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Quarta D, Grassi M, Lattanzi G, Gigante AP, D'Anca A, Potena D. Three predictive scores compared in a retrospective multicenter study of nonunion tibial shaft fracture. World J Orthop 2024; 15:560-569. [PMID: 38947264 PMCID: PMC11212531 DOI: 10.5312/wjo.v15.i6.560] [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: 12/03/2023] [Revised: 03/01/2024] [Accepted: 04/25/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Delayed union, malunion, and nonunion are serious complications in the healing of fractures. Predicting the risk of nonunion before or after surgery is challenging. AIM To compare the most prevalent predictive scores of nonunion used in clinical practice to determine the most accurate score for predicting nonunion. METHODS We collected data from patients with tibial shaft fractures undergoing surgery from January 2016 to December 2020 in three different trauma hospitals. In this retrospective multicenter study, we considered only fractures treated with intramedullary nailing. We calculated the tibia FRACTure prediction healING days (FRACTING) score, Nonunion Risk Determination score, and Leeds-Genoa Nonunion Index (LEG-NUI) score at the time of definitive fixation. RESULTS Of the 130 patients enrolled, 89 (68.4%) healed within 9 months and were classified as union. The remaining patients (n = 41, 31.5%) healed after more than 9 months or underwent other surgical procedures and were classified as nonunion. After calculation of the three scores, LEG-NUI and FRACTING were the most accurate at predicting healing. CONCLUSION LEG-NUI and FRACTING showed the best performances by accurately predicting union and nonunion.
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Affiliation(s)
- Davide Quarta
- Clinical Orthopedics, Department of Clinical and Molecular Science, Università Politecnica Delle Marche, Ancona 60126, Italy
| | - Marco Grassi
- Clinical Orthopedics, Department of Clinical and Molecular Science, Università Politecnica Delle Marche, Ancona 60126, Italy
| | - Giuliano Lattanzi
- Clinical Orthopedics, Department of Clinical and Molecular Science, Università Politecnica Delle Marche, Ancona 60126, Italy
| | - Antonio Pompilio Gigante
- Clinical Orthopedics, Department of Clinical and Molecular Science, Università Politecnica Delle Marche, Ancona 60126, Italy
| | - Alessio D'Anca
- Department of Information and Engineering, Università Politecnica delle Marche, Ancona 60121, Italy
| | - Domenico Potena
- Department of Information and Engineering, Università Politecnica delle Marche, Ancona 60121, Italy
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Daas S, Jlidi M, Baghdadi N, Bouaicha W, Mallek K, Lamouchi M, Khorbi A. Risk factors for malunion of distal tibia fractures treated by intramedullary nailing. J Orthop Surg Res 2024; 19:5. [PMID: 38169392 PMCID: PMC10762967 DOI: 10.1186/s13018-023-04472-3] [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: 10/12/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The treatment of distal tibia fractures (DTF) has historically been a difficult challenge for orthopedic surgeons because of the particular characteristics of this anatomical region. Intra medullary nailing (IMN) remains the best treatment option. However, achieving and maintaining perfect reduction and stable fixation with IMN can be technically challenging due to the large medullary cavity within a short distal fragment. The aim of our study is to determine the risk factors for malunion in DTF treated with IMN. METHODS It is a retrospective study including DTF treated surgically by IMN in the Orthopedics and Trauma Department at a tertiary hospital over a period of 7 years. The quality of reduction was evaluated by radiological assessment of the antero-posterior (AP) and lateral views of the tibia and ankle at the last follow-up. RESULTS Our series included 90 patients with an average age of 44.8 years. Sex-ratio was 2.6. Tobacco use was reported in 35.6% of the patients. Diabetes was present in 11.1% of the patients, and 12.2% of them had open fractures. According to the OTA/AO classification, the majority of injuries were classified as type A1 (76.7%). Fibula fractures were present in 86.7% of cases. The mean follow-up was 48 months. Malunion occurred in 13 cases. Based on the univariate analysis, smoking and dynamic fixation were significantly associated with malunion. In the multiple logistic regression analysis, dynamic fixation was found to be a significant factor that increased the risk of malunion by 7.5 times. CONCLUSION Neither patient demographics nor fracture characteristics were risk factors for malunion. Nevertheless, it should be noted that dynamic nailing must be avoided as it is associated with a higher risk of malunion. Furthermore, one to two medial to lateral distal locking screws provide sufficient stability without the need for additional fibular fixation. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Selim Daas
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Mohamed Jlidi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia.
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Nahla Baghdadi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Walid Bouaicha
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Karim Mallek
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Mouldi Lamouchi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Adel Khorbi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Palm VF, Hoogendoorn JM, Verhage SM. The role of fibula fixation in combined distal-third tibia and fibula fractures: a systematic literature review. Arch Orthop Trauma Surg 2024; 144:219-228. [PMID: 37831196 DOI: 10.1007/s00402-023-05092-6] [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: 08/11/2023] [Accepted: 09/26/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE The role of concomitant fibula fracture fixation in distal-third tibia fractures regarding alignment, union, and functional outcome is still a topic of debate. In this review, we summarize the available comparative literature regarding fibula fixation in distal third lower leg fractures. MATERIALS AND METHODS A systematic literature review of articles published between January 2000 and January 2022 in the PubMed, Cochrane, and EMBASE databases about this topic was performed. RESULTS 746 unique studies were identified of which four randomized-controlled trials and six retrospective studies were included. Nine studies compared alignment after tibia fixation with or without fibula fixation, six studies reported on tibial union, and three studies reported on functional outcome between groups. Pooling of data was not possible due to varying outcome measures and inclusion criteria. Fibula fixation was associated with less rotational malalignment, while there does not seem to be consensus regarding the effect on sagittal and coronal alignment. Six studies reported on the effect of fibula fixation on tibial union. None of these studies found a significant difference between treatment modalities. Furthermore, one out of three studies reporting functional outcome described a marginal beneficial functional outcome after fibula fixation. Ultimately, no differences in complication rates between treatment modalities were described. CONCLUSION Fixation of the fibula in distal-third lower leg fractures does not seem to have a significant effect on coronal and sagittal tibial alignment. Furthermore, fibula fixation is associated with significantly less rotational malalignment, although the clinical importance of this finding is questionable as true differences in rotational alignment between treatment modalities are small. Finally, fibula fixation does not affect union, functional outcome, or complication rate as adjuvant to tibia fixation. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Victor Franciscus Palm
- Department of Surgery, Haaglanden Medical Center, Secretariaat Heelkunde F1.31, Lijnbaan 12, 2512VA, The Hague, The Netherlands.
| | - Jochem Maarten Hoogendoorn
- Department of Surgery, Haaglanden Medical Center, Secretariaat Heelkunde F1.31, Lijnbaan 12, 2512VA, The Hague, The Netherlands
| | - Samuel Marinus Verhage
- Department of Surgery, Haaglanden Medical Center, Secretariaat Heelkunde F1.31, Lijnbaan 12, 2512VA, The Hague, The Netherlands
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Xiong Y, Zhang J, Liu H, Cai T, Xu W, Wu J. Intramedullary nail fixation of fibular fractures in combination with extra-articular distal tibial fractures (AO/OTA 43A): a single-center retrospective study. Acta Orthop Belg 2023; 89:719-726. [PMID: 38205766 DOI: 10.52628/89.4.12153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Treatment of fibular fractures associated with extra-articular distal tibia fractures is technically challenging and the purpose of this study was to evaluate the use of intramedullary nail fixation of fibular fractures when associated with this fracture. Between January 2018 and December 2021, 33 patients presenting extra-articular distal tibia fractures and fibular fractures (AO/OTA 43A) were treated. Clinical and radiological data were collected during routine postoperative follow-ups. Thirty-one patients were monitored for a period of time ranging from 12 to 23 months, with an average follow-up of 17.5 ± 3.3 months. Fibular bone union took an average of 3.6 ± 0.9 months. At the last follow-up, the average fibular alignment and postoperative ankle talocrural angles were 1.8° and 9.1°, respectively. No detectable radiographic rotational malalignment and serious complications related to the fibular incision was observed. The average AOFAS and OMAS scores at the most recent follow-up were 88.3 ± 6.2 and 87.4 ± 6.0, respectively. Intramedullary nail fixation worked well to keep the fibula in place in fibular fractures connected to extra-articular distal tibia fractures.
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van Veelen NM, van de Wall BJM, Bleeker NJ, Buenter IR, Link BC, Babst R, Knobe M, Beeres FJP. The value of fibular fixation in patients with stabilized distal tibia fractures. Eur J Trauma Emerg Surg 2022; 48:3257-3263. [PMID: 35122103 DOI: 10.1007/s00068-022-01888-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/17/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE There is currently no consensus regarding the need for fixation of concomitant fibula fractures in patients with surgically treated distal tibia fracture. Although studies have shown it to be beneficial for fractures involving the syndesmosis, it remains unclear for suprasyndesmotic fractures. This study evaluates what effect the fixation of such suprasyndesmotic fibula fractures had on patients who underwent fixation of distal tibia fractures. METHODS This retrospective cohort study included all consecutive adult patients who received surgical treatment for an extra-articular or simple intraarticular distal tibia fracture between 2012 and 2020 and had a concomitant fibula fracture proximal to the syndesmosis. Two groups were formed depending on whether the fibula was stabilized. The need for revision surgery, the occurrence of complications, fracture healing, rotational and angular malalignment were evaluated for both groups. RESULTS This study included 120 patients, of which 40 (33.3%) had operative treatment of the fibula fracture. Of those with stabilized fibula fractures, 28 (70%) were treated with a plate and 12 (30%) with a titanium elastic nail. The group of patients with surgically treated fibula fractures had significantly more angular malalignments (10% vs 1.2%, p = 0.042), while there was no difference regarding rotational malalignment or fracture healing. Further, infections of the fibular surgical site occurred in 15% of surgically treated patients leading to significantly more revision surgeries in this group (40% vs 20%, p = 0.03). All infections occurred when a plate was used. CONCLUSION This study was unable to show any benefit from stabilizing concomitant, suprasyndesmotic fibula fractures in surgically treated distal tibia fractures. On the contrary, infection, revision surgery and angular malalignment were more frequent when the fibula was fixed. Therefore, such concomitant fibula fractures should not routinely be fixed and if stabilization is deemed necessary, the implant should be chosen carefully.
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Affiliation(s)
- Nicole Maria van Veelen
- Department of Orthopedic and Trauma Surgery, Luzerner Kantonsspital Luzern, Lucerne, Switzerland.
| | | | - Nils Jan Bleeker
- Department of Orthopedic and Trauma Surgery, Luzerner Kantonsspital Luzern, Lucerne, Switzerland
| | - Isabelle Ruth Buenter
- Department of Orthopedic and Trauma Surgery, Luzerner Kantonsspital Luzern, Lucerne, Switzerland
| | - Björn-Christian Link
- Department of Orthopedic and Trauma Surgery, Luzerner Kantonsspital Luzern, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopedic and Trauma Surgery, Luzerner Kantonsspital Luzern, Lucerne, Switzerland.,Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Matthias Knobe
- Department of Orthopedic and Trauma Surgery, Luzerner Kantonsspital Luzern, Lucerne, Switzerland
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