 groups the mean operation time, the mean union time, the infection rate the rate of malunion and nonunion, the full weight bearing time. RESULTS No patient in the two groups developed a nonunion. None of the patients obtained a fair or poor outcome. Overall 52 patients obtained an excellent result (69.3%) and 23 obtained a good result (30.6%). DISCUSSION Our study results indicate a superiority of IMN over LP in terms of lower rates of infections and statistically significant shorter time to full weight bearing. Whereas LP appeared to be advantageous over IMN in terms of leading to a better anatomical and fixed reductions of the fracture and a lower rate of union complications. The two treatments achieved comparable results in terms of operation time, hospital stay, union time and functional outcomes.
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Affiliation(s)
- Michele Bisaccia
- Department of Orthopaedics and Traumatology, "S.M. Misericordia Hospital", University of Perugia, Perugia, Italy
| | - Andrea Cappiello
- Department of Orthopaedics and Traumatology, "S.M. Misericordia Hospital", University of Perugia, Perugia, Italy
| | - Luigi Meccariello
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
| | - Giuseppe Rinonapoli
- Department of Orthopaedics and Traumatology, "S.M. Misericordia Hospital", University of Perugia, Perugia, Italy
| | - Gabriele Falzarano
- Department of Medical and Surgical Sciences and Neuroscience, Section of Orthopedics and Traumatology, University of Siena, University Hospital "Santa Maria alle Scotte", Siena, Italy
| | - Antonio Medici
- Department of Medical and Surgical Sciences and Neuroscience, Section of Orthopedics and Traumatology, University of Siena, University Hospital "Santa Maria alle Scotte", Siena, Italy
| | - Cristina Ibáñez Vicente
- Department of Orthopaedics and Traumatology, "S.M. Misericordia Hospital", University of Perugia, Perugia, Italy
| | - Luigi Piscitelli
- Department of Orthopaedics and Traumatology, "S.M. Misericordia Hospital", University of Perugia, Perugia, Italy
| | - Verdiana Stano
- Department of Civil Engineering and Computer Engineering, Faculty of Medical Engineering, University of Rome Tor Vergata, Rome, Italy
| | - Olga Bisaccia
- Department of Radiology, "San Donato Hospital" University of Milano, Milano, Italy
| | - Auro Caraffa
- Department of Orthopaedics and Traumatology, "S.M. Misericordia Hospital", University of Perugia, Perugia, Italy
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Liu W, Yang L, Kong X, An L, Hong G, Guo Z, Zang L. Stiffness of the locking compression plate as an external fixator for treating distal tibial fractures: a biomechanics study. BMC Musculoskelet Disord 2017; 18:26. [PMID: 28103852 PMCID: PMC5248451 DOI: 10.1186/s12891-016-1384-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 12/23/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Locking compress plate, as external fixator, is an attractive technique for distal tibial fracture treatment. But it still remains unclear whether the external LCP has sufficient stiffness. Thus, the present study aims to make a comprehensive evaluation of the stiffness of external locking compress plate when it is used as an external fixator in distal tibial fractures treatment. METHODS Composite tibia was used to simulate distal tibia fracture (Orthopedic Trauma Association type 43 A3 fracture). The fractures were stabilized with medial distal tibial locking compress plates (LCP group), medial distal tibial locking compress plates with 30-mm plate-bone distances (EF-tibia group), and medial distal femur locking compress plates with 30-mm plate-bone distances (EF-femur group). Stiffness of each configuration was measured under axial compression loading and in axial torsion loading directions. Compression stiffness and torsional rigidity were compared across different groups. RESULTS Compared with LCP group, (1) EF-tibia group showed significantly lower (p < 0.001) compression stiffness and torsional rigidity; (2) EF-femur group showed significantly lower (p < 0.001) compression stiffness, but significantly higher (p < 0.001) torsional rigidity. CONCLUSIONS The results indicated that locking compress plate as an external fixator was flexible, and the distal femur locking compress plate was preferred over the distal tibial locking compress plate to be an external fixator in distal tibia fracture treatment.
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Affiliation(s)
- Wei Liu
- Department of Orthopedics, Beijing Chao Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Lihui Yang
- Department of Orthopedics, Beijing Chao Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Xiaochuan Kong
- Department of Orthopedics, Beijing Chao Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Likun An
- Department of Orthopedics, Beijing Chao Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Gang Hong
- Department of Orthopedics, Beijing Chao Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Zicheng Guo
- Department of Orthopedics, Beijing Chao Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Lei Zang
- Department of Orthopedics, Beijing Chao Yang Hospital, Capital Medical University, Beijing, 100020, China.
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Fang JH, Wu YS, Guo XS, Sun LJ. Comparison of 3 Minimally Invasive Methods for Distal Tibia Fractures. Orthopedics 2016; 39:e627-33. [PMID: 27286045 DOI: 10.3928/01477447-20160606-01] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 12/14/2015] [Indexed: 02/03/2023]
Abstract
This study compared the results of external fixation combined with limited open reduction and internal fixation (EF + LORIF), minimally invasive percutaneous plate osteosynthesis (MIPPO), and intramedullary nailing (IMN) for distal tibia fractures. A total of 84 patients with distal tibia shaft fractures were randomized to operative stabilization using EF + LORIF (28 cases), MIPPO (28 cases), or IMN (28 cases). The 3 groups were comparable with respect to patient demographics. Data were collected on operative time and radiation time, union time, complications, time of recovery to work, secondary operations, and measured joint function using the American Orthopaedic Foot and Ankle Society (AOFAS) score. There was no significant difference in time to union, incidence of union status, time of recovery to work, and AOFAS scores among the 3 groups (P>.05). Mean operative time and radiation time in the MIPPO group were longer than those in the IMN or EF + LORIF groups (P<.05). Wound complications after MIPPO were more common compared with IMN or EF + LORIF (P<.05). Anterior knee pain occurred frequently after IMN (32.1%), and irritation symptoms were encountered more frequently after MIPPO (46.4%). Although EF + LORIF was associated with fewer secondary procedures vs MIPPO or IMN, it was related with more pin-tract infections (14.3%). Findings indicated that EF + LORIF, MIPPO, and IMN all achieved similar good functional results. However, EF + LORIF had some advantages over MIPPO and IMN in reducing operative and radiation times, postoperative complications, and reoperation rate. [Orthopedics. 2016; 39(4):e627-e633.].
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Cabrolier J, Molina M. Is intramedullary nailing superior to plating in patients with extraarticular fracture of the distal tibia? Medwave 2015; 15 Suppl 3:e6306. [PMID: 26571329 DOI: 10.5867/medwave.2015.6306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Distal tibial metaphyseal fractures are generally produced by high-energy trauma such as car accidents and can cause severe disability due to pain and deformity. In the management of these fractures, there are multiple surgical alternatives, but it is uncertain which the best option is. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified six systematic reviews including three randomized trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded it is not clear whether one surgical option is better than the other, because the certainty of the evidence is very low. Two ongoing randomized trials might help solving this uncertainty.
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Affiliation(s)
- Jorge Cabrolier
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile. Address: Facultad de Medicina, Pontificia Universidad Católica de Chile, Lira 63, Santiago Centro, Chile.
| | - Marcelo Molina
- Departamento de Traumatología y Ortopedia, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile
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Sathiyakumar V, Thakore RV, Ihejirika RC, Obremskey WT, Sethi MK. Distal tibia fractures and medial plating: factors influencing re-operation. INTERNATIONAL ORTHOPAEDICS 2014; 38:1483-8. [PMID: 24770693 DOI: 10.1007/s00264-014-2345-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 03/27/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE We compared types of complications leading to re-operations in open and closed distal tibia fractures treated by locking or nonlocking medial plates. METHODS Ninety-three patients from 2002 to 2012 who underwent open reduction and internal fixation (ORIF) and medial plating for distal extra-articular or partial articular tibia fractures were identified. Charts were retrospectively reviewed to determine the incidence of re-operation based on the type of complication that developed. Fisher's exact and chi-square tests were performed to analyze the incidence of complications based on injury and type of plate used. RESULTS Thirty-three (35.5 %) patients required re-operations: 28.6 % (n = 16) with closed injuries had complications leading to re-operations compared with 45.9 % (n = 17) of patients with open injuries (p = 0.12). Patients with closed injuries were more likely to require re-operation due to hardware pain/prominence (p = 0.03), whereas patients with open injuries were more likely to require re-operation due to nonunion (p = 0.04). There were no significant differences in infection (p = 0.66) or malunion (p = 0.99) between groups. Locking plates showed higher costs but were not associated with decreased risk of re-operation. CONCLUSIONS There was a high re-operation rate associated with distal tibia medial plating, with significant differences in the reason for re-operation between open versus closed groups. Complication rates were not influenced by the use of locking plates. Results of this study suggest that methods be considered to reduce re-operation based on type of fracture, such as early bone grafting or the use of alternate implants for open fractures.
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Affiliation(s)
- Vasanth Sathiyakumar
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200 Medical Center East, South Tower, Nashville, TN, 37232, USA,
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