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Mahmood A, Subbaraman K, Gadullah M, Hawkes D, Bose D, Fenton P. Circular frame versus reamed intramedullary tibial nail in the treatment of grade III open tibial diaphyseal fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2505-2510. [PMID: 38662197 DOI: 10.1007/s00590-024-03946-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Grade III open tibial diaphyseal fractures are challenging to treat and controversy exists on whether to treat them with an intramedullary nail (IMN) or a circular frame (CF). This study aims to compare outcomes for intramedullary nail and circular frame in the treatment of open tibial diaphyseal fractures. METHODOLOGY Retrospective study at a major trauma center of all patients admitted with a grade III open tibial diaphyseal fracture between January 2016 and January 2022. The primary outcome measures were major complications: non-union, malunion, refracture, DBI and amputation. Secondary outcome measures were time to union and reoperation rates. RESULTS Fifty-five patients were included in the study, 32 patients in CF group and 23 patients in IMN group. There were no significant differences in the baseline demographics of patients in both groups. Major complications were recorded in 13 limbs (54%) in IMN group and in 18 limbs (56%) in CF group which were not statistically significant (p = 0.797). Deep bone infection rates were noted in 4 (12.5%) in the CF group, compared to 1 (4%) in IMN group; however, the result was not statistically significant (p = 0.240). Amputation rates as a result of infected non-unions were seen in 1 limb (4%) in IMN group and 2 limbs (6%) in CF group (p = 0.99). Median time to union was significantly shorter in IMN group at 30 weeks compared to 30 weeks for CF group (p = 0.04). CONCLUSION IMN should be the treatment of choice in the treatment of grade III open tibial diaphyseal fracture, but CF should be considered for delayed treatment and in patients with bone loss.
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Affiliation(s)
- Aatif Mahmood
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK.
| | | | - Moheeb Gadullah
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - David Hawkes
- Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, UK
| | - Deepa Bose
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Paul Fenton
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
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Dong W, Thorne T, Da Silva Z, Dauk M, Marchand L, Rothberg D, Higgins T, Haller J. Patient-Reported Outcome Measurement Information Systems Physical Function and Pain Interference Scores Are Correlated With Tibial Shaft Fracture Nonunion Following Intramedullary Nailing. J Orthop Trauma 2024; 38:201-206. [PMID: 38470150 DOI: 10.1097/bot.0000000000002799] [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] [Received: 08/22/2023] [Accepted: 03/05/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVES To assess trends in Patient-Reported Outcome Measurement Information Systems (PROMIS) Physical Function (PF) and Pain Interference (PI) in surgically treated tibial shaft fracture patients progressing to union versus nonunion. METHODS DESIGN Retrospective cohort study. SETTING Level 1 trauma center. PATIENT SELECTION CRITERIA Patients with operatively treated tibial shaft fractures (AO/OTA 42-A, B, C) using an intramedullary nail. OUTCOME MEASURES AND COMPARISONS PROMIS PF and PI were compared between patients progressing to union and patients requiring nonunion repair. RESULTS A total of 234 patients (196 union, 38 nonunion) were included consisting 144 men and 90 women. The mean age of included patients was 40.8 years. A significant difference in mean PROMIS PF between union and nonunion patients was observed at 1-3 months ( P = 0.005), 3-6 months ( P < 0.001), 6-9 months ( P = 0.003), and 6-12 months ( P = 0.018). The odds of developing nonunion for every unit decrease in PROMIS PF was significant at 3-6 months (OR 1.07, P = 0.028) and 6-9 months (OR 1.17, P = 0.015). A significant difference in mean PROMIS PI between union and nonunion patients was observed at 1-3 months ( P = 0.001), 3-6 months ( P = 0.005), and 6-9 months ( P = 0.005). The odds of developing nonunion for every unit increase in PROMIS PI was significant at 1-3 months (OR 1.11, P = 0.005), 3-6 months (OR 1.10, P = 0.011), and 6-9 months (OR 1.23, P = 0.011). CONCLUSIONS Poorly trending PROMIS PF and PI in the clinical setting is a factor that can be used to evaluate progression to nonunion following tibial shaft repair where imaging studies may lag behind. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Willie Dong
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
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Cibura C, Ull C, Rosteius T, Lotzien S, Godolias P, Rausch V, Schildhauer T, Kruppa C. The Use of the Ilizarov Fixator for the Treatment of Open and Closed Tibial Shaft and Distal Tibial Fractures in Patients with Complex Cases. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024; 162:166-178. [PMID: 36167325 DOI: 10.1055/a-1910-3606] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Open and closed fractures of the tibial shaft or distal tibia can be challenging for surgeons to treat if the fractures are accompanied by aggravating conditions, such as various accompanying diseases, pronounced soft tissue injuries, osteomyelitis, and/or noncompliance. The aim of this retrospective study was to present our approach and results with the Ilizarov fixator as a treatment option for such individually complex cases. MATERIALS AND METHODS Between 2005 and 2018, 20 patients were treated with the Ilizarov fixator for fractures of the tibial shaft/distal tibia. The indication for this was a 2nd- to 3rd-degree open fracture in 10 patients, a 1st-degree open fracture in one patient, and closed fractures in 9 patients. Aggravating conditions included soft tissue injuries, osteomyelitis, leg deformities, multiple traumas, smoking, alcohol/drug abuse, and obesity (BMI > 60). In addition to demographic data, the time of fixator treatment, complications, and the endpoint of consolidation were evaluated retrospectively. RESULTS The mean time of fixator treatment was 29 (range 15-65) weeks. Complete fracture consolidation was achieved in 13 patients (65%) with the Ilizarov fixator. The mean follow-up period after fixator removal was 36 (range 2-186) months in 14 patients. Five patients with complete consolidation were lost to further follow-up. One patient was amputated. In six patients without union, internal osteosynthesis was carried out. CONCLUSION The use of the Ilizarov fixator is a treatment option for individual high-risk patients with complicating courses but should be seen as a salvage procedure due to the high complication rate and long treatment process.
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Affiliation(s)
- Charlotte Cibura
- Chirurgische Klinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland
| | - Christopher Ull
- Chirurgische Klinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland
| | - Thomas Rosteius
- Chirurgische Klinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland
| | - Sebastian Lotzien
- Unfallchirurgie, Berufsgenossenschaftliches Universitatsklinikum Bergmannsheil, Bochum, Deutschland
| | - Periklis Godolias
- Chirurgische Klinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland
| | - Valentin Rausch
- Chirurgische Klinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland
| | - Thomas Schildhauer
- Chirurgische Klinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland
| | - Christiane Kruppa
- Chirurgische Klinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland
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Jeremic D, Grubor N, Bascarevic Z, Slavkovic N, Krivokapic B, Vukomanovic B, Davidovic K, Jovanovic Z, Tomic S. Comparative Analysis of Complication Rates in Tibial Shaft Fractures: Intramedullary Nail vs. Ilizarov External Fixation Method. J Clin Med 2024; 13:2034. [PMID: 38610799 PMCID: PMC11012543 DOI: 10.3390/jcm13072034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Abstract
Background: The external fixation (EF) Ilizarov method, shown to offer efficacy and relative safety, has unique biomechanical properties. Intramedullary nail fixation (IMN) is an advantageous alternative, offering biomechanical stability and a minimally invasive procedure. The aim of this study was to assess outcomes in patients undergoing tibia fracture fixation, comparing the Ilizarov EF and IMN methods in an early phase of IMN implementation in Serbia. Methods: This was a retrospective study including patients with radiologically confirmed closed and open (Gustilo and Anderson type I) tibial diaphysis fractures treated at the Institute for Orthopedic Surgery "Banjica'' from January 2013 to June 2017. The following demographic and clinical data were retrieved: age, sex, chronic disease diagnoses, length of hospital stay, surgical wait times, surgery length, type of anesthesia used, fracture, prophylaxis, mechanism of injury, postsurgical complications, time to recovery, and pain reduction. Pain intensity was measured by the Visual Analog Scale (VAS), a self-reported scale ranging from 0 to 100 mm. Results: A total of 58 IMN patients were compared to 74 patients who underwent Ilizarov EF. Study groups differed in time to recovery (p < 0.001), length of hospitalization (p = 0.007), pain intensity at the fracture site (p < 0.001), and frequency of general anesthesia in favor of intramedullary fixation (p < 0.001). A shorter surgery time (p < 0.001) and less antibiotic use (p < 0.001) were observed when EF was used. Additionally, we identified that the intramedullary fixation was a significant predictor of pain intensity. Conclusions: The IMN method offers faster recovery and reduced pain intensity in comparison to EF, while the length of surgery predicted the occurrence of any complication.
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Affiliation(s)
- Danilo Jeremic
- Institute for Orthopeadics “Banjica”, 11000 Belgrade, Serbia; (Z.B.); (N.S.); (B.K.); (B.V.); (Z.J.); (S.T.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Nikola Grubor
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Zoran Bascarevic
- Institute for Orthopeadics “Banjica”, 11000 Belgrade, Serbia; (Z.B.); (N.S.); (B.K.); (B.V.); (Z.J.); (S.T.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Nemanja Slavkovic
- Institute for Orthopeadics “Banjica”, 11000 Belgrade, Serbia; (Z.B.); (N.S.); (B.K.); (B.V.); (Z.J.); (S.T.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Branislav Krivokapic
- Institute for Orthopeadics “Banjica”, 11000 Belgrade, Serbia; (Z.B.); (N.S.); (B.K.); (B.V.); (Z.J.); (S.T.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Boris Vukomanovic
- Institute for Orthopeadics “Banjica”, 11000 Belgrade, Serbia; (Z.B.); (N.S.); (B.K.); (B.V.); (Z.J.); (S.T.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Kristina Davidovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Zelimir Jovanovic
- Institute for Orthopeadics “Banjica”, 11000 Belgrade, Serbia; (Z.B.); (N.S.); (B.K.); (B.V.); (Z.J.); (S.T.)
| | - Slavko Tomic
- Institute for Orthopeadics “Banjica”, 11000 Belgrade, Serbia; (Z.B.); (N.S.); (B.K.); (B.V.); (Z.J.); (S.T.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
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Weatherford B, Dubina A, Pensy RA, Paryavi E, O'Toole RV. Risk Factors for Wound Failure After Primary Closure of Type IIIA Open Tibia Fractures. Orthopedics 2024; 47:108-112. [PMID: 37561105 DOI: 10.3928/01477447-20230804-05] [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: 08/11/2023]
Abstract
The objective of our investigation was to explore risk factors associated with primary closure of type IIIA tibial fractures resulting in subsequent flap coverage. A retrospective study identified 278 patients with acute type IIIA open tibial fractures who underwent primary closure at a single center during an 8-year period. Treatment factors, including the number of debridements before closure, duration of external fixation, and timing of wound closure, were reported. The primary outcome was complication requiring unplanned operation of the study injury resulting in flap coverage. Fifty-five (20%) patients underwent flap coverage following complication after attempted primary closure. Patients who required a flap experienced a 42% complication rate after delayed flap coverage. The limb salvage rate was 95% for the study population. Three significant complication predictors were identified: 3 or more debridements before closure (odds ratio [OR], 29.8; 95% CI, 5.9-150.1; P<.001), wound closure more than 2 days after injury (OR, 9.8; 95% CI, 1.6-60.2; P=.01), and external fixation more than 14 days (OR, 7.3; 95% CI, 1.6-34.6; P=.01). Patients who had 3 or more debridements before closure had a 70.7% chance of having a complication resulting in a flap (29 of 41) compared with only a 6.8% chance of complication for those who had 2 or fewer debridements (14 of 205; P<.001). Risk factors for complication after primary closure of type IIIA open tibial fractures include number of debridements, wound closure after 2 days, and external fixation use for more than 14 days. Wounds requiring 3 or more debridements failed 70.7% after closure, suggesting alternative approaches should be considered in more severe cases. [Orthopedics. 2024;47(2):108-112.].
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Albushtra A, Mohsen AH, Alnozaili KA, Ahmed F, Aljobahi YMAA, Mohammed F, Badheeb M. External Fixation as a Primary and Definitive Treatment for Complex Tibial Diaphyseal Fractures: An Underutilized and Efficacious Approach. Orthop Res Rev 2024; 16:75-84. [PMID: 38404536 PMCID: PMC10894515 DOI: 10.2147/orr.s450774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/18/2024] [Indexed: 02/27/2024] Open
Abstract
Background External fixation is one of the most often utilized treatment options for complicated tibial diaphyseal fractures (TDF). The purpose of this study was to assess the efficacy of unilateral external fixators as primary and definitive therapy for complex TDF in a resource-limited setting. Materials and Methods A retrospective study between June 2016 and March 2021 included 110 subjects with TDF who were treated with an external fixator as definitive fixation in hospitals affiliated with Ibb University. The patient's demographic characteristics, complications, and outcomes were gathered and analyzed. Factors associated with pin site infection were also investigated. Results The mean age was 42.1 ± 10.1 years, with 92.7% being male. Rural residents accounted for 22.7%. Smoking and diabetes mellitus were present in 27.3% and 30.0%, respectively. General complications occurred in 12.0%, with pulmonary embolism being the most common at 4.5%. Orthopedic complications included pin-track infections in 27.3% (30) and osteomyelitis in 1.8% (2). Pin site infections required medical treatment in 21 cases and external fixator changes in five. Two cases each needed several debridements for osteomyelitis and soft tissue. Full union occurred in 79.1% (87) over 23.1 ± 3.2 weeks and final alignment in 97.3% (107) over 34.8 ± 4.8 weeks. Malunions occurred in 1.8% (2), and one case had hypertrophic nonunion. Factors like rural residency, smoking, diabetes, open fractures, worst fracture grade (Gustilo and Anderson type C), and general complications occurrence significantly correlated with pin site infection (all p-values < 0.05). Conclusion A unilateral external fixator as a primary and definitive treatment is a viable, simple, and effective option for TDF with a high success rate even in a resource-limited setting. In this study, residents in rural areas, smoking, diabetes, open fracture, worst fracture grade, and general complication occurrence were associated with pin site infection occurrence.
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Affiliation(s)
- Ahmed Albushtra
- Department of Orthopedic, School of Medicine, Ibb University, Ibb, Yemen
| | | | - Khaled Ali Alnozaili
- Department of Orthopedic, School of Medicine, 21 September University, Sana’a, Yemen
| | - Faisal Ahmed
- Department of Urology, School of Medicine, Ibb University, Ibb, Yemen
| | | | - Fawaz Mohammed
- Department of Orthopedic, School of Medicine, Ibb University, Ibb, Yemen
| | - Mohamed Badheeb
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT, USA
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Thwaites S, Abrahams J, Thewlis D, Rickman M. The absence of reporting standards and a lack of objective, performance-based outcomes following intramedullary nailing of tibial shaft fractures: findings from a scoping review into 179 articles. Eur J Trauma Emerg Surg 2024; 50:59-70. [PMID: 37555990 PMCID: PMC10924025 DOI: 10.1007/s00068-023-02338-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/23/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE This scoping review was conducted to summarise the outcome tools reported in the assessment of tibial shaft fractures treated with intramedullary (IM) nailing, with a key focus on knee pain and function, and performance-based outcomes. METHODS PubMed and Embase databases were searched on May 31, 2023. All study designs and populations were included, including ex vivo studies without fracture. Studies with only open or intra-articular fractures, or other fracture fixation, were excluded. Reported outcome tools and pertinent study characteristics were extracted and summarised. RESULTS Of 488 articles identified, 179 met the inclusion criteria. For in vivo studies (n = 152), there were 13,705 fractures; the IM nailing approach not described for 30% of these. There were 133 unique patient outcomes, with a binary assessment of knee pain (29% of studies) and Lysholm score (21%) most common. Only 10/152 (7%) in vivo studies included an objective, performance-based measure of knee function. Fracture union was most frequent (52%) of 81 different clinical outcomes. For ex vivo studies (n = 29), there were 408 tibias included, with nail insertion location most prevalent (66% of studies) of 34 reported outcomes. CONCLUSION The heterogeneity of outcome tools reported limits comparison between studies and the most commonly reported patient outcomes may not be the most appropriate. Future studies should report the IM nailing approach and consider capturing both patient-reported and performance-based outcomes to help inform surgical decision making.
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Affiliation(s)
- Simon Thwaites
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia.
| | - John Abrahams
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dominic Thewlis
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mark Rickman
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Wang Y, Xia R, Pericic TP, Bekkering GE, Hou L, Bala MM, Gao Y, Wu M, Gloss D, Siemieniuk RA, Fei Y, Rochwerg B, Guyatt G, Brignardello-Petersen R. How do network meta-analyses address intransitivity when assessing certainty of evidence: a systematic survey. BMJ Open 2023; 13:e075212. [PMID: 38035750 PMCID: PMC10689416 DOI: 10.1136/bmjopen-2023-075212] [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: 04/29/2023] [Accepted: 10/31/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVES To describe how systematic reviews with network meta-analyses (NMAs) that used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) NMA approach addressed intransitivity when assessing certainty of evidence. DESIGN Systematic survey. DATA SOURCES Medline, Embase and Cochrane Database of Systematic Reviews from September 2014 to October 2022. ELIGIBILITY CRITERIA Systematic reviews of randomised controlled trials with aggregate data NMAs that used the GRADE NMA approach for assessing certainty of evidence. DATA EXTRACTION AND SYNTHESIS We documented how reviewers described methods for addressing intransitivity when assessing certainty of evidence, how often they rated down for intransitivity and their explanations for rating down. RESULTS Of the 268 eligible systematic reviews, 44.8% (120/268) mentioned intransitivity when describing methods for assessing the certainty of evidence. Of these, 28.3% (34/120) considered effect modifiers and from this subset, 67.6% (23/34) specified the effect modifiers; however, no systematic review noted how they chose the effect modifiers. 15.0% (18/120) mentioned looking for differences between the direct comparisons that inform the indirect estimate. No review specified a threshold for difference in effect modifiers between the direct comparisons that would lead to rating down for intransitivity. Reviewers noted rating down indirect evidence for intransitivity in 33.1% of systematic reviews, and noted intransitivity for network estimates in 23.0% of reviews. Authors provided an explanation for rating down for intransitivity in 59.6% (31/52) of the cases in which they rated down. Of the 31 in which they provided an explanation, 74.2% (23/31) noted they detected differences in effect modifiers and 67.7% (21/31) specified in what effect modifiers they detected differences. CONCLUSIONS A third of systematic reviews with NMAs using the GRADE approach rated down for intransitivity. Limitations in reporting of methods to address intransitivity proved considerable. Whether the problem is that reviewers neglected to address rating down for transitivity at all, or whether they did consider but not report, is not clear. At minimum systematic reviews with NMAs need to improve their reporting practices regarding intransitivity; it may well be that they need to improve their practice in transitivity assessment. How to best address intransitivity may remain unclear for many reviewers thus additional GRADE guidance providing practical instructions for addressing intransitivity may be desirable.
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Affiliation(s)
- Ying Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ruyu Xia
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, People's Republic of China
| | | | | | - Liangying Hou
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, People's Republic of China
| | - Malgorzata M Bala
- Department of Hygiene and Dietetics, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Ya Gao
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, People's Republic of China
| | - Michael Wu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David Gloss
- Charleston Area Medical Center, Charleston, West Virginia, USA
| | - Reed Alexander Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Yutong Fei
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, People's Republic of China
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Thorne T, Kellam P, Nelson C, Li H, Zhang Y, Cizik A, Marchand L, Haller JM. Minimal Clinically Important Differences of Patient-Reported Outcomes Measurement Information System Physical Function in Patients With Tibial Shaft Fracture. J Orthop Trauma 2023; 37:401-406. [PMID: 36952600 PMCID: PMC10612014 DOI: 10.1097/bot.0000000000002600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVE To calculate the minimal clinically important differences (MCIDs) of patient-reported outcomes measurement information system physical function (PROMIS PF) scores for patients with operatively treated tibial shaft fractures. DESIGN Retrospective Cohort Study. SETTING A Level 1 trauma center. PATIENTS All operatively treated tibial shaft fractures identified by Current Procedural Terminology codes. INTERVENTION Enrolled patients treated acutely with operative fixation of their tibia. MAIN OUTCOME MEASUREMENTS MCIDs were calculated by distribution-based and anchor-based methods, calculated from PROMIS PF scores completed at least at two-time points postoperatively. MCIDs were calculated at different time points including overall, 7-12 weeks, 3-6 months, and 6-24 months. MCIDs were calculated for different subgroups including open fractures, closed fractures, any complications, and no complications. RESULTS MCID for PROMIS PF scores was 5.7 in the distribution-based method and 7.84 (SD 18.65) in the anchor-based method. At 6-24 postoperatively, the months the distribution-based MCID was 5.95 from a postoperative baseline 27.83 (8.74) to 42.85 (9.61), P < 0.001. At 6-24 months, the anchor-based MCID was 10.62 with a score difference between the improvement group of 16.03 (10.73) and the no improvement group of 5.41 (15.75), P < 0.001. Patients with open fractures (distribution-based 6.22 and anchor-based 8.05) and any complications (distribution-based 5.71 and anchor-based 9.29) had similar or higher MCIDs depending on the methodology used than the overall cohort MCIDs. CONCLUSION This study identified distribution-based MCID of 5.7 and anchor-based MCID of 7.84 calculated from PROMIS PF scores in operative tibial shaft fractures. Distribution-based methods yielded smaller MCIDs than anchor-based methods. These MCID scores provide a standard to compare clinical and investigational outcomes.
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Affiliation(s)
- Tyler Thorne
- University of Utah Department of Orthopaedic Surgery, Salt Lake City, UT
| | - Patrick Kellam
- University of Utah Department of Orthopaedic Surgery, Salt Lake City, UT
| | - Chase Nelson
- University of Utah Department of Orthopaedic Surgery, Salt Lake City, UT
| | - Haojia Li
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Yue Zhang
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Amy Cizik
- University of Utah Department of Orthopaedic Surgery, Salt Lake City, UT
| | - Lucas Marchand
- University of Utah Department of Orthopaedic Surgery, Salt Lake City, UT
| | - Justin M Haller
- University of Utah Department of Orthopaedic Surgery, Salt Lake City, UT
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Coelho A, Sánchez-Soler JF, Fernández-Dominguez JM, Amorim-Barbosa T, Torres-Claramunt R, Perelli S, Monllau JC. Arthroscopically Assisted Suprapatellar Tibial Nail Removal. Arthrosc Tech 2023; 12:e1329-e1333. [PMID: 37654875 PMCID: PMC10466188 DOI: 10.1016/j.eats.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/29/2023] [Indexed: 09/02/2023] Open
Abstract
Intramedullary nailing remains the most popular and preferred method of fixation for tibial shaft fractures. The infrapatellar approach through the patellar tendon has long been considered the gold standard. However, the suprapatellar approach has gained popularity because of the advantages of being easier to perform when treating proximal shaft and metaphyseal fractures and there being less postoperative anterior knee pain. Despite increased use of this approach, the removal of the implant from the same suprapatellar approach is tricky, and in most cases, the removal is performed through a new transpatellar tendon approach. This article describes arthroscopically assisted suprapatellar tibial nail removal using the same approach and instrumentation of the nail insertion. The technique has the advantage of preserving the patellar tendon without causing secondary damage to it. Through arthroscopy, direct visualization of the patellofemoral joint aids in preventing possible cartilage injury. Moreover, any associated intra-articular lesions can be diagnosed and addressed.
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Affiliation(s)
- Alexandre Coelho
- Orthopedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Francisco Sánchez-Soler
- Orthopedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | | | - Tiago Amorim-Barbosa
- Orthopedic Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Raúl Torres-Claramunt
- Orthopedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Institut Català de Traumatologia, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Simone Perelli
- Orthopedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Institut Català de Traumatologia, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Carles Monllau
- Orthopedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Institut Català de Traumatologia, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
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11
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Jeremić D, Rajovic N, Gluscevic B, Krivokapic B, Rajkovic S, Bogosavljevic N, Davidovic K, Tomic S. Updated Meta-Analysis of Randomized Controlled Trials Comparing External Fixation to Intramedullary Nailing in the Treatment of Open Tibial Fractures. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1301. [PMID: 37512111 PMCID: PMC10383038 DOI: 10.3390/medicina59071301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Abstract
Background: The purpose of this study was to collect all available randomized controlled trials (RCT) on the treatment of open tibial fractures with an external fixator (EF) and intramedullary nailing (IMN) for meta-analysis to provide reliable evidence-based data for clinical decision-making. Material and methods: The systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and AMSTAR (Assessing the Methodological Quality of Systematic Review). An electronic search of PubMed, Cochrane Library, and Web of Science was performed until 1 March 2023 to identify RCTs which compared either IMN or EF to fix the open tibial fracture. Outcome measures were: postoperative superficial and deep infection, time to union, delayed union, malunion, nonunion and hardware failure. In addition, pain and health-related quality of life were evaluated after 3 and 12 months of follow-up. Results: Sixteen publications comprising 1011 patients were included in the meta-analysis. The pooled results suggested that the IMN technique had a lower postoperative superficial infection and malunion rate (RR = 3.56, 95%CI = 2.56-4.95 and RR = 1.96, 95%CI = 1.12-3.44, respectively), but higher hardware failure occurrence in contrast to EF (RR = 0.30; 95%CI = 0.13-0.69). No significant differences were found in the union time, delayed union or nonunion rate, and postoperative deep infection rate between the treatments. Lower levels of pain were found in the EF group (RR = 0.05, 95%CI = 0.02-0.17, p < 0.001). A difference in quality of life favoring IMN after 3 months was found (RR = -0.04, 95%CI = -0.05-0.03, p < 0.001), however, no statistical difference was found after 12 months (RR = 0.03, 95%CI = -0.05-0.11, p = 0.44). Conclusions: Meta-analysis presented reduced incidence rates of superficial infection, malunion, and health-related quality of life 3 months after treatment in IMN. However, EF led to a significant reduction in pain and incidence rate of hardware failure. Postoperative deep infection, delayed union, nonunion and health-related quality of life 12 months following therapy were similar between groups. More high-quality RCTs should be conducted to provide reliable evidence-based data for clinical decision-making.
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Affiliation(s)
- Danilo Jeremić
- Institute for Orthopedic Surgery "Banjica", 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Nina Rajovic
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Boris Gluscevic
- Institute for Orthopedic Surgery "Banjica", 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Branislav Krivokapic
- Institute for Orthopedic Surgery "Banjica", 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Stanislav Rajkovic
- Institute for Orthopedic Surgery "Banjica", 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Nikola Bogosavljevic
- Institute for Orthopedic Surgery "Banjica", 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Kristina Davidovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Department of Radiology, Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Slavko Tomic
- Institute for Orthopedic Surgery "Banjica", 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
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12
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Yang L, Guo J, He J, Shao J. Skin grafting treatment of adolescent lower limb avulsion injury. Front Surg 2022; 9:953038. [PMID: 36189402 PMCID: PMC9521200 DOI: 10.3389/fsurg.2022.953038] [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: 05/25/2022] [Accepted: 08/30/2022] [Indexed: 11/25/2022] Open
Abstract
Background Under the influence of various factors, the number of lower extremity avulsion injuries in adolescents is increasing year by year. The main modality of treatment is skin grafting. There are many types of skin grafting. Although many studies on skin grafting after avulsion injuries have been published in the past few decades, there are differences in the treatment options for adolescents with post avulsion injuries. Main body Thorough debridement and appropriate skin grafts are essential for the surgical management of avulsion injuries for optimal prognosis. In the acquisition of grafts, progress has been made in equipment for how to obtain different depths of skin. The severity of the avulsion injury varies among patients on admission, and therefore the manner and type of skin grafting will vary. Especially in adolescents, graft survival and functional recovery are of great concern to both patients and physicians. Therefore, many efforts have been made to improve survival rate and activity. Conclusion This review summarizes the principles of treatment of avulsion injuries, the historical development of skin grafts, and the selection of skin grafts, hoping to be helpful for future research.
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13
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Kyengera DK, O’Hara NN, Slobogean GP, Howe AL, Blachut PA, O’Brien PJ, Stockton DJ. Unreamed Intramedullary Nailing Versus External Fixation for the Treatment of Open Tibial Shaft Fractures in Uganda: A Randomized Clinical Trial. J Orthop Trauma 2022; 36:349-357. [PMID: 35234730 PMCID: PMC9391253 DOI: 10.1097/bot.0000000000002362] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare unreamed intramedullary nailing versus external fixation for the treatment of Gustilo-Anderson type II and IIIA open tibial fractures admitted to a hospital in rural Uganda. DESIGN Randomized clinical trial. SETTING Regional referral hospital in Uganda. PATIENTS Fifty-five skeletally mature patients with a Gustilo-Anderson type II or IIIA open tibia shaft fracture treated within 24 hours of injury between May 2016 and December 2019. INTERVENTION Unreamed intramedullary nailing (n = 31) versus external fixation (n = 24). MAIN OUTCOME MEASUREMENTS The primary outcome was function within 12 months of injury, measured using the Function IndeX for Trauma (FIX-IT) score. Secondary outcomes included health-related quality of life (HRQoL) using the 3-level version of the 5-dimension EuroQol instrument (EQ-5D-3L), radiographic healing using the Radiographic Union Scale for Tibia (RUST) fractures score, and clinical complications. RESULTS Treatment with an intramedullary nail resulted in a 1.0-point higher [95% credible intervals (CrI), 0.1 to 1.9] FIX-IT score compared with external fixation. Results were similar for the secondary patient-reported outcomes, EQ-5D-3L and the visual analog scale component of the EuroQol instrument (EQ-VAS). RUST scores were not different between groups at any time point. Treatment with an intramedullary nail was associated with a 22.1% (95% CrI, -42.6% to 1.7%) lower rate of malunion and a 20.8% (95% CrI, -44.0% to 2.9%) lower rate of superficial infection. CONCLUSION In rural Uganda, treatment of open tibial shaft fractures with an unreamed intramedullary nail results in marginal clinically important improvements in functional outcomes, although there is likely an important reduction in malunion and superficial infection. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel K. Kyengera
- Department of Orthopaedics, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | - Andrea L. Howe
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Piotr A. Blachut
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia
| | - Peter J. O’Brien
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia
| | - David J. Stockton
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia
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14
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Basile A, Palmieri L, Lanzetti R, Sessa P, Spoliti M, Giai Via A, Pipino G. Suprapatellar intramedullary nailing of tibial shaft fractures in pregnancy. A report of two cases. BMC Pregnancy Childbirth 2022; 22:528. [PMID: 35765043 PMCID: PMC9241291 DOI: 10.1186/s12884-022-04835-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background Treatment of closed tibial shaft fractures in the 3rd trimester of pregnancy is controversial. Since there are few case reports published in literature, there is no consensus on the appropriate management of these fractures. This case report proposes intramedullary nailing throught the suprapatellar approach for the treatment of tibial shaft fracture in pregnant women, never described before in literature. Case presentation We report 2 cases of a tibial diaphyseal fracture treated by intramedullary nailing in women at the 3rd trimester of pregnancy. Conclusion Surgical treatment of tibial shaft fracture of pregnant women in the 3rd trimester of pregnancy with intramedullary nailing seems to be safe. The use of the specific suprapatellar approach helps in the intra-operative management of the pregnant patients.
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Affiliation(s)
- Attilio Basile
- Department of Orthopedic Surgery and Traumatology, San Camillo-Forlanini Hospital, Rome, Italy
| | - Laura Palmieri
- Department of Orthopedic Surgery and Traumatology, Policlinico Tor Vergata, School of Medicine, University of Tor Vergata, Rome, Italy
| | - Riccardo Lanzetti
- Department of Orthopedic Surgery and Traumatology, San Camillo-Forlanini Hospital, Rome, Italy
| | - Pasquale Sessa
- Department of Orthopedic Surgery and Traumatology, San Camillo-Forlanini Hospital, Rome, Italy
| | - Marco Spoliti
- Department of Orthopedic Surgery and Traumatology, San Camillo-Forlanini Hospital, Rome, Italy
| | - Alessio Giai Via
- Department of Orthopedic Surgery and Traumatology, San Camillo-Forlanini Hospital, Rome, Italy. .,School of Medicine, University of Salerno, Salerno, Italy.
| | - Gennaro Pipino
- UCM Malta University, campus Lugano, Lugano, Switzerland.,Department of Orthopedic Surgery and Traumatology, Villa Erbosa Hospital, Gruppo San Donato, Bologna, Italy
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15
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Reddy AK, Checketts JX, Scott JT, Norris GR, Norris BL. Network meta-analysis: What is its purpose in Orthopaedic literature? Injury 2022:S0020-1383(22)00435-1. [PMID: 35798576 DOI: 10.1016/j.injury.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/20/2022] [Indexed: 02/02/2023]
Abstract
Systematic reviews, of level-I primary literature, are the gold standard for the formation of Clinical Practice Guidelines in Orthopaedic Surgery. When systematic reviews have multiple groups of data, meta-analyses can be conducted to analyse the direct comparison of the data points (pairwise meta-analysis). Over recent years, statisticians have created a new statistical model called network meta-analyses that can be applied to systematic reviews. network meta-analyses allow for comparison of different treatment outcomes that may or may not have been directly assessed through level-I primary studies. network meta-analyses are appearing more and more in Orthopaedic Surgery literature; therefore, in this article, we discuss what a Network Meta-analysis is and its application in Orthopaedics.
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Affiliation(s)
- Arjun K Reddy
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111W 17th St., Tulsa, OK, USA; Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, OK, USA.
| | - Jake X Checketts
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, OK, USA
| | - Jared T Scott
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, OK, USA
| | - Grayson R Norris
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, OK, USA
| | - Brent L Norris
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, OK, USA; Orthopaedic & Trauma Services of Oklahoma, Tulsa, OK, USA
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16
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Garabano G, MacKechnie MC, Pereira S, Brown K, Flores MJ, Pesciallo CA, Miclau T, Bidolegui F. Open Tibial Fracture Treatment in Argentina: Reoperation Rates Following Surgical Management. JB JS Open Access 2022; 7:e21.00153. [PMID: 35747171 PMCID: PMC9208878 DOI: 10.2106/jbjs.oa.21.00153] [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] [Indexed: 11/30/2022] Open
Abstract
The purposes of the present study were (1) to characterize open tibial fractures and their treatment in trauma centers located across different regions of Argentina and (2) to evaluate the rates of and indications for reoperation after the surgical treatment of such fractures. Methods This retrospective multicenter study evaluated open tibial fractures in Argentina that were operatively treated by experienced orthopaedic trauma surgeon-members of the Argentine Association of Orthopedic Trauma (AATO) between January 2015 and June 2020. Data were collected from 13 hospital databases; 8 hospitals were designated as "interior," and 5 hospitals were designated as "exterior." The study included 701 skeletally mature patients, all of whom had a minimum of 12 months of follow-up. Information was collected on patient demographics, injury pattern and mechanism, fracture classification, treatment modality, reoperation rates, time between definitive fixation and reoperation, and indications for reoperation. Results Seventy-six percent of presenting injuries were the result of a high-energy mechanism. Intramedullary nailing represented the most common type of fixation (88%). One hundred and fifty patients (21%) required reoperation. Delayed union/nonunion was the most common indication for reoperation in patients who had been previously treated with intramedullary nail fixation (31%; 39 of 126), and infection was the most common indication for reoperation in patients who had been treated with plate fixation (43%; 3 of 7). The time between the injury and definitive fixation was significantly different between the interior and exterior trauma centers (13.8 versus 4.7 days; p < 0.001), as was the time between definitive fixation and reoperation (69.3 versus 25.2 days; p = 0.004). The reoperation rates for the interior and exterior trauma centers were similar (20% versus 24%; p = 0.2). Infection, delayed union/nonunion, and implant removal were the most common indications for reoperation across groups. Conclusions An improved understanding of the factors that influence treatment may help to guide future areas for improvement, establish educational goals, and create additional nationwide guidelines for open tibial fracture treatment. Level of Evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Madeline C. MacKechnie
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | | | - Kelsey Brown
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Michael J. Flores
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | | | - Theodore Miclau
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
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17
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Bhanushali A, Kovoor JG, Stretton B, Kieu JT, Bright RA, Hewitt JN, Ovenden CD, Gupta AK, Afzal MZ, Edwards S, Jaarsma RL, Graff C. Outcomes of early versus delayed weight-bearing with intramedullary nailing of tibial shaft fractures: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2022; 48:3521-3527. [PMID: 35238986 PMCID: PMC9532312 DOI: 10.1007/s00068-022-01919-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/12/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Early weight bearing (EWB) is often recommended after intramedullary nailing of tibial shaft fractures, however, the risks and benefits have not been critically evaluated in a systematic review or meta-analysis. Therefore, the aims of this study were to perform a systematic review and meta-analysis comparing EWB and delayed weight-bearing (DWB) after intramedullary nailing of tibial shaft fractures and assess the relationship between weight-bearing, fracture union and healing. METHOD This review included studies comparing the effects of EWB, defined as weight-bearing before 6 weeks, and DWB on fracture union and healing. PubMed, Embase, CINAHL, and the Cochrane Library were searched from inception to 9 May 2021. Risk of bias was assessed using the Down's and Black Checklist and Cochrane Risk of Bias Tool 2.0. Data were synthesised in a meta-analysis, as well as narrative and tabular synthesis. RESULTS Eight studies were included for data extraction and meta-analysis. The analysis produced mixed results and found a significant decrease in mean union time (-2.41 weeks, 95% confidence interval: -4.77, -0.05) with EWB and a significant Odd's Ratio (OR) for complications with DWB (OR: 2.93, 95% CI: 1.40, 6.16). There was no significant difference in rates of delayed union, non-union, re-operation and malunion. CONCLUSION The included studies were of moderate risk of bias and demonstrated shorter union time and fewer complications with EWB. However, current evidence is minimal and has significant limitations. The role of EWB in high-risk patients is yet to be examined. Further well-designed, randomised studies are required on the topic.
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Affiliation(s)
- Ameya Bhanushali
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua G Kovoor
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA, 5011, Australia
| | | | - James T Kieu
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Joseph N Hewitt
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA, 5011, Australia
| | - Christopher D Ovenden
- Discipline of Surgery, University of Adelaide, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mohamed Z Afzal
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Suzanne Edwards
- School of Public Health, Adelaide Health Technology Assessment, University of Adelaide, Adelaide, South Australia, Australia
| | - Ruurd L Jaarsma
- Flinders Medical Centre, Department of Orthopaedics and Trauma, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Christy Graff
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia. .,Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA, 5011, Australia. .,Discipline of Surgery, University of Adelaide, Women's and Children's Hospital, Adelaide, South Australia, Australia.
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18
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Natalwala I, Chuo CB, Shariatmadari I, Barlow G, Moulder E, Bates J, Sharma H. Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail. Strategies Trauma Limb Reconstr 2022; 16:161-167. [PMID: 35111255 PMCID: PMC8778722 DOI: 10.5005/jp-journals-10080-1536] [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] [Indexed: 12/04/2022] Open
Abstract
Introduction High-energy grade III open fractures of tibia are associated with significant complications and generate debate over the ideal fixation method. This study compares the clinical outcomes for circular frame fixation (CFF) vs intramedullary nail fixation (IMF) in grade III open tibial fractures. Materials and methods Single-centre retrospective study of patients admitted from January 2008 to December 2016. All patients with grade III open diaphyseal tibial fractures (AO 42 A, B, C), treated with either CFF or IMF, were included. The primary outcome was deep bone infection (DBI). Secondary outcomes were delayed or non-union, secondary intervention, and amputation. Results A total of 48 limbs in 47 patients had CFF, and 25 limbs in 23 patients had IMF. Median time to definitive fixation was significantly longer for CFF at 9 days (IQR 3–13) compared to IMF at 1 day (IQR 0–3.5) (p <0.001). The DBI rate was significantly lower (2 vs 16%) in the CFF group (p = 0.04). There were 14 limbs (29%) with delayed or non-union in the CFF group vs 5 limbs (20%) in the IMF group. In the CFF group, significantly more limbs required bone grafting for delayed or non-union (p = 0.03). However, there was a greater proportion of limbs in the CFF group with segmental fractures or bone loss (46 vs 4%) and these high-energy fracture patterns were associated with secondary bone grafting (p = 0.005), and with delayed or non-union (p = 0.03). A subgroup analysis of patients without segmental fractures or bone loss treated with either CFF or IMF showed no significant difference in secondary bone grafting (p >0.99) and delayed or non-union rates (p = 0.72). Overall, one patient in each group went on to have an amputation. Conclusion Our study found that CFF had a lower rate of DBI compared to IMF. Injuries with high-energy fracture patterns (segmental fractures or bone loss) were more likely to have delayed or non-union and require secondary bone grafting. These factors should be considered when selecting the appropriate method of definitive fixation. How to cite this article Natalwala I, Chuo CB, Shariatmadari I, et al. Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail. Strategies Trauma Limb Reconstr 2021;16(3):161–167.
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Affiliation(s)
- Ibrahim Natalwala
- Department of Plastic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
- Ibrahim Natalwala, Department of Plastic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom, e-mail:
| | - Cher Bing Chuo
- Department of Plastic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Isla Shariatmadari
- Department of General Surgery, Bristol Hospitals NHS Trust, Bristol, United Kingdom
| | - Gavin Barlow
- Department of Infectious Diseases, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Elizabeth Moulder
- Department of Trauma and Orthopaedic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Joanna Bates
- Department of Radiology, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Hemant Sharma
- Department of Trauma and Orthopaedic Surgery, Hull University Teaching Hospitals, Hull, United Kingdom
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19
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Al-Hourani K, Tornetta P. In Reply to Commentary on: "Definitive Fixation Outcomes of Open Tibial Shaft Fractures: Systematic Review and Network Meta-analysis". J Orthop Trauma 2021; 35:572. [PMID: 34224483 DOI: 10.1097/bot.0000000000002217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Khalid Al-Hourani
- Edinburgh Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Paul Tornetta
- Department of Orthopaedics, Boston Medical Center, Boston, MA
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20
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Al-Hourani K, Donovan R, Stoddart MT, Foote CJ, Kelly MB, Tornetta P. Definitive Fixation Outcomes of Open Tibial Shaft Fractures: Systematic Review and Network Meta-analysis. J Orthop Trauma 2021; 35:561-569. [PMID: 34050075 DOI: 10.1097/bot.0000000000002090] [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: 02/10/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To delineate if there were differences in outcomes between definitive fixation strategies in open tibial shaft fractures. DATA SOURCES MEDLINE, EMBASE, CENTRAL, and OpenGrey. STUDY SELECTION Randomized and Quasi-randomized studies analyzing adult patients (>18 years) with open tibial shaft fractures (AO-42), undergoing definitive fixation treatment of any type. DATA EXTRACTION Data regarding patient demographics, definitive bony/soft-tissue management, irrigation, type of antibiotics, and follow-up. Definitive intervention choices included unreamed intramedullary nailing (UN), reamed intramedullary nailing, plate fixation, multiplanar, and uniplanar external fixation (EF). The primary outcome was unplanned reoperation rate. Cochrane risk of bias tool and Grading of Recommendation Assessment, Development and Evaluation systems were used for quality analysis. DATA SYNTHESIS A random-effects meta-analysis of head-to-head evidence, followed by a network analysis that modeled direct and indirect data was conducted to provide precise estimates [relative risk (RR) and associated 95% confidence interval (95% CI)]. RESULTS In open tibial shaft fractures, direct comparison UN showed a lower risk of unplanned reoperation versus EF (RR 0.67, 95% CI 0.43-1.05, P = 0.08, moderate confidence). In Gustilo type III open fractures, the risk reduction with nailing compared with EF was larger (RR 0.61, 95% CI 0.37-1.01, P = 0.05, moderate confidence). UN had a lower reoperation risk compared with reamed intramedullary nailing (RR 0.91, 95% CI 0.58-1.4, P = 0.68, low confidence); however, this was not significant and did not demonstrate a clear advantage. CONCLUSIONS Intramedullary nailing reduces the risk of unplanned reoperation by a third compared with EF, with a slightly larger reduction in type III open fractures. Future trials should focus on major complication rates and health-related quality of life in high-grade tibial shaft fractures. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Khalid Al-Hourani
- Edinburgh Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Richard Donovan
- Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom
| | - Michael T Stoddart
- Department of Orthopaedic Surgery, The Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Clary J Foote
- Department of Orthopaedic Surgery, McMaster University, ON, Canada ; and
| | - Michael B Kelly
- Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA
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21
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Maleki M, Tehrani AF, Aray A, Ranjbar M. Intramedullary nail holes laser indicator, a non-invasive technique for interlocking of intramedullary nails. Sci Rep 2021; 11:21166. [PMID: 34707138 PMCID: PMC8551185 DOI: 10.1038/s41598-021-00382-8] [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: 02/11/2021] [Accepted: 10/12/2021] [Indexed: 11/09/2022] Open
Abstract
Interlocking of intramedullary nails is a challenging procedure in orthopedic trauma surgery. Numerous methods have been described to facilitate this process. But they are exposed patient and surgical team to X-rays or involves trial and error. An accurate and non-invasive method has been provided to easily interlocking intramedullary nails. By transferring a safe visible light inside the nail, a drilling position appears which use to drilling bone toward the nail hole. The wavelength of this light was obtained from ex-vivo spectroscopy on biological tissues which has optimal transmission, reflectance, and absorption properties. Moreover, animal and human experiments were performed to evaluate performance of the proposed system. Ex-vivo performance experiments were performed successfully on two groups of cow and sheep samples. Output parameters were procedure time and drilling quality which there were significant differences between the two groups in procedure time (P < 0.05). But no significant differences were observed in drilling quality (P > 0.05). Moreover, an In-vivo performance experiment was performed successfully on a middle-aged man. To compare the provided method, targeting-arm, and free-hand techniques, two human experiments were performed on a middle-aged and a young man. The results indicate the advantage of the proposed technique in the procedure time (P < 0.05), while the drilling quality is equal to the free-hand technique (P = 0.05). Intramedullary nail holes laser indicator is a safe and accurate method that reduced surgical time and simplifies the process. This new technology makes it easier to interlocking the intramedullary nail which can have good clinical applications.
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Affiliation(s)
- Mohammadreza Maleki
- Department of Mechanical Engineering, Isfahan University of Technology, 84156-83111, Isfahan, Iran.
| | - Alireza Fadaei Tehrani
- Department of Mechanical Engineering, Isfahan University of Technology, 84156-83111, Isfahan, Iran
| | - Ayda Aray
- Department of Physics, Isfahan University of Technology, 84156-83111, Isfahan, Iran
| | - Mehdi Ranjbar
- Department of Physics, Isfahan University of Technology, 84156-83111, Isfahan, Iran
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22
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A Systematic Review and Analysis of the Quality of Randomized Controlled Trials Comparing Infrapatellar and Suprapatellar Approach for Nailing of Tibial Fractures. J Orthop Trauma 2021; 35:506-511. [PMID: 33813543 DOI: 10.1097/bot.0000000000002058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the quality of evidence presented in prospective randomized controlled trials (RCTs) regarding suprapatellar versus infrapatellar approaches to tibia intramedullary nails using grading systems other than Oxford Levels of Evidence (LOE). DATA SOURCES A systematic review was performed using the phrases "tibial nail OR tibia OR intramedullary" AND "suprapatellar OR infrapatellar" AND "approach OR insertion" to search the PubMed database between 1999 and 2018 filtering for English language and full articles. STUDY SELECTION Included articles were prospective trials that compared infrapatellar and suprapatellar approaches to tibial intramedullary nails in adult patients. DATA EXTRACTION Studies were evaluated and scored by 2 independent observers using 3 different systems: Oxford LOE, Modified Coleman Methodology Score, and Revised Consolidated Standards of Reporting Trials (CONSORT). DATA SYNTHESIS Comparison for grading between observers was compared with a correlation coefficient and kappa statistic. CONCLUSIONS RCTs are historically regarded as the gold standard for establishing principles of evidence-based medicine. However, our evaluation of the evidence shows that though they followed the Oxford LOE, RCTs were considered poor by the other 2 methods. The majority of studies that were included in our review were considered poor using the Modified Coleman and CONSORT systems. Half the articles supported suprapatellar tibial nailing over the infrapatellar approach, whereas other half demonstrated equivocal results between the 2 techniques. This study highlights the importance of evaluating studies judiciously regardless of their study design or level of evidence.
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23
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Gao Y, Wang H, Tu P, Hu J, Wang Q, Chen X. A novel dynamic electromagnetic tracking navigation system for distal locking of intramedullary nails. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 209:106326. [PMID: 34433127 DOI: 10.1016/j.cmpb.2021.106326] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 07/29/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The accurate distal locking of intramedullary (IM) nails is a clinical challenge for surgeons. Although many navigation systems have been developed, a real-time guide method with free radiation exposure, better user convenience, and high cost performance has not been proposed. METHODS This paper aims to develop an electromagnetic navigation system named TianXuan-MDTS that provides surgeons with a proven surgical solution. And the registration method with external landmarks for IM nails and calibration algorithm for guiders were proposed. A puncture experiment, model experiments measured by 3D Slicer and cadaver experiments (2 cadaveric leg specimens and 6 drilling operations) are conducted to evaluate its performance and stability. RESULTS The registration deviations (TRE) is 1.05± 0.13 mm. In the puncture experiment, a success rate of 96% can be achieved in 45.94 s. TianXuan-MDTS were evaluated on 3 tibia model. The results demonstrated that all 9 screw holes were successfully prepared at a rate of 100% in 91.67 s. And the entry point, end point, and angular deviations were 1.60±0.20 mm, 1.47±0.18 mm, and 3.10±0.84°, respectively. Postoperative fluoroscopy in cadaver experiments showed that all drills were in the distal locking holes, with a success rate of 100% and the average time 143.17± 18.27 s. CONCLUSIONS The experimental results indicate that our system with novel registration and calibration methods could serve as a feasible and promising tool to assist surgeons during distal locking.
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Affiliation(s)
- Yao Gao
- School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Huixiang Wang
- Department of Orthopaedics, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Puxun Tu
- School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Junlei Hu
- School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Qiugen Wang
- Trauma Center, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaojun Chen
- School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China; Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, China.
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24
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Timing of Flap Coverage With Respect to Definitive Fixation in Open Tibia Fractures. J Orthop Trauma 2021; 35:430-436. [PMID: 34267149 DOI: 10.1097/bot.0000000000002033] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection. DESIGN A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage. SETTING Fourteen level-1 trauma centers across the United States. PATIENTS Two hundred ninety-six (n = 296) consecutive patients with Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage. INTERVENTION Delay definitive fixation and flap coverage in tibial type III fractures. MAIN OUTCOME MEASUREMENTS (1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding. RESULTS Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P < 0.001). CONCLUSION Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Patel KH, Logan K, Krkovic M. Strategies and outcomes in severe open tibial shaft fractures at a major trauma center: A large retrospective case-series. World J Orthop 2021; 12:495-504. [PMID: 34354937 PMCID: PMC8316841 DOI: 10.5312/wjo.v12.i7.495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/16/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Severe open tibia fractures are challenging to treat with a lack of published clear management strategies. Our aim was to provide an overview of the largest single-center experience in the literature, with minimum 1-year follow-up, of adult type 3 open tibial shaft fractures at Cambridge University Hospitals (a United Kingdom major trauma center). We sought to define patient characteristics and our main outcome measures were infection, union and re-fracture. AIM To retrospectively define patient and injury characteristics, present our surgical methods and analyze our outcomes-namely infection, union and re-fracture rates. METHODS Consecutive series of 74 patients with 75 open tibial fractures treated between 2014 and 2020 (26 classified as Gustilo-Anderson 3A, 47 were 3B and two were 3C). Nine patients underwent intramedullary nailing (IMN), 61 underwent Taylor spatial frame (TSF) fixation and 5 were treated with Masquelet technique (IMN and subsequent bone grafting). RESULTS Mean follow-up was 16 mo (IMN) and 25 mo (TSF). We had an infection rate of 6.7% (5), non-union rate of 4% (3) and re-fracture rate of 2.7% (2). Average time to union was 22 wk for IMN and 38.6 wk for TSF. Thirty-three cases had a bone defect with a mean of 5.4 cm (2-11). Patient age, sex, diabetes, smoking status or injury severity did not have a significant effect on union time with either fixation method. Our limb salvage rate was 98.7%. CONCLUSION Grade 1 to 3A injuries can effectively be treated with reamed or unreamed IMN. Grade 3B/C injuries are best treated by circular external fixators as they provide good, reproducible outcomes and allow large bone defects to be addressed via distraction osteogenesis.
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Affiliation(s)
- Kavi H Patel
- Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
| | - Karl Logan
- Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
| | - Matija Krkovic
- Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, United Kingdom
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Albareda J, Ibarz E, Mateo J, Suñer S, Lozano C, Gómez J, Redondo B, Torres A, Herrera A, Gracia L. Are the unreamed nails indicated in diaphyseal fractures of the lower extremity? A biomechanical study. Injury 2021; 52 Suppl 4:S61-S70. [PMID: 33707035 DOI: 10.1016/j.injury.2021.02.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intramedullary nailing is generally accepted as the first choice for the treatment of diaphyseal fractures of femur and tibia, with a gradual incease in the use of unreamed nails. Different studies during last years show controversial outcomes. Some authors strongly favor unreamed nailing, but most of the authors conclude that reamed nailing have proved to be more successful. MATERIAL AND METHODS This study simulates unreamed intramedullary nailing of four femoral and three tibial fracture types by means of Finite Element (FE) models, at early postoperative stages with a fraction of physiological loads, in order to determine whether sufficient stability is achieved, and if the extent of movements and strains at the fracture site may preclude proper consolidation. RESULTS The behavior observed in the different fracture models is very diverse. In the new biomechanical situation, loads are only transmitted through the intramedullary nail. Mean relative displacement values of fractures in the femoral bone range from 0.30 mm to 0.82 mm, depending on the fracture type. Mean relative displacement values of the tibial fractures lie between 0.18 and 0.62 mm, depending on the type of fracture. Concerning mean strains, for femoral fractures the maximum strains ranged between 12.7% and 42.3%. For tibial fractures the maximum strains ranged between 10.9% and 40.8%. CONCLUSIONS The results showed that unreamed nailing provides a very limited mechanical stability, taking into account that analyzed fracture patterns correspond to simple fracture without comminution. Therefore, unreamed nailing is not a correct indication in femoral fractures and should be an exceptional indication in open tibial fractures produced by high-energy mechanism.
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Affiliation(s)
- J Albareda
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - E Ibarz
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
| | - J Mateo
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Miguel Servet University Hospital. Zaragoza, Spain
| | - S Suñer
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain
| | - C Lozano
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain
| | - J Gómez
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital.
| | - B Redondo
- Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - A Torres
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - A Herrera
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
| | - L Gracia
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
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Tarng YW, Lin KC, Lin KJ, Yang YP, Chien Y, Wei HW. A novel low-profile external skeletal fixator for type IIIB open tibial fractures: A biomechanical and clinical pilot study. J Chin Med Assoc 2021; 84:528-535. [PMID: 33595994 DOI: 10.1097/jcma.0000000000000506] [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: 11/25/2022] Open
Abstract
BACKGROUND Although external fixator is standard for managing staged treatment of open tibial fracture, the main disadvantage of this device is too bulky to be tolerated by most patients for longtime use. The purposes of this pilot study were to compare the biomechanical properties of a novel low-profile external fixator (LP-ESF) with a traditional ESF and also to evaluate its performance in patients with Gustilo type IIIb tibial open fractures. METHODS A prospective clinical pilot study started from January 2015 to December 2017, and 18 patients with Gustilo type IIIb open tibial fractures underwent the fixation with a novel LP-ESF system. The biomechanical properties of the LP-ESF were compared with the Synthes External Fixation System according to the standard ASTM F1541-02. These patients were divided into two groups according to the size of bony defect. The postoperative clinical outcomes were subsequently collected. RESULTS The biomechanical properties of the LP-ESF were comparable with those of Synthes External Fixation System and had an improved the axial/torsional stiffness and ultimate strength. In the clinical study, all patients with LP-ESF had fracture union. The duration of application of LP-ESF was 3.5 to 18 months until fracture union. In 10 of 18 patients, their fractures were immobilized with the LP-ESF until bone union, and no pin tract infection and no chronic osteomyelitis were recorded. The 36-Item Short Form Health Survey life quality and health survey were good to excellent in these patients. Notably, the LP-ESF allowed a patient with severe bone and soft-tissue defects to preserve the leg and joints function. CONCLUSION In this study, we found that the novel LP-ESFs had improved clinical outcomes. The long-term LP-ESF application seems to be tolerable in our patients. This novel approach permits better controls in deep infection and faster healing of fractures, and thus may provide a viable alternative treatment for Gustilo type IIIb open tibial fractures.
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Affiliation(s)
- Yih-Wen Tarng
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Orthopaedics, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Kai-Cheng Lin
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Kun-Jhih Lin
- Department of Electrical Engineering, Chung Yuan Christian University, Taoyuan, Taiwan, ROC
- Technology Translation Center for Medical Device, Chung Yuan Christian University, Taoyuan, Taiwan, ROC
| | - Yi-Ping Yang
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yeuh Chien
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hung-Wen Wei
- Department of Electrical Engineering, Chung Yuan Christian University, Taoyuan, Taiwan, ROC
- Technology Translation Center for Medical Device, Chung Yuan Christian University, Taoyuan, Taiwan, ROC
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Ponugoti N, Rudran B, Selim A, Nahas S, Magill H. Infrapatellar versus suprapatellar approach for intramedullary nailing of the tibia: a systematic review and meta-analysis. J Orthop Surg Res 2021; 16:94. [PMID: 33509237 PMCID: PMC7844899 DOI: 10.1186/s13018-021-02249-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/19/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Intramedullary nailing (IMN) is a conventional technique for the treatment of tibial shaft fractures. It has been suggested that the suprapatellar (SP) approach holds advantages over the traditional infrapatellar (IP) approach. Current literature lacks adequate data to provide robust clinical recommendations. This meta-analysis aims to determine the efficacy of infrapatellar versus suprapatellar techniques for IMN. METHODS An up-to-date literature search of the Embase, Medline, and registry platform databases was performed. The search was conducted using a predesigned search strategy and all eligible literature was critically appraised for methodological quality via the Cochrane's collaboration tool. Fluoroscopy time, operative time, pain score, knee function, deep infection, non-union and secondary operation rates were all considered. CONCLUSION A total of twelve studies were included in the meta-analysis. The results of this analysis show that suprapatellar nailing is associated with reduced post-operative pain scores and improved functional outcomes. The data suggest no significant difference in terms of operative times, fluoroscopy times, rates of deep infection, non-union or secondary procedures when compared to infra-patellar techniques. Further studies are required to confirm these findings and assess long-term results.
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Wennergren D, Bergdahl C, Selse A, Ekelund J, Sundfeldt M, Möller M. Treatment and re-operation rates in one thousand and three hundred tibial fractures from the Swedish Fracture Register. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2021; 31:143-154. [PMID: 32743684 PMCID: PMC7815548 DOI: 10.1007/s00590-020-02751-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 07/25/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Approximately, 50 persons per 100,000 per year sustain a tibial fracture. There is, however, a lack of large cohort studies that describe the treatment and re-operation frequencies of tibial fractures. The aim of this study was to describe the treatment and re-operation rates of tibial fractures in all segments of the tibia. METHODS Data related to all patients aged 16 and above treated for tibial fractures (ICD-10 S82.10-31) at Sahlgrenska University Hospital in 2011-2015 were extracted from the Swedish Fracture Register. To make sure all re-operations were included in the study, the operation planning system was checked for all patients included in the study. RESULTS The study comprised 1371 tibial fractures - 712 proximal, 417 diaphyseal and 242 distal tibial fractures. Among the proximal and distal tibial fractures, plate fixation was the most commonly used surgical method, whereas among tibial shaft fractures, an intramedullary nail was the most commonly used surgical method. Almost 30% (29.8%) of all surgically treated tibial fractures underwent re-operation. Among proximal tibial fractures, 24.0% underwent re-operation; tibial shaft fractures 37.0% and distal tibial fractures 26.8%. Re-operations due to infection were more or less equally common in all segments (3.9-5.4%). CONCLUSION This study describes the treatment and re-operation rates after tibial fractures in a cohort of 1371 tibial fractures at Sahlgrenska University Hospital during a period of 5 years. The study shows an overall re-operation rate of 29.8% for fractures in all segments of the tibia.
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Affiliation(s)
- David Wennergren
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Orthopaedics, Sahlgrenska University Hospital, SE-413 45, Mölndal, Gothenburg, Sweden.
| | - Carl Bergdahl
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, SE-413 45, Mölndal, Gothenburg, Sweden
| | - Amanda Selse
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Ekelund
- Centre of Registers, Western Healthcare Region, Gothenburg, Sweden
| | - Mikael Sundfeldt
- Department of Orthopaedics, Sahlgrenska University Hospital, SE-413 45, Mölndal, Gothenburg, Sweden
| | - Michael Möller
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, SE-413 45, Mölndal, Gothenburg, Sweden
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Albright PD, MacKechnie MC, Roberts HJ, Shearer DW, Padilla Rojas LG, Segovia J, Quintero JE, Amadei R, Baldy Dos Reis F, Miclau T. Open Tibial Shaft Fractures: Treatment Patterns in Latin America. J Bone Joint Surg Am 2020; 102:e126. [PMID: 32890042 DOI: 10.2106/jbjs.20.00292] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open tibial shaft fractures are an important source of disability in Latin America. High-income countries (HICs) worldwide have established standardized treatment protocols for open tibial fractures, but less is known about their treatment in middle-income countries (MICs) in Latin America. This survey of Latin American orthopaedic surgeons characterizes open tibial fracture treatment patterns. METHODS Orthopaedic surgeons from 20 national orthopaedic societies throughout Latin America completed an online survey assessing their treatment of open tibial fractures. Demographic information was collected. Treatment patterns were queried according to 2 groupings of Gustilo-Anderson (GA) fracture types: treatment of type-I and type-II fractures (GA-I/II) and treatment of type-III fractures (GA-III). Treatment patterns were evaluated across 4 domains: antibiotic prophylaxis, irrigation and debridement, fracture stabilization, and wound management. Summary statistics were reported; analysis was performed using the Fisher exact test (p < 0.05). RESULTS There were 616 survey participants from 20 Latin American countries (4 HICs and 16 MICs). Initial external fixation followed by staged internal fixation was preferred for GA-I/II (51.0%) and GA-III fractures (86.0%). Nearly one-third (31.5%) of GA-IIIB fractures did not receive a soft-tissue coverage procedure. Stratifying by country socioeconomic status, surgeons in MICs more commonly utilized delayed internal fixation for GA-I/II (53.3% versus 22.0%, p < 0.001) and GA-III fractures (94.0% versus 80.4%, p = 0.002). Surgeons in MICs more commonly used primary closure for GA-I/II (88.9% versus 62.8%, p < 0.001) and GA-III fractures (32.6% versus 9.8%, p < 0.001). CONCLUSIONS This survey reports Latin American orthopaedic surgeons' treatment patterns for open tibial shaft fractures. Surgeons in MICs reported higher delayed internal fixation use for all fracture types, while surgeons in HICs more routinely avoid primary closure. Soft-tissue coverage procedures are not performed in nearly one-third of GA-IIIB fractures because of a lack of operative personnel and training.
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Affiliation(s)
- Patrick D Albright
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota.,Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Madeline C MacKechnie
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Heather J Roberts
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - David W Shearer
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
| | | | - Julio Segovia
- Hospital Central Instituto de Previsión Social, Asunción, Paraguay
| | | | - Rafael Amadei
- Hospital Interzonal General de Agudos, San Martín de la Plata, La Plata, Argentina
| | | | - Theodore Miclau
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
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Zhang N, Liu K, She Y, Zhao W, Zeng J, Lin G. Efficacy and safety of acupuncture and moxibustion for herpes zoster: A protocol for systematic review and network meta analysis. Medicine (Baltimore) 2020; 99:e21905. [PMID: 32899021 PMCID: PMC7478486 DOI: 10.1097/md.0000000000021905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Herpes zoster (HZ) is currently treated primarily with antiviral drugs, yet this treatment has been debated. Acupuncture is becoming a more important treatment in this protocol. For example, pain intensity is lower among HZ patients who receive acupuncture plus moxibustion than among those who receive pharmacotherapy. There are many types of acupuncture interventions, including electroacupuncture, moxibustion, bloodletting. In this study, a network meta-analysis (NMA) is used to rank various interventions of acupuncture. METHODS AND ANALYSIS Electronic searches of abstracts and titles will be performed in MEDLINE, EMBASE, CENTRAL, CBM, CNKI, CQVIP, and Wanfang Data databases, from inception to December 31, 2019. Published and unpublished controlled trials with different acupuncture interventions will be selected, trials of antiviral drugs as the control group. All patients of HZ will be included, except for those diagnosed with PHN, immunocompromised patients, or those with complications. The effective therapy rate and the incidence of PHN are primary outcomes. The NMA will be analyzed with Stata 13.0 and GeMTC 0.14.3. DISCUSSION The NMA will be established to compare various interventions of acupuncture for the therapy of HZ, that could resolve the limitations of previous methodologies with this protocol. It will be possible to determine the best acupuncture intervention for more primary outcomes of therapy, including subgroup analysis of patients with aged ≥50 years and those of aged <50 years. ETHICS AND DISSEMINATION The NMA does not require ethical approval. The data analyzed is not personal. It is only systematically used to evaluate the effectiveness of acupuncture treatments. The results will be disseminated through international conference reports and peer-reviewed manuscripts. STRENGTH AND LIMITATIONS OF THIS STUDY A comprehensive methodology is established to rank various interventions of acupuncture by which best evidence-based intervention may be recommended for those population groups of aged ≥50 years and aged <50 years. PROSPERO REGISTRATION NUMBER CRD42019118369.
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Affiliation(s)
- Na Zhang
- Guangzhou University of Chinese Medicine
| | - Kun Liu
- Guangzhou University of Chinese Medicine
| | - Yalin She
- Guangzhou University of Chinese Medicine
| | - Weixuan Zhao
- First Affiliated Hospital of Guangdong Pharmaceutical University
| | - Jingchun Zeng
- Department of Acupuncture, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
| | - Guohua Lin
- Department of Acupuncture, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
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Plate-Assisted Intramedullary Nailing of Gustilo Type IIIB Open Tibial Diaphyseal Fractures: Does Adjunctive Plate Retention Affect Complication Rate? J Orthop Trauma 2020; 34:363-369. [PMID: 31972709 DOI: 10.1097/bot.0000000000001738] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To investigate the complication rates after use of retained adjunctive plate (RAP) fixation with intramedullary nailing of Gustilo-Anderson type IIIB open tibia fractures, as part of a 2-stage orthoplastic approach. DESIGN Consecutive cohort study. PATIENTS/PARTICIPANTS One hundred and thirty-seven consecutive patients with a Gustilo-Anderson type IIIB open diaphyseal tibia fracture (OTA/AO 42) treated between May 2014 and January 2018. Ninety-eight patients (RAP = 67; non-RAP = 31) met the inclusion criteria and underwent 2-stage reconstruction. All patients were treated using a small fragment adjunctive plate to hold the fracture reduced before intramedullary nailing. INTERVENTION At stage 2, the temporary small fragment (in-fix) plate was removed and the site further thoroughly debrided. After this, the fracture is reduced and held with a new small fragment plate to facilitate the definitive intramedullary nailing. This new plate was either retained (RAP) as part of the definitive fixation at second stage or removed before wound coverage. MAIN OUTCOME MEASUREMENT The main outcome measures were reoperation rate, deep infection, nonunion, and flap-related complication. RESULTS Six patients (6/98, 6.1%) proceeded to nonunion (RAP 5/67, non-RAP 1/31). This was not significant (P = 0.416). Two hundred twelve operations were undertaken, and the median was 2. Sixteen (16/212, 7.5%) complication-related reoperations were undertaken, affecting 8 patients (8/67, 11.9%) in the RAP group. Eight patients (8/98, 8.2%) developed a deep infection (RAP 6/67, non-RAP 2/31). This was not significant (P = 0.674). CONCLUSIONS In the context of an orthoplastic approach, the use of a RAP with definitive intramedullary nailing does not seem to significantly increase the rate of deep infection or nonunion in patients with type IIIB open tibial shaft fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Haonga BT, Liu M, Albright P, Challa ST, Ali SH, Lazar AA, Eliezer EN, Shearer DW, Morshed S. Intramedullary Nailing Versus External Fixation in the Treatment of Open Tibial Fractures in Tanzania: Results of a Randomized Clinical Trial. J Bone Joint Surg Am 2020; 102:896-905. [PMID: 32028315 PMCID: PMC7508278 DOI: 10.2106/jbjs.19.00563] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open tibial fractures are common injuries in low and middle-income countries, but there is no consensus regarding treatment with intramedullary nailing versus external fixation. The purpose of the present study was to compare the outcomes of initial treatment with intramedullary nailing or external fixation in adults with open tibial fractures. METHODS We conducted a randomized clinical trial (RCT) at a tertiary orthopaedic center in Tanzania. Adults with acute diaphyseal open tibial fractures were randomly assigned to statically locked, hand-reamed intramedullary nailing or uniplanar external fixation. The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Secondary outcomes included quality of life as measured with the EuroQol-5 Dimensions (EQ-5D) questionnaire, radiographic alignment, and healing as measured with the modified Radiographic Union Scale for Tibial fractures (mRUST). RESULTS Of the 240 patients who were enrolled, 221 (92.1%) (including 111 managed with intramedullary nailing and 110 managed with external fixation) completed 1-year follow-up. There were 44 primary outcome events (with rates of 18.0% and 21.9% in the intramedullary nailing and external fixation groups, respectively) (relative risk [RR] = 0.83 [95% confidence interval (CI), 0.49 to 1.41]; p = 0.505). There was no significant difference between the groups in terms of the rate of deep infection. Intramedullary nailing was associated with a lower risk of coronal malalignment (RR = 0.11 [95% CI, 0.01 to 0.85]; p = 0.01) and sagittal malalignment (RR = 0.17 [95% CI, 0.02 to 1.35]; p = 0.065) at 1 year. The EQ-5D index favored intramedullary nailing at 6 weeks (mean difference [MD] = 0.07 [95% CI = 0.03 to 0.11]; p < 0.001), but this difference dissipated by 1 year. Radiographic healing (mRUST) favored intramedullary nailing at 6 weeks (MD = 1.2 [95% CI = 0.4 to 2.0]; p = 0.005), 12 weeks (MD = 1.0 [95% CI = 0.3 to 1.7]; p = 0.005), and 1 year (MD = 0.8 [95% CI = 0.2 to 1.5]; p = 0.013). CONCLUSIONS To our knowledge, the present study is the first RCT assessing intramedullary nailing versus external fixation for the treatment of open tibial fractures in sub-Saharan Africa. Differences in primary events were not detected, and only coronal alignment significantly favored the use of intramedullary nailing. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Billy T. Haonga
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Max Liu
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Patrick Albright
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Sravya T. Challa
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Syed H. Ali
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Ann A. Lazar
- Division of Oral Epidemiology, School of Dentistry, University of California San Francisco, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California
| | - Edmund N. Eliezer
- Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - David W. Shearer
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Saam Morshed
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco School of Medicine, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California
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Design and Analysis of Customized Fixation Plate for Femoral Shaft. Indian J Orthop 2020; 54:148-155. [PMID: 32257031 PMCID: PMC7096597 DOI: 10.1007/s43465-019-00025-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 05/02/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND In the recent years, several techniques have been used to treat femur diaphyseal fracture. Among all the traditional fixation techniques, unstable fixation remains the biggest challenge for orthopedists. Researchers have recommended new approaches to deal with diaphyseal femur fracture. However, solely few had been successful in getting some better results. In the present work, a methodology comprising of design and finite-element analysis of a counter fit customized fixation plate has been suggested to provide a stable fixation. MATERIALS AND METHODS In the present work, reverse engineering (RE) approach has been invoked to create a 3D model of a fresh fractured femur diaphysis bone using the computed tomography (CT) scan data available in digital imaging and communications in medicine (DICOM) format. To provide stable fixation, a counter fit customized fixation plate at medial side has been designed and simulated under static physiological loading conditions for three different biocompatible materials, viz., titanium alloy (Ti6Al4V), stainless steel (SS-316L), and cobalt-chromium-molybdenum alloy (Co-Cr-Mo). RESULTS Static stress distribution and deformation analysis of the clinical setup have been performed for the aforementioned materials. It has been observed that the stresses and deformation developed in all the materials are quite low. It implies that customized fixation plates will provide stable fixation resulting in improved fracture union. CONCLUSION The proposed work will assist the medical practitioners regarding the design and analysis of customized implants. This will reduce the post surgical failures and residual pain due to non-union fractured region.
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Hao ZC, Xia Y, Xia DM, Zhang YT, Xu SG. Treatment of open tibial diaphyseal fractures by external fixation combined with limited internal fixation versus simple external fixation: a retrospective cohort study. BMC Musculoskelet Disord 2019; 20:311. [PMID: 31266474 PMCID: PMC6607594 DOI: 10.1186/s12891-019-2679-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 06/12/2019] [Indexed: 02/03/2023] Open
Abstract
Background The treatment of open tibial shaft fractures is challenging. External fixation (EF) is comparatively safe in treating these open injuries, meanwhile it has the advantages of easy application, minimal additional disruption, and convenient subsequent soft tissue repair. Nevertheless, its application is accompanied by a series of problems in alignment and bone healing. Therefore, limited internal fixation (LIF), such as cortical screws, has been used based on the external fixator for better therapeutic effect. The aim of this study is to compare the outcomes of EF combined with LIF and simple EF in the management of open tibial shaft fractures, evaluating the efficacy and safety of using the combined technique in treating such fractures. Methods From January 2012 to December 2016, patients with open tibial shaft fractures treated with EF with or without LIF augmentation were identified. A total of 152 patients were included in the analysis, and there were 85 patients in the simple external fixation group and 67 patients in the EF-LIF group. General assessment indicators included the direct cost of hospitalization and the times of first surgery, full weight bearing, and complete union. Infections and complications in union or limb alignment were compared as primary outcomes. Additionally, the number of patients who changed the fixation system for various reasons were analysed. Results Effective follow-up of all participants for statistical analysis was obtained. The follow-up time averaged 17.15 months (range: 12.00 to 24.00 months) in the EF group and 16.20 months (range: 12.00 to 19.00 months) in the EF-LIF group. Combined fixation provided shortened time to bear full weight and achieve complete bone union, while requiring additional first surgery time. No significant difference was found in infection rates or direct cost of hospitalization. Delayed union and non-union in the EF-LIF group were significantly decreased (20.9% versus 40.0, 1.5% versus 14.1%, p < 0.05). In limb alignment, patients with combined fixation exhibited reduced malreduction, loss of reduction, and malunion. In terms of secondary fixation, the EF-LIF group showed a markedly lower incidence (5.8% versus 34.1%, p < 0.001). Conclusion Compared with simple EF, combined fixation is an effective and safe alternative for management of open tibial diaphyseal fractures. It provides superior initial reduction, better stability and decreases the risk of inferior alignment and delayed union without increasing the risk of infection.
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Affiliation(s)
- Zi-Chen Hao
- Department of Emergency, Trauma Center, Changhai Hospital, The Second Military Medical University, No 168, Changhai Road, Yangpu District, Shanghai, 200433, People's Republic of China
| | - Yan Xia
- Department of Emergency, Trauma Center, Changhai Hospital, The Second Military Medical University, No 168, Changhai Road, Yangpu District, Shanghai, 200433, People's Republic of China
| | - De-Meng Xia
- Department of Emergency, Trauma Center, Changhai Hospital, The Second Military Medical University, No 168, Changhai Road, Yangpu District, Shanghai, 200433, People's Republic of China
| | - Yun-Tong Zhang
- Department of Emergency, Trauma Center, Changhai Hospital, The Second Military Medical University, No 168, Changhai Road, Yangpu District, Shanghai, 200433, People's Republic of China.
| | - Shuo-Gui Xu
- Department of Emergency, Trauma Center, Changhai Hospital, The Second Military Medical University, No 168, Changhai Road, Yangpu District, Shanghai, 200433, People's Republic of China.
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Li H, Yu D, Wu S, Zhang Y, Ma L. Multiple Comparisons of the Efficacy and Safety for Seven Treatments in Tibia Shaft Fracture Patients. Front Pharmacol 2019; 10:197. [PMID: 31024295 PMCID: PMC6467001 DOI: 10.3389/fphar.2019.00197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/15/2019] [Indexed: 11/13/2022] Open
Abstract
Background: A tibia shaft fracture is one of the most common long bone fractures, with two general types, open fracture and close fracture. However, there is no universally accepted guideline suggesting which treatment to use under certain circumstances. Therefore, a comprehensive network meta-analysis (NMA) is needed to summarize existing studies and to provide more credible data-based medical guidelines. Methods: Available literature was identified by searching medical databases with relevant key terms. Studies that met the inclusion and exclusion criteria, baseline, intervention, and the outcome of treatments, were extracted. A comparative connection of these studies was demonstrated through net plots. Continuous variables and binary variables were reported as mean difference (MD) and odds ratio (OR) with a 95% credible interval (CrI), respectively. The comparison of direct and indirect outcome and their P-value were listed in the node-splitting table. Treatments for each endpoint were ranked by their surface under the cumulative ranking curve (SUCRA) value. A heat plot was created to illustrate the contribution of raw data and the inconsistency between direct and indirect comparisons. Results: According to the search strategy, 697 publications were identified, and 25 records were included, involving 3,032 patients with tibia shaft fractures. Seven common surgical or non-surgical treatments, including reamed intramedullary nailing (RIN), un-reamed intramedullary nailing (UIN), minimally reamed intramedullary nailing (MIN), ender nailing (EN), external fixation (EF), plate, and cast, were compared, in terms of time to union, reoperation, non-union, malunion, infection and implant failure. Plate performed relatively better for time to union, while cast might be the best choice in close cases to reduce the risks of reoperation, non-union, malunion, and infection. To prevent implant failure, EN seemed to be better. Conclusion: Cast might have the highest probability of the most optimal choice for tibia shaft fracture in close cases, while reamed intramedullary nailing ranked second.
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Affiliation(s)
- Haibo Li
- Department of Orthopaedic, Tianjin Hospital, Tianjin, China
| | - Dapeng Yu
- Department of Emergency Trauma Surgery, the Wendeng Osteopathic Hospital, Weihai, China
| | - Shaobin Wu
- Department of Orthopaedic, Weifang Traditional Chinese Hospital, Weifang, China
| | - Yihang Zhang
- Graduate Student Education Center, Shandong Academy of Medical Sciences, Jinan, China
| | - Liang Ma
- Department of Orthopaedic, Affiliated Hospital of Shandong University of Chinese Medicine, Jinan, China
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GRADE approach to rate the certainty from a network meta-analysis: addressing incoherence. J Clin Epidemiol 2018; 108:77-85. [PMID: 30529648 DOI: 10.1016/j.jclinepi.2018.11.025] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 10/26/2018] [Accepted: 11/30/2018] [Indexed: 01/22/2023]
Abstract
This article presents official guidance from the Grading of Recommendations Assessments, Development, and Evaluation (GRADE) working group on how to address incoherence when assessing the certainty in the evidence from network meta-analysis. Incoherence represents important differences between direct and indirect estimates that contribute to a network estimate. Bias due to limitations in study design or publication bias, indirectness, and intransitivity may be responsible for incoherence. Addressing incoherence requires a judgment regarding the importance of the impact on the network estimate. Reviewers need to be alert to the possibility of misguidedly arriving at excessively low ratings of certainty by rating down for both incoherence and other closely related GRADE domains. This article describes and illustrates each of these issues and provides explicit guidance on how to deal with them.
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Cazzato G, Saccomanno MF, Noia G, Masci G, Peruzzi M, Marinangeli M, Maccauro G. Intramedullary nailing of tibial shaft fractures in the semi-extended position using a suprapatellar approach: A retrospective case series. Injury 2018; 49 Suppl 3:S61-S64. [PMID: 30415670 DOI: 10.1016/j.injury.2018.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 02/08/2023]
Abstract
Tibial shaft fractures are extremely common injuries. High rate of union, acceptable alignment in all planes, and a low complication rate have been reported when diaphyseal fractures are treated by intramedullary nailing. However, knee pain after tibial nailing has historically been problematic. While the exact aetiology of the knee pain is still unknown, surgical approach relative to the patellar tendon, nerve transection, violation of the fat pad or joint capsule as well as nail diameter and implant prominence have been claimed as possible causes. Therefore, establishing an appropriate starting point remains a crucial step in the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Literature is lacking on this topic, therefore the present article discusses clinical outcomes of 25 patients treated by suprapatellar nailing at 2 years follow up and a literature review.
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Affiliation(s)
- G Cazzato
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy
| | - M F Saccomanno
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy.
| | - G Noia
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy
| | - G Masci
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy
| | - M Peruzzi
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy
| | - M Marinangeli
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy
| | - G Maccauro
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli 8, 00168, Rome, RM, Italy
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Russo AP, Caubere A, Ghabi A, Grosset A, Mangin P, Rigal S, Mathieu L. Sequential management of tibial fractures using a temporary unicortical external fixator. SICOT J 2018; 4:39. [PMID: 30192226 PMCID: PMC6128168 DOI: 10.1051/sicotj/2018035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/29/2018] [Indexed: 12/27/2022] Open
Abstract
Introduction: The development of damage control orthopedics (DCO) procedures has led to the development of temporary unicortical external fixators (TUEFs) intended to limit deep infectious complications and facilitate early conversion to internal fixation. Methods: A retrospective study was conducted in two French military trauma centers, including on patients being treated for tibial fractures with a TUEF (UNYCO® − Orthofix®) followed by an early conversion to intramedullary nailing. Results: Eleven patients with an average age of 41 were included between September 2015 and June 2017. A total of 12 TUEFs were implanted for one closed fracture and 11 open fractures, including one type I, eight types II, and two Gustilo types IIIB. The indication of DCO was related to hemodynamic instability in three cases, to the severity of soft tissue lesions in eight cases, and to the context of treatment in one case. The conversion to IM nailing was made after an average of 7.6 days. No significant loss of reduction was observed until internal osteosynthesis, which was performed with “fixator in place” in ten cases. The coverage of Gustilo type III injuries was performed by free flap transfers at the same time as IM nailing. All the patients were reviewed with an average follow-up of 16.5 months. Bone union was achieved in all cases. Two IM nailing dynamizations were carried out, but no bone grafting was required. Two cases of pandiaphysitis were observed and treated without functional complications. Discussion: Despite a limited number of patients, this study demonstrates the reliability of the TUEF to maintain the reduction of tibial fractures and facilitate early conversion to IM nailing. Unicortical fixation does not prevent septic complications related to the severity of soft tissue injuries.
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Affiliation(s)
- Anne-Pauline Russo
- Department of Orthopedic Surgery, Traumatology and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Alexandre Caubere
- Department of Orthopedic Surgery and Traumatology, Sainte-Anne Military Hospital, Toulon, France
| | - Ammar Ghabi
- Department of Orthopedic Surgery, Traumatology and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Antoine Grosset
- Department of Orthopedic Surgery, Traumatology and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Philippe Mangin
- Department of Orthopedic Surgery, Traumatology and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Sylvain Rigal
- Department of Orthopedic Surgery, Traumatology and Reconstructive Surgery, Percy Military Hospital, Clamart, France - Department of Surgery, French Military Health Service Academy, École du Val-de-Grâce, Paris, France
| | - Laurent Mathieu
- Department of Orthopedic Surgery, Traumatology and Reconstructive Surgery, Percy Military Hospital, Clamart, France - Department of Surgery, French Military Health Service Academy, École du Val-de-Grâce, Paris, France
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Abstract
Open fractures of the lower extremity are the most common open long bone injuries, yet their management remains a topic of debate. This article discusses the basic tenets of management and the subsequent impact on clinical outcome. These include the rationale for initial debridement, antimicrobial cover, addressing the soft-tissue injury and definitive skeletal management. The classification of injury severity continues to be a useful tool in guiding treatment and predicting outcome and prognosis. The Gustilo-Anderson classification continues to be the mainstay, but the adoption of severity scores such as the Ganga Hospital score may provide additional predictive utility. Recent literature has challenged the perceived need for rapid debridement within 6 hours and the rationale for prolonged antibiotic therapy in the open fracture. The choice of definitive treatment must be decided against known efficacy and injury severity/type. Recent data demonstrate better outcomes with internal fixation methods in most open tibial fractures, but external fixation continues to be an appropriate choice in more severe injuries. The incidence of infection and non-union has decreased with new treatment approaches but continues to be a source of significant morbidity and mortality. Assessment of functional outcome using various measures has been prevalent in the literature, but there is limited consensus regarding the best measures to be used.
Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170072
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Affiliation(s)
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, University of Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, UK
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Ma L, Zhao Z, Zhang B, Jiang W, Fu L, Zhang X, Liao H. Three-dimensional augmented reality surgical navigation with hybrid optical and electromagnetic tracking for distal intramedullary nail interlocking. Int J Med Robot 2018; 14:e1909. [PMID: 29575601 DOI: 10.1002/rcs.1909] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 02/07/2018] [Accepted: 02/08/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Longfei Ma
- Department of Biomedical Engineering, School of Medicine; Tsinghua University; Beijing China
| | - Zhe Zhao
- Department of Orthopedics Surgery; Beijing Tsinghua Changgung Hospital; Beijing China
| | - Boyu Zhang
- Department of Biomedical Engineering, School of Medicine; Tsinghua University; Beijing China
| | - Weipeng Jiang
- Department of Biomedical Engineering, School of Medicine; Tsinghua University; Beijing China
| | - Ligong Fu
- Department of Orthopedics Surgery; Beijing Tsinghua Changgung Hospital; Beijing China
| | - Xinran Zhang
- Department of Biomedical Engineering, School of Medicine; Tsinghua University; Beijing China
| | - Hongen Liao
- Department of Biomedical Engineering, School of Medicine; Tsinghua University; Beijing China
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Suprapatellar versus infrapatellar approach for tibia intramedullary nailing: A meta-analysis. Int J Surg 2018; 51:133-139. [PMID: 29367045 DOI: 10.1016/j.ijsu.2018.01.026] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/17/2017] [Accepted: 01/02/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE This meta-analysis was performed to determine the efficacy of suprapatellar versus infrapatellar approach for tibia intramedullary nailing (IMN). METHODS A systematic search was performed in PubMed, Embase, Cochrane library, CNKI and Wanfang. Cochrane collaboration's tool and the Newcastle-Ottawa scale were used to evaluate literature qualities. Meta-analysis was performed using RevMan 5.3 software. RESULTS Eight studies were eligible, including two randomized controlled trials (RCTs) and six retrospective cohort trials. There were no significant differences between suprapatellar and infrapatellar approaches in operation time, coronal plane alignment, and incidence of postoperative deep infection, nonunion and secondary operation. However, suprapatellar nailing achieved a significant shorter fluoroscopy time, less VAS pain score, better sagittal plane alignment and lower incidence of angular malalignment. Though pooled results indicated no significant difference in terms of final follow-up knee functional score, the RCT subgroup analysis showed that a higher knee functional score existed in suprapatellar group. CONCLUSIONS For tibia IMN, suprapatellar approach might be superior to infrapatellar approach with shorter fluoroscopy time, less knee pain, better knee function recovery, and more accurate fracture reduction. Meanwhile, no increased risk of postoperative complications was identified. More RCTs are required for further research.
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Tan Y, Hu J, Ren L, Zhu J, Yang J, Liu D. A Passive and Wireless Sensor for Bone Plate Strain Monitoring. SENSORS (BASEL, SWITZERLAND) 2017; 17:E2635. [PMID: 29144380 PMCID: PMC5713191 DOI: 10.3390/s17112635] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/11/2017] [Accepted: 11/13/2017] [Indexed: 11/17/2022]
Abstract
This paper reports on a sensor for monitoring bone plate strain in real time. The detected bone plate strain could be used for judging the healing state of fractures in patients. The sensor consists of a magnetoelastic material, which can be wirelessly connected and passively embedded. In order to verify the effectiveness of the sensor, a tibia-bone plate-screw (TBS) model was established using the finite element analysis method. A variation of the bone plate strain was obtained via this model. A goat hindquarter tibia was selected as the bone fracture model in the experiment. The tibia was fixed on a high precision load platform and an external force was applied. Bone plate strain variation during the bone fracture healing process was acquired with sensing coils. Simulation results indicated that bone plate strain decreases as the bone gradually heals, which is consistent with the finite element analysis results. This validated the soundness of the sensor reported here. This sensor has wireless connections, no in vivo battery requirement, and long-term embedding. These results can be used not only for clinical practices of bone fracture healing, but also for bone fracture treatment and rehabilitation equipment design.
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Affiliation(s)
- Yisong Tan
- School of Mechanical Engineering, Northeast Electric Power University, Jilin 132012, China.
| | - Jiale Hu
- School of Mechanical Engineering, Northeast Electric Power University, Jilin 132012, China.
| | - Limin Ren
- School of Mechanical Engineering, Northeast Electric Power University, Jilin 132012, China.
| | - Jianhua Zhu
- School of Mechanical Engineering, Northeast Electric Power University, Jilin 132012, China.
| | - Jiaqi Yang
- School of Mechanical Engineering, Northeast Electric Power University, Jilin 132012, China.
| | - Di Liu
- School of Mechanical Engineering, Northeast Electric Power University, Jilin 132012, China.
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Trajectory of Short- and Long-Term Recovery of Tibial Shaft Fractures After Intramedullary Nail Fixation. J Orthop Trauma 2017; 31:559-563. [PMID: 28538288 DOI: 10.1097/bot.0000000000000886] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the trajectory of recovery after tibial shaft fracture treated with intramedullary nail over the first 5 years and to evaluate the magnitude of the changes in functional outcome at various time intervals. DESIGN Prospective cohort study. SETTING A Level 1 trauma center. PATIENTS/PARTICIPANTS One hundred thirty-two patients with tibial shaft fracture (OTA 42-A, B, C) were enrolled into the Center's prospective orthopaedic trauma database between January 2005 and February 2010. Functional outcome data were collected at baseline, 6 months, 1 year, and 5 years. INTERVENTION Enrolled patients were treated acutely with intramedullary nailing of their tibia. MAIN OUTCOME MEASUREMENTS Evaluation was performed using the Short Form-36 and Short Musculoskeletal Function Assessment (SMFA). RESULTS Mean SF-36 physical component scores improved between 6 and 12 months (P = 0.0008) and between 1 and 5 years (P = 0.0029). Similarly, mean SMFA dysfunction index scores improved between 6 and 12 months (P = 0.0254) and between 1 and 5 years (P = 0.0106). In both scores, the rate or slope of this improvement is flatter between 1 and 5 years than it is between 6 and 12 months. Furthermore, SF-36 and SMFA scores did not reach baseline at 5 years (SF-36 P < 0.0001, SMFA P = 0.0026). A significant proportion of patients were still achieving a minimal clinically important difference in function between 1 and 5 years (SF-36 = 54%, SMFA = 44%). CONCLUSIONS The trajectory of functional recovery after tibial shaft fracture is characterized by an initial decline in function, followed by improvement between 6 and 12 months. There is still further improvement beyond 1 year, but this is of flatter trajectory. The 5-year results indicate that function does not improve to baseline by 5 years after injury. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Muscatelli S, Howe A, O'Hara NN, O'Toole RV, Sprague SA, Slobogean GP. Comparison of Irrigation Times Using Gravity and High-Pressure Lavage. Orthopedics 2017; 40:e413-e416. [PMID: 28075437 DOI: 10.3928/01477447-20170109-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/05/2016] [Indexed: 02/03/2023]
Abstract
The benefits of high-pressure pulsatile lavage for open fracture irrigation have been controversial based on conflicting experimental animal research. Recently published data definitively demonstrated that irrigation pressure does not affect the incidence of reoperation for the treatment of open fractures. However, proponents of pulsatile lavage argue a faster irrigation time is an important benefit of the high-pressure treatment. The purpose of this study was to determine the difference in irrigation time between gravity and high-pressure lavage. The experimental setup was designed to mimic clinical practice and compared mean irrigation flow times for high-pressure pulsatile lavage and gravity flow with 2 commonly used tube diameters. Each irrigation setup was tested 5 times at 3 different irrigation bag heights. Analysis of variance and Student's t tests were used to compare the mean flow times of 3 irrigation methods at each height and among the 3 heights for each irrigation method. The mean irrigation flow time in the various experimental models ranged from 161 to 243 seconds. Gravity irrigation with wide tubing was significantly faster than pulsatile lavage or gravity with narrow tubing (P<.001). Increasing irrigation bag height had only a marginal effect on the overall flow times (<9% difference). The difference in mean flow time among the testing techniques was slightly longer than 1 minute, which is unlikely to have a material impact on procedural costs, operating times, and subsequent gains in patient safety. [Orthopedics. 2017; 40(3):e413-e416.].
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A Prospective Randomized Trial to Assess Fixation Strategies for Severe Open Tibia Fractures: Modern Ring External Fixators Versus Internal Fixation (FIXIT Study). J Orthop Trauma 2017; 31 Suppl 1:S10-S17. [PMID: 28323796 DOI: 10.1097/bot.0000000000000804] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The treatment of high-energy open tibia fractures is challenging in both the military and civilian environments. Treatment with modern ring external fixation may reduce complications common in these patients. However, no study has rigorously compared outcomes of modern ring external fixation with commonly used internal fixation approaches. The FIXIT study is a prospective, multicenter randomized trial comparing 1-year outcomes after treatment of severe open tibial shaft fractures with modern external ring fixation versus internal fixation among men and women of ages 18-64. The primary outcome is rehospitalization for major limb complications. Secondary outcomes include infection, fracture healing, limb function, and patient-reported outcomes including physical function and pain. One-year treatment costs and patient satisfaction will be compared between the 2 groups, and the percentage of Gustilo IIIB fractures that can be salvaged without soft tissue flap among patients receiving external fixation will be estimated.
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CORR Insights ®: Prediction of Postoperative Clinical Recovery of Drop Foot Attributable to Lumbar Degenerative Diseases, via a Bayesian Network. Clin Orthop Relat Res 2017; 475:881-883. [PMID: 28050822 PMCID: PMC5289211 DOI: 10.1007/s11999-016-5225-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 12/20/2016] [Indexed: 01/31/2023]
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Abstract
BACKGROUND Open fractures are orthopaedic emergencies that carry a high risk for infection, non-union and soft tissue complications. Evidence-based treatment is impeded by the lack of high-quality evidence-based studies. The aim of this investigation was to elucidate the current practice of open fracture management in Germany and to determine major differences in treatment. METHODS Surgeons were asked to complete an online questionnaire consisting of 45 items developed by an expert consensus. The first part covered questions on general principles of open fracture management. The second part included questions on soft tissue management, the preferred method of initial surgical stabilisation, microbiological testing, employment of pulsatile lavage and local antibiotics, antibiotic regimen, second-look operations, and blood testing. RESULTS Of 653 respondents, 364 (65 %) completed the first part and 314 (48 %) completed the second part of the online survey. 55 % answered that a standard operating procedure for the diagnosis and treatment of patients with open fractures exists in their hospital. Only 25 % leave pre-hospitalisation applied dressings intact until arrival of the patient in the operating room, and 40 % make this decision depending on information provided by pre-hospitalisation emergency personnel. 84 % participants exclude the use of antibiotic-coated implants in the treatment of open fractures. The favoured stabilisation method in Gustilo type I fractures is definitive internal osteosynthesis and primary wound closure for 61 % of respondents. In Gustilo type II (74 %) and type III fractures (93 %), temporary external fixation is preferred. High-pressure pulsatile lavage is used by 22 % responding surgeons in Gustilo type I fractures, 53 % for type II fractures and 67 % for type III fractures. CONCLUSIONS Open fracture management differs considerably among surgeons in Germany. Further studies are needed to deliver high-quality evidence concerning primary fracture stabilisation, soft tissue management and second-look operations. Existing evidence-based recommendations for general treatment, antibiotic prophylaxis and soft tissue management should be followed more strictly in clinical practice.
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Clelland SJ, Chauhan P, Mandari FN. The epidemiology and management of tibia and fibula fractures at Kilimanjaro Christian Medical Centre (KCMC) in Northern Tanzania. Pan Afr Med J 2016; 25:51. [PMID: 28250875 PMCID: PMC5321146 DOI: 10.11604/pamj.2016.25.51.10612] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 09/26/2016] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Tibia/fibula fractures are one of the commonest admissions to the orthopaedic department at a resource-limited Northern Tanzanian hospital. These fractures are associated with poor prognosis and pose a huge socioeconomic burden on developing countries. However, to date there is a paucity of epidemiological data on lower-limb fractures in Tanzania. METHODS A retrospective review of admissions to the orthopaedic department at Kilimanjaro Christian Medical Centre (KCMC) was completed between February 2015 and 2016. Inpatient record books were used to source epidemiological data which was subsequently analysed. RESULTS 199 of the 1016 patients admitted sustained tibia/fibula fractures. 78% (n=156) of admissions were male and the most frequently affected age group was 21-30 years. Motor traffic accidents (MTAs) were the most common cause and accounted for 78% of fractures, with nearly half of these involving motorbikes (42%). Falls were identified as the second most common cause (13%). It was determined that 72% (n=143) of fractures were open, 19% (n=38) were comminuted and the most common site of injury was the distal-third of tibia/fibula. The most frequently recorded treatments were surgical toilet/debridement (66% of patients) and the application of a backslab (34% of patients). CONCLUSION Males in the 21-30 age group, who were involved in MTAs, were most commonly affected by tibia/fibula fractures. Given that MTA incidence is increasing in Tanzania, there is a growing public health concern that this will be reflected by a step-increase in the number of people who sustain lower-limb fractures.
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Affiliation(s)
- Samuel John Clelland
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Priyesh Chauhan
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
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Ludwig M, Hymes RA, Schulman J, Pitta M, Ramsey L. Intramedullary Nailing of Open Tibial Fractures: Provisional Plate Fixation. Orthopedics 2016; 39:e931-6. [PMID: 27359285 DOI: 10.3928/01477447-20160623-08] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 04/20/2016] [Indexed: 02/03/2023]
Abstract
Tibia fracture is the most common type of long bone fracture, and intramedullary nailing is the preferred treatment. In open fractures, a provisional plate is often used to maintain reduction. It is unknown whether this practice increases the risk of infection or other complications. This study retrospectively compared patients who were treated at a level 1 trauma center with intramedullary nailing of an open tibia fracture. Patients who were included: (1) were 18 years or older; (2) were treated between January 1, 2005, and June 30, 2013; (3) had an open fracture of the tibia; and (4) were treated operatively with intramedullary nailing, with or without provisional plate fixation. Patient sex, history of diabetes, history of smoking, mechanism of injury, and side of injury were analyzed. Postoperative complications included infection, delayed union or non-union, compartment syndrome, and death. After the authors controlled for age, Gustilo-Anderson type, and AO/Orthopaedic Trauma Association classification, they found that provisional plate use did not significantly increase the risk of infection (adjusted odds ratio, 1.64; 95% confidence interval, 0.51-5.32; P=.41) or any other complications (adjusted odds ratio, 1.24; 95% confidence interval, 0.46-3.35; P=.67). In the subgroup of patients who had a provisional plate (n=35), removal of the plate did not significantly decrease the risk of infection (adjusted odds ratio, 0.43; 95% confidence interval, 0.07-2.69; P=.36) or other complications (adjusted odds ratio, 0.55; 95% confidence interval, 0.12-2.46; P=.44). In open tibia fractures treated with intramedullary nailing, provisional plate stabilization, a valuable reduction aid, did not increase the risk of infection or other complications. Because of the small subgroup size, however, definitive conclusions cannot be drawn about removal of these provisional plates. [Orthopedics. 2016; 39(5):e931-e936.].
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