The role of fibular fixation in combined fractures of the tibia and fibula: a biomechanical investigation

Fibula fixation in the treatment of tibial pilon fractures - Is it really necessary?

BACKGROUND

There is a lack of consensus about the role of fibula fixation in these complex fractures, with only two clinical studies in the literature. We hypothesize that the fibula fracture need not be fixed in the tibial pilon fractures if primary stability can be achieved with tibial fixation alone.

METHODS

We reviewed 79 patients with operatively treated tibial pilon with associated fibula fractures from 2007 to 2017 and divided them into two groups; patients with fibula fracture fixation and those without fixation. The primary outcome measure was any mechanical complications. Secondary outcomes were wound complications and other morbidities.

RESULTS

There were 54 (68.4%) patients with fibula fixation and 25 (31.6%) patients without fixation. There were no statistically significant differences in mechanical complications between the two groups. However, patients without fibula fixation were noted to have more wound complications (44% vs 25.9%, p = 0.108) although this was not statistically significant. In terms of removal of implant (ROI), there were no differences noted in patients with or without fibula fixation (33.3% vs 28%, p = 0.796). There were also no significant differences in ROI for those fixed with plate and screws when compared to those fixed with Rush rod and K wire within the group with fibula fixation.

CONCLUSION

Fibula fixation in the treatment of tibial pilon fractures is not routinely necessary and does not result in decreased mechanical complications such as malunion, delayed union, nonunion and implant failure. Fibula fracture fixation should be reserved for cases where it may aid reduction or provide additional stability.

Minimally invasive treatment of AO B ankle fractures: Surgical technique and long-term outcomes

BACKGROUND

Ankle fractures are the most common traumatic bone injuries of the lower limb. Over 50% of ankle fractures occur at the syndesmosis level (type AO B). The goal of treatment is to achieve an anatomical reduction and appropriate stabilization. The present study aimed to evaluate the clinical-functional and radiological results, and complications of minimally invasive reduction and fixation technique for ankle fractures type AO B. The surgical technique also is detailed.

MATERIAL AND METHODS

A prospective analysis of 451 patients undergoing surgery for type AO B displaced ankle fracture was performed. All patients were treated with minimally invasive surgery. The following times were recorded: time between trauma and osteosynthesis, hospitalization length, surgical time, and exposure time to fluoroscopy. Age and gender, mechanism of injury, and characteristics of fractures were recorded. For functional outcome, AOFAS score, VAS, and Weber score were used. Radiographic analysis was performed. The average follow-up was 112 months.

RESULTS

Mean age was 48.2 years old. Average length of stay in hospital was 5.72 h. Mean duration of the surgery was 32.8 min. Average fluoroscopic exposure time during surgery was 9.25 s. Mean bone union time was 38.2 days. Weber's score was on average 1.5/24 points and the long-term follow-up AOFAS score was on average 97.5/100. Postoperative complications incidence was 2.7%.

CONCLUSIONS

Distal fibula fixation with the MIPO technique presented good functional outcomes and could be helpful in the avoidance of the complications associated with conventional open reduction and internal fixation. However, it needs more exposition to intraoperative fluoroscopy.

LEVEL OF EVIDENCE

II.

The midterm outcomes of ankle Dias-Tachdjian pronation-eversion external rotation physeal fracture in children treated by open reduction internal fixation with one-stage medial-lateral combined incision

The objective of this study was to report the midterm outcomes and complications of ankle Dias-Tachdjian pronation-eversion external rotation (PEER) physeal fracture in children treated by ORIF with combined medial and lateral incision. A total of 21 children with ankle Dias-Tachdjian PEER physeal fracture underwent open reduction internal fixation treatment with combined medial and lateral incision between January 2015 and October 2017. The lateral distal tibia angle (LDTA) was measured to evaluate angular deformity and the X-rays were taken to evaluate the premature physeal arrest. All patients were followed up for an average time of 20.1 months (ranging from 17 to 25 months). Bone healing was achieved in all cases. American Orthopedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) score of the patients improved from median 31 (11, 38) preoperation to median 68 (63, 73) postoperation to median score 91 (87, 96) at last follow-up. LDTA of the patients improved from 70.5 ± 4.9 preoperation to 90.0 ± 1.2 postoperation, to measure 90.6 ± 3.7 at last follow-up. The differences were statistically significant (P < 0.05). There is no premature physeal closure, ankle deformity in 19 cases. They could normally exercise and take part in normal sport activities. The remaining two cases had physeal bone bridge and premature physeal closure but could still carry on daily activities and thus were categorized as good. ORIF with one-stage medial-lateral combined incision for ankle Dias-Tachdjian PEER physeal fracture can decrease the rate of premature physeal closure and should be a treatment choice.

The Role of Fibular Fixation in Distal Tibia-Fibula Fractures: A Meta-Analysis

OBJECTIVES

The necessity of fibular fixation in distal tibia-fibula fractures remains controversial. This study aimed to assess its impact on radiographic outcomes as well as rates of nonunion and infection.

METHODS

A systematic search of the electronic databases of PubMed, Embase, and Cochrane library was performed to identify studies comparing the outcomes of reduction and internal fixation of the tibia with or without fibular fixation. Radiographic outcomes included malalignment and malrotation of the tibial shaft. Data regarding varus/valgus angulation, anterior/posterior angulation, internal/external rotation deformity, and the rates of nonunion and infection were extracted and then polled. A meta-analysis was performed using the random-effects model for heterogeneity.

RESULTS

Additional fibular fixation was statistically associated with a decreased rate of rotation deformity (OR = 0.13; 95% CI 0.02-0.82, p=0.03). However, there was no difference in the rate of malreduction between the trial group and the control group (OR = 0.86; 95% CI 0.27-2.74, p=0.80). There was also no difference in radiographic outcomes of varus-valgus deformity rate (OR = 0.17; 95% CI 0.03-1.00, p=0.05) or anterior-posterior deformity rate (OR = 0.76; 95% CI 0.02-36.91, p=0.89) between the two groups. Meanwhile, statistical analysis showed no significant difference in the nonunion rate (OR = 0.62; 95% CI 0.37-1.02, p=0.06) or the infection rate (OR = 0.81; 95% CI 0.18-3.67, p=0.78) between the two groups.

CONCLUSIONS

Additional fibular fixation does not appear to reduce the rate of varus-valgus deformity, anterior-posterior deformity, or malreduction. Meanwhile, it does not appear to impair the union process or increase the odds of infection. However, additional fibular fixation was associated with decreased odds of rotation deformity compared to controls.

Percutaneous bridge plating of extra-articular distal fibular fracture for the management of distal tibia type III open fracture

PURPOSE

The aim of this study is to conduct clinical and radiographic evaluations of the use of percutaneous bridge plating for distal fibular fractures combined with distal tibia type III open fractures.

METHODS

Thirty-four patients with acute distal third fibular shaft fractures (4F2A_(c) and 4F2B_(c) according to the AO/OTA classification) combined with distal tibia type III open fractures were enrolled. Concurrent fibular fractures were fixed with the percutaneous bridge plating simultaneously, while distal tibia open fractures were temporally stabilized with a spanning external fixator. Clinical and radiographic outcomes were evaluated using the Lower Extremity Functional Scale (LEFS), the proportional length difference of the fibula, the talocrural angle, the union rate of the fibula and tibia, the operation time, and complications at the final follow-up.

RESULTS

All fibular fractures healed with an average bone healing time of 20.7 ± 6.3 weeks (range, 16-35). The mean proportional length difference was 0.492 ± 0.732% compared with that in the uninjured fibula. The functional assessment result according to the LEFS was 74.0 ± 3.70 points (range, 57-80). No cases of fibula fracture infection developed throughout the follow-up period in any of the patients. Iatrogenic postoperative superficial peroneal nerve injury was not found in any of the patients.

CONCLUSION

With the perspective of minimizing soft tissue problems due to high-energy trauma, the application of percutaneous bridge plating for the treatment of distal fibular fractures can be an alternative to conventional treatment methods.

The impact of plate length, fibula integrity and plate placement on tibial shaft fixation stability: a finite element study

BACKGROUND

Tibial shaft fractures account for approximately 15% of long bone fractures. Locked plates with minimally invasive plate osteosynthesis techniques are used widely by surgeons. The purpose of this study is to investigate the impact of factors meaning the plate length, fibula integrity, and placement of the plate on the stability of tibial shaft fracture fixation.

METHODS

A finite element model of the tibial shaft fracture was built. An axial force of 2500 N was applied to simulate the axial compressive load on an adult knee during single-limb stance. The equivalent von Mises stress and displacement of the fractured ends were used as the output measures.

RESULTS

In models with plates on the lateral side of the tibia, displacement in models fixed with a 12-hole plate showed the smallest value. In models with plates on the medial side of the tibia, displacement in models fixed with 14-hole plate showed the smallest value. The peak stress of plates implanted on the medial side of the tibia was higher than that of plates on the lateral side. The peak stress and the displacement of models involved with the fibula were lower than that of models without fibula, regardless of the length or location of plates.

CONCLUSIONS

For models with plates on the medial side of the tibia, the 14-hole plate is the best choice in terms of stability. While for models with plates on the lateral side of the tibia, the 12-hole plate demonstrated the optimal biomechanical stability. The integrity of the fibula improves the anti-vertical compression stability of the construct. The peak stress of plates implanted on the medial side of the tibia was higher than that of plates on the lateral side, which indicated that the construct with medially implanted plate has a higher risk of implant failure.

When is indicated fibular fixation in extra-articular fractures of the distal tibia?

Background and aim of the work: There is no consensus about indications for fibular osteosynthesis in extra-articular fractures of the distal tibia (DTF). This study analyses patients affected by DTF associated to fibular fracture and has the aim to define whether the level of fibular fracture has an influence on bone healing and consequently when its fixation is indicated. Methods: Eighty-seven patients were operated from January 2005 to December 2016. Inclusion criteria were: the presence of skeletal maturity, the absence of physical limitations before trauma and a type 43-A AO closed fracture. Clinical outcomes were evaluated using Olerud–Molander Ankle Score (OMAS) and the Disability Rating Index (DRI). Malrotation was also assessed as well as incidence of nonunion and malalignment through x-rays. Results: No differences in clinical scores were reported at follow-up between patients in which fibular fixation was performed (Group 1) in comparison with those in which this procedure was not executed (Group 2). Nonunions were registered in 8 cases: four in Group 1 and four in Group 2. A statistically significant difference in incidence of external malrotation and valgus malalignment between the groups was documented, with a higher risk in patients of the second group. Conclusions: The level of fibular fracture is important to determine when the fixation of this bone is indicated. In supra-syndesmotic fractures osteosynthesis leads to a higher incidence of nonunions. Fibular osteosynthesis could prevent malrotation and malalignment and is advisable in distal metaphyseal fracture of this bone (trans- or infrasyndesmotic lesion) with syndesmotic injury. (www.actabiomedica.it)

Slippage of Tightrope Button in Syndesmotic Fixation of Weber C Malleolar Fractures: A Case Series

BACKGROUND

Tightrope fixation is an emerging technique for syndesmotic fixation with promising results. However, our case series highlights the slippage of Tightrope buttons as a complication of suture button syndesmotic fixation of Weber C malleolar fractures using limited contact dynamic compression (LCDCP) plates.

METHODS

We report a series of cases from our database in which slippage of the Tightrope button through the LCDCP holes in Weber C malleolar fractures was noted. We measured the medial clear space (MCS), tibiofibular clear space (TFCS), and distal tibiofibular overlap (DTFO) and computed the largest change in these measurements from the first postoperative follow-up radiographs. Patient records were reviewed for persistent symptoms that could be attributed to the loss of syndesmotic fixation and stability.

RESULTS

Follow-up radiographs of 3 patients showed a slippage of the Tightrope button through the LCDCP holes. Two of the patients reported persistent ankle pain and swelling with prolonged activity. The mean increases in MCS and TFCS among these patients were 0.7 (±0.081) mm and 1.5 (±0.798) mm, respectively. The mean decrease in DTFO was 2.2 (±0.864) mm. We next highlight 3 patients with Weber C malleolar fractures who underwent suture button syndesmotic fixation using double-stacked one-third tubular plates instead of the LCDCP.

CONCLUSION

This case series reported Tightrope button slippage as an early complication of syndesmotic fixation of Weber C malleolar fractures. We propose the use of double-stacked one-third tubular plates instead of the LCDCP to avoid this complication.

LEVEL OF EVIDENCE

Level V, expert opinion.

Surgical repair of a tibial fracture in a two-week-old grey seal (Halichoerus grypus)

Objective: To report the successful management of a suspected infected tibial fracture in a common grey seal.

Study design: Case report.

Animal: Female common grey seal (Halichoerus grypus), 2 weeks old, 20 kg.

Methods: A closed, complete, transverse fracture of the left tibial distal diaphysis was debrided, reduced and stabilized using a string-of-pearls (SOP) locking plate covered with polymethylmethacrylate impregnated with gentamicin. Fracture of the ipsilateral fibula was left untreated. Postoperative radiographs were obtained immediately, and at 10 days, three weeks, and six weeks post-surgery, and a computed tomographic examination was performed 2.5 months post-surgery. A species-specific progressive rehabilitation programme was conducted.

Results: Bone healing of both fractures and absence of injury of the distal tibial growth plate were evident on the 2.5 month follow-up examination, and also full range-of-motion of the flipper was preserved and no lameness or difficulty with swimming and hunting were detected. On computed tomography, signs of chronic left coxofemoral and ilial wing trauma were incidentally detected. The seal was released three months postoperatively.

Conclusion: A transverse infected distal fracture of the tibia and fibula in a young common grey seal was successfully managed with the combination of single SOP plating of the tibia, local antibiotic release and a specific rehabilitation programme.

Clinical relevance: Surgical treatment of a long-bone fracture in a wild immature grey seal was successful with a combination of techniques adapted to the species.

Does Provisional Plating of Closed Tibia Fractures Have Higher Complication Rates?

OBJECTIVES

To compare infection and nonunion rates after provisional plating (PP) with standard reduction (SR) techniques for closed tibia fractures treated with an intramedullary nail.

DESIGN

Retrospective comparative study.

SETTING

Level 1 academic trauma center.

PATIENTS/PARTICIPANTS

Of the 348 closed tibia fractures (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 42) treated using an intramedullary nail from January 2007 through June 2015, 231 (40 PP and 191 SR) patients met inclusion/exclusion criteria.

INTERVENTION

The patients received either a provisional plate or an SR before intramedullary nail placement.

MAIN OUTCOME MEASUREMENT

Infection and nonunion.

RESULTS

The PP cohort had a significantly higher proportion of high-energy injury mechanism and a significantly higher proportion of diabetes than the SR cohort. We were unable to demonstrate a difference in rates of infection [PP cohort (1/40, 2.5%) vs. SR cohort (6/191, 3.1%), P = 1.0], nonunion [PP cohort (3/40, 7.5%) vs. SR cohort (9/191, 4.7%), P = 0.44], or malunion [PP cohort (0/40, 0%) vs. SR cohort (8/191, 4.2%), P = 0.36]. Symptomatic implant removal was similar between the 2 groups [PP cohort (4/40, 10%) vs. SR cohort (27/191, 14%), P = 0.61].

CONCLUSION

PP can be used for complex, closed tibia fractures without an increased risk of infection, nonunion, and malunion compared with standard closed reduction techniques.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Role of Fibular Fixation in the Treatment of Combined Distal Tibia and Fibula Fracture: A Randomized, Control Trial

Background:

This randomized, parallel-group, non-blinded study was designed to determine the role of fibular fixation in the treatment outcomes of combined distal tibia and fibula fractures.

Materials and Methods:

Sixty patients with distal tibial and fibular fractures were randomly divided in two groups of case and controls. In the case group, fibula was fixed prior to the fixation of tibia. In the control group, tibia was fixed without fibular fixation. Primary outcomes were varus–valgus angulation, anterior–posterior angulation, union and side effects. Follow-up visit and radiographs were taken 2 and 4 weeks as well as 3, 6 and 9 months after surgery.

Results:

During the follow-up, 11 out of 60 patients in case and control groups were excluded. We recruited 24 and 25 patients in the case and control group, respectively. Intramedullary nailing was used in 8 patients of case and 11 patients of control group. Plate and screw were used in 16 patients in the case and 14 patients in the control group. Varus/valgus and anterior–posterior angulation were not statistically significant between two groups (P ≥ 0.05). The frequency of tibial and fibula union after 1, 3, 6 and 9 months in case and controls groups were not statistically significant (P ≥ 0.05). The frequency of nonunion of tibia and fibula, infection and nerve injury in studied groups were not statistically significant (P ≥ 0.05).

Conclusion:

We did not observe any significant improvement using fibular fixation in the treatment outcomes of tibia distal fractures.

Fibular Fixation in Distal Tibia Fractures: Reduction Aid or Nonunion Generator?

The role of fibular fixation in patients with distal tibia fractures is controversial. Although the stability of the fibula is critical in patients with syndesmotic instability or highly comminuted pilon fractures, fibular fixation in extraarticular distal tibia fractures or elementary intraarticular distal tibia fractures is more controversial. Biomechanical studies, as performed in sawbones or cadaveric models, denote advantages to fibular fixation with respect to specific uniplanar motion. However, the increased stability is susceptible to the fracture pattern of the tibia, fixation strategy for the tibia, fixation strategy for the fibula, and loading pattern of the entire construct. Clinical studies examining fibular fixation in patients with concomitant distal third tibia fractures have also not been definitive in their conclusions. Fibular fixation may improve the ability to obtain and maintain reduction in complex fractures of the distal tibia, but as a result of the increased stability of the construct, may also increase rates of nonunion in this challenging patient population.

A biomechanical comparison study of a modern fibular nail and distal fibular locking plate in AO/OTA 44C2 ankle fractures

Background

A lateral approach with open reduction and internal fixation with a plate is a very effective technique for the majority of distal fibular fractures. However, this open approach for ankle fixation may be complicated by wound dehiscence and infection, especially in high-risk patients. An alternative to plating is an intramedullary implant, which allows maintenance of length, alignment, and rotation and which allows for decreased soft tissue dissection. While there has been clinical data suggesting favorable short-term outcomes with these implants, there is no current biomechanical literature investigating this technology in this particular fracture pattern. This study sought to biomechanically compare an emerging technology with an established method of fixation for distal fibular fractures that traditionally require an extensive exposure.

Methods

Ten matched cadaveric pairs from the proximal tibia to the foot were prepared to simulate an Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 44C2 ankle fracture and randomized to fixation with a distal fibular locking plate or intramedullary fibular rod. A constant 700-N axial load was applied, and all specimens underwent testing for external rotation stiffness, external rotation cyclic loading, and torque to failure. The syndesmotic diastasis, stiffness, torque to failure, angle at failure, and mode of failure were obtained from each specimen.

Results

There was no significant difference in syndesmotic diastasis during cyclic loading or at maximal external rotation between the rod and plate groups. Post-cycle external rotation stiffness across the syndesmosis was significantly higher for the locking plate than the fibular rod. There was no significant difference between the rod and plate in torque at failure or external rotation angle. The majority of specimens had failure at the syndesmotic screw.

Conclusions

In the present cadaveric study of an AO/OTA 44C2 ankle fracture, a modern fibular rod demonstrated less external rotation stiffness while maintaining the syndesmotic diastasis to within acceptable tolerances and having similar failure characteristics.

Torsional Failure of Carbon Fiber Composite Plates Versus Stainless Steel Plates for Comminuted Distal Fibula Fractures

BACKGROUND

Carbon fiber composite implants are gaining popularity in orthopedics, but with few independent studies of their failure characteristics under supra-physiologic loads. The objective of this cadaveric study was to compare torsional failure properties of bridge plating a comminuted distal fibula fracture with carbon fiber polyetheretherketone (PEEK) composite and stainless steel one-third tubular plates.

METHODS

Comminuted fractures were simulated in 12 matched pairs of fresh-frozen human fibulas with 2-mm osteotomies located 3 cm proximal to the tibiotalar joint. Each fibula pair was randomized for fixation and implanted with carbon fiber and stainless steel 5-hole one-third tubular plates. The constructs were loaded in external rotation at a rate of 1-degree/sec until failure with a materials testing system. Torsional stiffness and mode of failure, as well as displacement, torque, and energy absorption for the first instance of failure and peak failure, were determined. Statistical analysis was performed with paired t tests and chi-square.

RESULTS

There were no significant differences among the 12 pairs for torsional stiffness, first failure torque, peak failure displacement, peak failure torque, or peak failure energy. Stainless steel plates exhibited significantly higher displacement (P < .001) and energy absorption (P = .001) at the first indication of failure than the carbon fiber plates. Stainless steel plates permanently deformed significantly more often than the carbon fiber plates (P = .035). Carbon fiber plates exhibited no plastic deformation with delamination of the composite, and brittle catastrophic failure in 1 specimen.

CONCLUSIONS

In a comminuted human fibula fracture fixation model, carbon fiber implants exhibited multiple pre-peak failures at significantly lower angles than the first failure for the stainless steel implants, with some delamination of composite layers and brittle catastrophic failure rather than plastic deformation.

CLINICAL RELEVANCE

The torsional failure properties of carbon fiber composite one-third tubular plates determined in this independent study provide novel in vitro data for this alternative implant material.

Outcomes After Intramedullary Nailing of Distal Tibial Fractures

OBJECTIVES

To determine outcomes in the treatment of distal tibial fractures treated with intramedullary nails.

DESIGN

Retrospective analysis.

SETTING

Level I trauma center with follow-up in a private orthopaedic practice.

MAIN OUTCOME MEASUREMENTS

Radiographic determination of alignment, nonunion, and malunion, clinical outcome (range of motion, and implant-associated complaints), wound complications, and fibular fixation.

PATIENTS

A total of 105 patients with OTA/AO type A and C tibial fractures (<11 cm from the joint line) treated with intramedullary nailing.

RESULTS

Distance of the fracture from the joint line averaged 6.1 cm (range, 0-11). Mean follow-up was 25.6 months (range, 12-74). Nonunion occurred in 20 (19%) fractures and were significantly associated with open fractures (P = 0.012), wound complications (P < 0.001), and the need for fibular fixation (P = 0.007). Sagittal plane alignment averaged 2.5 degrees (±4.4) valgus. Malunion occurred in 25 (23.8%) fractures and again were significantly associated with open fractures (P = 0.045). Fifty (47.6%) patients had implant-related pain, which resolved in 27 (54.0%) after removal.

CONCLUSIONS

Intramedullary nailing of distal tibial fractures is a suitable treatment option. Acceptable alignment and range of motion can be achieved. Both nonunions and malunions were significantly associated with open fractures, wound complications, and fibular fixation. Implant removal was needed in 25% of cases.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The influence of distal locking on the need for fibular plating in intramedullary nailing of distal metaphyseal tibiofibular fractures

Using human cadaver specimens, we investigated the role of supplementary fibular plating in the treatment of distal tibial fractures using an intramedullary nail. Fibular plating is thought to improve stability in these situations, but has been reported to have increased soft-tissue complications and to impair union of the fracture. We proposed that multidirectional locking screws provide adequate stability, making additional fibular plating unnecessary. A distal tibiofibular osteotomy model performed on matched fresh-frozen lower limb specimens was stabilised with reamed nails using conventional biplanar distal locking (CDL) or multidirectional distal locking (MDL) options with and without fibular plating. Rotational stiffness was assessed under a constant axial force of 150 N and a superimposed torque of ± 5 Nm. Total movement, and neutral zone and fracture gap movement were analysed.

In the CDL group, fibular plating improved stiffness at the tibial fracture site, albeit to a small degree (p = 0.013). In the MDL group additional fibular plating did not increase the stiffness. The MDL nail without fibular plating was significantly more stable than the CDL nail with an additional fibular plate (p = 0.008).

These findings suggest that additional fibular plating does not improve stability if a multidirectional distal locking intramedullary nail is used, and is therefore unnecessary if not needed to aid reduction.

Cite this article: Bone Joint J 2014;96-B:385–9.

Distal tibial metaphyseal fractures: does blocking screw extend the indication of intramedullary nailing?

Aim. To evaluate the clinical use of blocking screws as a supplement to stability in distal tibial metaphyseal fractures treated with statically locked intramedullary nail. Main Outcome Measurement. Alignment and reduction preoperatively, postoperatively, and at healing were the main outcome measured with an emphasis on maintenance of initial reduction on followup. Patients and Methods. This was a prospective study of 20 consecutive cases of distal tibial metaphyseal fractures treated with statically locked intramedullary nailing with supplementary blocking screw between August 2006 and September 2007 with a maximum followup of 3 years. Medullary canal diameter was measured at the levels of fracture and isthmus. Results. The mean diameter of tibia at the level of isthmus was 11.9 mm and at the fracture site was 22.9 mm. Mean length of distal fracture segment was 4.6 cm. Mean varus/valgus alignment was 10.3 degrees preoperatively and 1.7 degrees immediatly postoperatively and was maintained till union. Using Karlstrom-Olerud score the outcome was excellent to good in 90%. Conclusion. We conclude that the use of blocking screw as a supplement will aid in achieving and maintaining the reduction of distal tibial metaphyseal fractures when treated with intramedullary nailing thereby extending the indication of intramedullary nailing.

The potential effect of anatomic relationship between the femur and the tibia on medial meniscus tears

BACKGROUND

The anatomic and the kinematical relationships between the femur and the tibia have been previously examined in both normal and diseased knees. However, less attention has been directed to the effect of these relationships on the meniscal diseases. Therefore, we aimed to investigate the impact of femorotibial incongruence on both lateral and medial meniscal tears.

MATERIALS AND METHODS

A total of 100 images obtained from MRI of 100 patients (39 males and 61 females) were included in the study. Diameters of the medial and the lateral femoral condyles, thicknesses of the menisci, and diameters of the medial and the lateral tibial articular surfaces were measured.

RESULTS

The medial meniscus tear was detected in 40 (40 %) patients. However, no lateral meniscus tear was found. Significant relationships were found between the diameters of the posterior medial femoral condyle and the medial tibial superior articular surface and between the diameters of the posterior lateral femoral condyle and the lateral tibial superior articular surface. The mean values for the diameter of the medial condyle of the femur, the lateral condyle of the femur, the medial superior articular surface of the tibia, and the lateral superior articular surface of the tibia were found to be significantly higher in cases with meniscus tear compared to cases without meniscus tear. However, no significant difference was present regarding the thicknesses of the medial and the lateral menisci. A positive relationship between the diameter of the posterior medial femoral condyle and the tibial medial superior articular surface was found in cases with (n = 40) (r (2) = 0.208, p = 0.003) and without tear (n = 60) (r (2) = 0.182, p = 0.001). In addition, a significant positive relationship was found between the diameter of the posterior medial femoral condyle and the medial tibial superior articular surface in cases with and without tear.

CONCLUSION

The impact of femorotibial incongruence on the medial meniscus tear is important for the understanding of the lesions.

To fix or not to fix? The role of fibular fixation in distal shaft fractures of the leg

BACKGROUND

The role of stabilisation of the fibula in distal two-bone fractures of the leg is controversial. Some studies indicate the need for fibular stabilisation in 43 AO fractures, but few studies consider the role of the fibula in 42 AO fractures. The aim of the current paper is to explain the role of stabilisation of the fibula in 42 AO fractures, correlating the rates of healing and non-union between patients with and without fibula fixation.

MATERIALS AND METHODS

A total of 60 patients with 42 AO (distal) shaft fracture of the tibia with associated fracture of the fibula were selected. Patients were divided into two groups according to whether or not the fibula was fixed: Group I (n=26) comprised patients who had their fibula fixed while Group II (n=34) comprised patients who did not. The fibular fracture was classified according to the AO and related to the level of the tibial fracture. Other parameters examined were the union rate of the two groups correlated to the fracture pattern and position of the fibular fracture; the demographic data, such as age and gender; the presence of an open fracture, and the type of tibial fixation device used (nail or plate).

RESULTS

None of the parameters considered (open injury, AO classification, device used and level of the fibular fracture relative to the tibial) were shown to have an influence on the development of a non-union.

CONCLUSION

This study showed a higher non-union rate when the fracture of the tibia and fibula were at the same level, the tibia was fixed with a bridging plate and the fibula left untouched. For this reason, we recommend fibular fixation in all 42 distal fractures when both fractures lie on the same plane and the tibial fracture is relatively stabilised.

Assessment of the role of fibular fixation in distal-third tibia-fibula fractures and its significance in decreasing malrotation and malalignment

BACKGROUND

In the treatment of distal-third tibia/fibula fractures treated by interlocking nailing, the role of fibular fixation is not clearly defined. This study aimed to assess the benefits of fibular fixation in such fractures.

METHODS

Sixty patients with fractures of the lower third of the leg were enrolled into the study and divided into two groups based on whether the fibula was fixed (group A) or not (group B). Fracture tibia was treated with interlocked intramedullary nailing and fibular fixation was done using a 3.5-mm Limited Contact Dynamic Compression Plate (LC-DCP). The two groups were compared for differences in rotation at ankle, angulation at the fracture site, time of union and complications. Clinical and functional outcomes were assessed regularly. Merchant-Dietz criteria were used to assess ankle function.

RESULTS

The demographics of the two groups were similar. Average valgus angulation was significantly less in group A (average 5°) versus group B (average 9°). The degree of rotational malalignment at the ankle in group A was average 7° versus average 15° in group B. The outcome of two groups for clinical ankle score, time of union and complications showed no significant differences.

CONCLUSION

Fixation of the fibula along with interlocking nailing of the tibia decreases the malalignment of the tibia and malrotation of the ankle in distal-third fractures of the tibia and fibula as compared with only interlocking nailing.

Locked plate fixation of the comminuted distal fibula: a biomechanical study

BACKGROUND

The purpose of this study was to compare the biomechanical properties of locked versus nonlocked lateral fibular bridge plating of comminuted, unstable ankle fractures in a mode of catastrophic failure.

METHODS

We created comminuted Weber C fractures in 8 paired limbs from fresh cadavers. Fractures were plated with either standard or locked one-third tubular bridge plating techniques. Specimens were biomechanically evaluated by external rotation to failure while subjected to a compressive load approximating body weight. We measured the angle to failure, torque to failure, energy to failure and construct stiffness.

RESULTS

There was no significant difference in construct stiffness or other biomechanical properties between locked and standard one-third tubular plating techniques.

CONCLUSION

We found no difference in biomechanical properties between locked and standard bridge plating of a comminuted Weber C fibular fracture in a model of catastrophic failure. It is likely that augmentation of fixation with K-wires or transtibial screws provides a construct superior to locked bridge plating alone. Further biomechanical and clinical analysis is required to improve understanding of the role of locked plating in ankle fractures and in osteoporotic bone.

The protective effect of locking screw placement on nonlocking screw extraction torque in an osteoporotic supracondylar femur fracture model

OBJECTIVE

To examine the impact of number and position of locking screws in the diaphyseal portion of an osteoporotic distal femoral fracture model with hybrid fixation.

METHODS

Four groups containing 5 osteoporotic bone models were used with varying combinations of diaphyseal screw fixation: 4 nonlocking screws (control); 1 locking screw adjacent to the osteotomy and 3 nonlocking screws; 1 locking screw in the most proximal screw hole of the plate and 3 nonlocking screws; and 2 locking screws at opposite ends of the diaphyseal fixation with 2 nonlocking screws in between. Fixation in the distal articular segment was identical in all constructs. Testing was performed for 50,000 cycles at 2 Hz using simultaneous axial compression (700 N) and bidirectional torque (±5 Nm) applied along the long axis of the bone. All screws were inserted with 4 Nm of torque.

RESULTS

The extraction torque for nonlocking screws in those specimens that had a locking screw nearest the osteotomy was significantly greater than those that did not (P = 0.037). In addition, the 10 constructs with a locking screw nearest the osteotomy had no failures compared with 5 of 10 failures in those without a locking screw in this position (P = 0.033).

CONCLUSIONS

The placement of a locking screw adjacent to the osteotomy was more beneficial in protecting against failure and maintaining the extraction torque of neighboring proximal nonlocking screws. No benefit in adjacent screw extraction torque was seen with a locking screw proximal in the diaphysis. Two locking screws at opposite ends of the diaphyseal fixation were not superior to a single locking screw adjacent to the osteotomy in failure rates or screw extraction torque.

[Intramedullary nailing of the distal tibia illustrated with the Expert(TM) tibia nail]

OBJECTIVE

Restoration of axis, length, and rotation of the lower leg. Sufficient primary stability of the osteosynthesis for functional aftercare and to maintain joint mobility. Good bony healing in closed and open fractures.

INDICATIONS

Closed and open fractures of the tibia and complete lower leg fractures distal to the isthmus (AO 42), extraarticular fractures of the distal tibia (AO 43 A1/A2/A3), segmental fractures of the tibia with a fracture in the distal tibia, and certain intraarticular fractures of the distal tibia without impression of the joint line with the use of additional implants (AO 43 C1)

CONTRAINDICATIONS

Patient in reduced general condition (e.g., bed ridden), flexion of the knee of less than 90°, patients with knee arthroplasty of the affected leg, infection in the area of the nail's insertion, infection of the tibial cavity, complex articular fractures of the proximal or distal tibia with joint depression.

SURGICAL TECHNIQUE

Closed reduction of the fracture preferably on a fracture table or using a distractor or an external fixation frame. If necessary, use pointed reduction clamps or sterile drapery. In some cases, additional implants like percutaneous small fragment screws, poller screws or k-wires are helpful. Open reduction is rarely necessary and must be avoided. Opening of the proximal tibia in line with the medullary canal. Canulated insertion of the Expert(TM) tibia nail (ETN; Synthes GmbH, Oberdorf, Switzerland) with reaming of the medullary canal. Control of axis, length, and rotation. Distal interlocking with the radiolucent drill and proximal interlocking with the targeting device.

POSTOPERATIVE MANAGEMENT

Immediate mobilization of ankle and knee joint. Mobilization with 20 kg weight-bearing with crutches. X-ray control 6 weeks postoperatively and increased weight-bearing depending on the fracture status. In cases with simple fractures, good bony contact, or transverse fracture pattern, full weight-bearing at the end of week 6 is targeted.

RESULTS

Between July 2004 and May 2005, 180 patients were included in a multicenter study. The follow-up rate was 81% after 1 year. Of these, 91 fractures (50.6%) were located in the distal third of the tibia. In this segment, the rate of delayed union was 10.6%. Malalignment of > 5° was observed in 5.4%. A secondary malalignment after initial good reduction was detected in only 1.1% of all cases. The implant-specific risk for screw breakage was 3.2%. One patient sustained a deep infection. If additional fibula plating was performed an 8-fold higher risk for delayed bone healing was observed (95%CI: 2.9-21.2, p< 0.001). If the fracture of the fibula was at the same height as on the tibia, the risk for delayed healing was even 14-fold (95% CI: 3.4-62.5, p< 0.001). Biomechanically plating of the fibula does not increase stability in suprasyndesmal distal tibia-fibular fractures treated with an intramedullary nail. Using the ETN with its optimized locking options, fibula plating is not recommended, thus, avoiding soft tissue problems and potentially delayed bone healing.

Surgical treatment of extra-articular or simple intra-articular distal tibial fractures: external fixation versus intramedullary nailing

OBJECTIVE

To compare intramedullary nailing (IMN) with external fixation (EF) in the treatment of tibial shaft fractures located within 5 cm of the ankle.

SETTING

University teaching hospital.

DESIGN

Retrospective comparative study.

PATIENTS

Sixty-seven patients with a mean age of 48 years (range, 16-78 years; 24 women, 43 men).

INTERVENTION

Thirty-three fractures were treated with EF from 1998 to 2004 and 34 fractures were treated with reamed IMN from 2004 to 2007.

MAIN OUTCOME MEASURES

Olerud-Molander ankle score, RAND-36 Item Health Survey, and the number of secondary interventions.

RESULTS

The healing time was 21 weeks in the IMN group and 23 weeks in the EF group (P = 0.53). One fracture in the IMN group and three in the EF group malunited (P = 0.62). Olerud-Molander ankle score was 75 in the IMN group and 74 in the EF group (P = 0.51). There was no difference in any of the RAND-36 subscores measuring physical functioning. More patients in the EF group had secondary intervention resulting from delayed healing (8 versus 1, P = 0.03). The patients in the EF group also needed more secondary interventions as a result of any complication (15 versus 2, P < 0.001). There was one deep infection in the IMN group.

CONCLUSION

Distal extra-articular or simple intra-articular fractures can be treated with modern IMNs or nonbridging EF. Although functional results are similar, EF carries a significant greater risk of secondary interventions; based on these data, IMN is recommended.

Threaded screw head inserts improve locking plate biomechanical properties

OBJECTIVES

The purpose of this study was to determine if the stiffness and fatigue life of locking one third tubular plates are enhanced by placing a locking screw head to fill the empty hole of the plate. We hypothesize that both the stiffness and fatigue life of the plates will be improved at physiologically relevant loads by filling the empty center hole of each plate.

METHODS

The mechanical stiffness and fatigue life of plates with an open versus filled center hole were assessed through finite element analysis and experimentally using a synthetic bone model under four-point bending. Two plate manufacturers were evaluated, Synthes (n) and Stryker (r). Five-hole one third tubular plates were mechanically cycled with and without filling the central screw hole while load, displacement, and number of cycles were collected. Stiffness was calculated and cycles to failure and mode of failure were monitored. Five plates were evaluated for the filled (F) and open (O) configurations for the n and r plates.

RESULTS

Finite element analysis indicated that filling the hole resulted in reduction in maximum stress at the periphery of the center hole by a factor of 2.43 and 2.29 for the n and r plates, respectively. Experimentally, a fourfold improvement was observed in fatigue life of the Synthes plates when a screw head was used to fill the central screw hole (P < 0.005; nF = 45,450 cycles versus nO = 10,305 cycles). The Stryker plates reached the maximum number of cycles (1 million) without fatigue failure in both O and F configurations. Improved bending stiffness was noted for both the n and r plates when the central hole was filled compared with open. For the Stryker plate, this increase was statistically significant (P < 0.011).

CONCLUSIONS

The methodology proposed in this study for extending fatigue life and increasing stiffness of locking plates can potentially be extended to any locking plate. Adding a screw head or screw heads to open holes in locking plates adds little additional time or expense and no morbidity to the procedure but can have substantial effects on the mechanical properties of the implant, particularly in lower-profile plates that are initially less rigid and robust.

Distal quarter leg fractures fixation: The intramedullary nailing alone option

INTRODUCTION

Intramedullary (IM) nailing is the classical treatment for diaphyseal fractures of the tibia. Stabilizing fractures of the distal quarter is recognized as being delicate. We report a continuous, multicenter prospective study of distal tibia-fibula fractures treated with anterograde intramedullary nailing.

HYPOTHESIS

The working hypothesis was to identify the problems encountered with IM nailing alone of distal leg fractures.

PATIENTS AND METHODS

From May 2007 to November 2008, 51 fractures in 51 patients (19 females and 32 males; mean age, 46.2 years [range, 17-93 years]) were treated with IM nailing. The fractures were classified according to the association pour l'ostéosynthèse (AO) classification, with most type A1 (29/51). Thirteen fractures presented a distal articular extension treated with screws in five cases. Fixation consisted in intramedullary nailing, reamed in all cases, performed on a standard or orthopaedic surgery table. Nailing was static and distally locked (50/51). The patients were evaluated clinically and radiologically, with AP and lateral images of both legs and the Olerud score.

RESULTS

We report one death and eight patients lost to follow-up, providing 42 cases to reviewing at 1 year. The bone union rate was 97.6% in a mean 15.7 weeks. Immediately after surgery, 14 axial deviations greater than 5° were observed, mainly valgus, with only one greater than 10°. The absence of fibular fixation was the only identifiable risk factor for appearance of an initial axial deviation as well as fracture instability over time. Two infections were observed and at 6 months four secondary displacements, one of which can be explained by changing the distal locking due to infection. Four dynamizations were performed. No other risk factor was found. The mean Olerud functional score at 12 months was 83.5 points.

DISCUSSION

The clinical results are comparable to those reported in the literature. From a radiological point of view, the rates and times to bone union were identical. However, the rates of malunion were clearly higher. The risk factors for malunion found in the literature are metaphyseal enlargement, fracture comminution, a too distal location of fracture site, young patient age, patient installation on a standard operating table, and technical errors. The absence of supplementary fibular fixation, the subject of debate in the literature, was the only statistically significant point found in the present study. Nailing distal fractures of the leg provides good clinical results. However, with regard to the malunion rates, the technique must be precise and rigorous. We recommend systematic fibular fixation and use of an orthopaedic table.

LEVEL OF EVIDENCE

Level IV; cohort type prospective study.

Distal leg fractures: How critical is the fibular fracture and its fixation?

INTRODUCTION

Extra-articular distal tibia fractures include a tibial fracture line located partially or totally in the metaphyseal bone and a fibular fracture in variable areas or sometimes absent. There is no consensus in the literature on the conduct to address the fibula fracture. The main objective of this study was to assess its impact on tibial reduction and union.

HYPOTHESIS

Fibular fixation plays a positive role in reducing tibial displacement and improving mechanical stability of the entire lesion.

MATERIAL AND METHODS

This study was based on the multicenter observational group of the 2009 SOFCOT symposium, i.e., 142 metaphyseal fractures of the tibia. The fibula was intact in 10 cases and fractured in 132. In the three main categories of surgical treatment for the tibia (nailing, plating, external fixation) (126 fractures), the fibular lesion was not treated in 79 cases (61%) in this series, nine were treated with intramedullary pinning, and 38 with plate and screw fixation.

RESULTS

There was no statistical relation between the anatomic situation of the diaphysis and the anatomic type of the fibular fracture or between the anatomic type of the fibular fracture and its situation compared to the tibial fracture line. The intertubercular and neck fractures were type A1 or B1 (P<0.001) and were combined to a tibia fracture with a torsional component; the medial-diaphyseal and subtubercular fractures were associated with tibial fracture lines with a simple transversal or comminution or metaphyseal-diaphyseal component (P<0.032). The rate of pseudarthrosis of the fibular fracture was 4.7% at 1 year; in all these cases, fibular treatment had been conservative. All treatments combined, the tibial axes were statistically better corrected when the fibula was treated with fixation. In four of the 11 cases of axial tibial malunion, the primary fibular fixation caused or worsened them.

DISCUSSION

The present clinical series provides results similar to the biomechanical studies. The consequences of fibular fixation perpetuating a tibia reduction abnormality or on the contrary the absence of fibular fixation appeared as probable factors of residual reduction defects, lack of stability of the tibiofibular complex, and tibia non-union.

LEVEL OF EVIDENCE

Level IV (prospective cohort study).

Role of the fibula in lower leg fractures: an in vivo investigation in rats

Whether or not the fibula should be fixated in combined fractures of the tibia and fibula remains controversial. Several clinical and biomechanical studies have investigated the role of the fibula in lower leg fractures without leading to a common conclusion. We assumed that an intact or stable fibula would provide better healing conditions in lower leg fractures treated with an intramedullary nail. In an in vivo study, 40 male Wistar rats were randomly assigned to two groups. In both groups, the tibia was osteotomized, whereas the fibula was left intact in one group and osteotomized in the other group. The tibia fracture was fixated with an intramedullary nail. After sacrifice of the animals, mineral density, mineral content, and mechanical characteristics of the healing osteotomies were evaluated. We found that a combination of tibia and fibula fracture significantly impaired fracture healing during the early phase after the incident, when treated with an intramedullary nail, suggesting that an intact or stabilized fibula provides additional support and better healing conditions to a tibia fracture.

Extending the Indication of Intramedullary Nailing of Tibial Fractures

Intramedullary nailing is an effective and well-established method for the treatment of a wide spectrum of tibial fractures. Nevertheless, the handling of metaphyseal and open fracture remains challenging. Surgical and technical advancements have opened up new possibilities to broaden the indication of intramedullary nailing in these areas.

The effect of concurrent fibular fracture on the fixation of distal tibia fractures: a laboratory comparison of intramedullary nails with locked plates

OBJECTIVE

To compare the fixation stability of intramedullary nails to that of locked plates for the treatment of distal metaphyseal tibia and fibula fractures.

METHODS

A simulated, distal metaphyseal tibia fracture was created in 8 pairs of cadaveric tibia-fibula specimens. One of each pair was treated using an intramedullary nail (Trigen IM Nail System; SN Richards, Memphis, TN) and the other with a locked plate (Peri-Loc Periarticular Locked Plating System; SN Richards). Each specimen was vertically loaded to 250 N in central, anterior, posterior, medial, and lateral locations; loaded to 250 N in cantilever bending in anterior to posterior and posterior to anterior directions; and loaded to 250 N mm in torsion. Load-displacement curves were generated to determine the construct stiffness for each loading scenario, with comparisons made between the 2 treatment groups. Each specimen was then cyclically loaded with 750 N vertical loads applied for 10, 100, 1000, and 10,000 cycles. Measurements of fracture displacements were made and compared between treatment groups. A fibular osteotomy was then created in each specimen at the same level as the tibia fracture to simulate a same-level tibia-fibular fracture. Torsional stiffness assessment and cyclic vertical loading for 10, 100, 1000, and 10,000 cycles were repeated and fracture displacement measurements were again obtained.

RESULTS

The locked plate construct was stiffer than the intramedullary nail construct for central, anterior, and posterior loading scenarios (P < 0.005, P < 0.03, and P < 0.02, respectively). The intramedullary nail construct was stiffer than the locked plate construct for both anterior to posterior and posterior to anterior cantilever bending (P < 0.03 and P < 0.02, respectively). No statistically significant difference in stiffness was noted between treatment groups for medial and lateral vertical loading or for torsional loading (P = 0.09, P = 0.32, and P = 0.84, respectively). There was no significant difference between treatment groups with respect to fracture displacement after cyclic vertical loading. After creation of the fibular osteotomy fracture, construct displacements after 1000 and 10,000 cycles significantly increased and torsional stiffness significantly decreased for both treatment groups. The locked plate constructs had significantly less displacement after cyclic loading of 1000 and 10,000 than the locked nail constructs (P < 0.001 and P < 0.0001, respectively). Locked plate constructs were stiffer in torsion after osteotomy than the intramedullary nail constructs (P < 0.05).

CONCLUSION

This study demonstrated that, in the treatment of distal metaphyseal tibia fractures, locked plates provided more stable fixation than intramedullary nails in vertical loading but were less effective in cantilever bending. An intact fibula in the presence of a distal tibia fracture improved the fracture fixation stability for both treatment methods. In fracture patterns in which the fibula cannot be effectively stabilized, locked plates offer improved mechanical stability when compared with locked intramedullary nails.

Two-ring Hybrid External Fixation of Distal Tibial Fractures: A Review of 47 Cases

BACKGROUND

The healing of a metaphyseal fracture line is a major problem in cases of distal tibial fracture treated with external fixation.

METHODS

Forty-seven distal tibial fractures treated with two-ring Ilizarov hybrid external fixation (16 AO/OTA type A and 31 type C, 10 open) were followed up. Fracture reduction and union time was evaluated and IOWA and RAND 36-Item Health Survey scores were used to assess functional outcome.

RESULTS

Thirty-five fractures united uneventfully in a median time of 20 weeks, but 12 fractures needed additional procedures because of delayed union. According to univariate analysis, the risk factors for a longer time needed for fracture union were translational displacement and current smoking, and the risk factors for reoperation because of delayed union translational displacement fibular fracture fixation, and the number of cigarettes smoked per day. In multivariate analysis, translational displacement was a risk factor for both longer time to fracture union and reoperation and fibular fracture fixation was a risk factor for reoperation. If the translational displacement was less than 3 mm, the reoperation rate was 6%, whereas if the displacement was more than 3 mm, it was 83%. Reoperation was performed on 50% of the patients who underwent fibular fixation and on 15% of the patients who did not undergo fibular fixation. There were only marginal decreases in the range of motion and arthritis scores in the AO/OTA fracture types other than type C3. There were no significant differences in RAND 36 scores between the general Finnish population aged 18 to 64 years and our patients.

CONCLUSIONS

Hybrid external fixation of distal tibial fractures is associated with delayed union, which is closely related to the degree of residual translational displacement after reduction. Fixation of an associated fibular fracture does not help to achieve better contact in the tibial fracture and increases the risk of delayed union.

Distal tibial metaphyseal fractures: the role of fibular fixation

Distal tibial extra-articular fractures are often a result of complex high-energy trauma, which commonly involves associated fibular fractures and soft tissue injury. The goal of tibial fixation is to maximise fracture stability without increasing soft tissue morbidity from surgical intervention. The role of adjunctive fibular fixation in distal tibial metaphyseal fractures has been controversial; although fibular fixation has been shown to improve stability of distal tibial fractures, there has been increased potential for soft tissue-related complications and a delay to tibial fracture healing. Adjunctive fixation of concomitant fibular fractures without associated syndesmotic or ankle pathology is not necessary in surgically stabilised extra-articular metaphyseal fractures of the distal tibia.

[Management strategies in the first operative phase after long-bone injury of the lower extremity in multiple-injured patients. A systematic literature review]

OBJECTIVE

Lower extremity injuries make up a substantial proportion of the injuries in multiply injured patients. The aim of this systematic literature analysis was to give an overview of the levels of evidence for different management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients to enable, in the presence of adequate evidence, the development of clinical management corridors or, if the evidence was found to be inadequate, to document the necessity for scientific proof.

METHODS

Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (EL 1 to 5 according to the Oxford system).

RESULTS

The necessity for primary or secondary definitive osteosynthesis of femur/tibia shaft fractures is still a matter of discussion. Intramedullary nailing is the preferred operative procedure for definitive treatment of femur shaft fractures. Stabilization of proximal and distal femur and tibia fractures is predominantly based on expert opinion. According to the literature, perioperative antibiotic prophylaxis is essential in fracture treatment.

CONCLUSION

Numerous comparative studies (EL 2) dealing with management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients are available, but there are only a few randomized studies. Based on the available data, it is possible to develop a rational therapy for this patient population.

Does fibular plating improve alignment after intramedullary nailing of distal metaphyseal tibia fractures?

OBJECTIVE

Evaluate whether supplementary fibular fixation helped maintain axial alignment in distal metaphyseal tibia-fibula fractures treated by locked intramedullary nailing.

DESIGN

Retrospective chart and radiographic review.

SETTING

Three, level 1, trauma centers.

PATIENTS

Distal metaphyseal tibia-fibula fractures were separated into 2 groups based on the presence of adjunctive fibular plating. Group 1 consisted of fractures treated with small fragment plate fixation of the fibula and intramedullary (IM) nailing of the tibia, whereas group 2 consisted of fractures treated with IM nailing of the tibia without fibular fixation.

OUTCOME MEASURES

Malalignment of the tibial shaft was defined as 1) >5 degrees of varus/valgus angulation, or 2) >10 degrees anterior/posterior angulation. Measures of angulation were obtained from radiographs taken immediately after the surgery, a second time 3 months later, and at 6-month follow-up. Leg length and rotational deformity were not examined.

RESULTS

Seventy-two fractures were studied. In 25 cases, the associated fibula fracture was stabilized, and in 47 cases the associated fibula fracture was not stabilized. Cases were more likely to have the associated fibula fracture stabilized where the tibia fracture was very distal. In multivariate adjusted analysis, plating of the fibula fracture was significantly associated with maintenance of reduction 12 weeks or later after surgery (odds ratio = 0.03; P = 0.036). The use of 2 medial-lateral distal locking bolts also was protective against loss of reduction; however, this association was not statistically significant (odds ratio = 0.29; P = 0.275).

CONCLUSIONS

In this study, the proportion of fractures that lost alignment was smaller among those receiving stabilization of the fibula in conjunction with IM nailing compared with those receiving IM nailing alone. Adjunctive fibular stabilization was associated significantly with the ability to maintain fracture reduction beyond 12 weeks. At the present time, the authors recommend fibular plating whenever IM nailing is contemplated in the unstable distal tibia-fibular fracture.

Mechanical contribution of the fibula to torsion stiffness in the lower extremity

The role of the fibula in rotational stability of the lower extremity, taking into account the intact knee joint and tibia, to the best of our knowledge, has not been investigated. A cadaver study was designed to determine the torque transfer down the lower extremity, with and without the fibula. Six fresh, frozen human cadaver legs were used. The knee joint was left intact and the foot disarticulated. An external rotation up to 5 degrees , coupled with axial compression, was applied to the femur passing through the knee joint in extension and down the lower extremity to the fixed distal end, where torque (N m) was measured via a load cell. Each specimen was further tested with the fibula, cut 4 cm from the distal end, and finally with the entire fibula disarticulated at the proximal end and removed. To achieve 5 degrees rotation, torques reached 1.82 N m (SD, 0.66 N m). When the fibula was cut, the torque reduced a small yet significant amount of 5%. With the entire fibula removed, the torque reduction was significant and more pronounced at 11%. The fibula provided a small yet significant role in torsion stability. From this study, where the biomechanical characteristics of the fibula is explicated, it is hoped that this information will have use in further understanding the biomechanical role of the fibula, especially, in relation to the altered mechanics associated with lower limb pathology involving a deficient fibula.

Nonunions of the distal tibia treated by reamed intramedullary nailing

OBJECTIVE

The purpose of this study is to determine the efficacy of reamed intramedullary nailing in the treatment of nonunions of the distal one-fourth of the tibia. Nonunions of the distal tibia are particularly difficult to treat given the short distal segment, the proximity to the ankle joint, and the fragile soft-tissue envelope. Intramedullary nailing is an attractive solution to this problem because it avoids extensive dissection, and the implant remains intraosseous, posing minimal problem for the soft tissues.

DESIGN

Retrospective review of patient charts and radiographs.

SETTING

Tertiary care orthopaedic hospital.

PATIENTS/PARTICIPANTS

Thirty-two patients with nonunions of the distal one-fourth of the tibia. Prior treatments included casting, internal fixation with plates and screws, intramedullary nailing, and external fixation. Seven patients had a history of infection, but no patient had signs of active infection at the time of surgery.

INTERVENTION

Study patients were treated by reamed, locked intra-medullary nailing.

MAIN OUTCOME MEASUREMENTS

Main outcome measurements included time to union, correction of deformity, and complications including infection and reoperation.

RESULTS

Average length of follow-up was 25 months (range 4-81 months). Twenty-nine out of 32 patients achieved union at an average of 3.5 months after reamed, locked intramedullary nailing. Of the remaining three, 2 patients united after dynamization (one at 4 months after dynamization and the other at 7 months), and the third patient united 4 months after exchange nailing. Deformity was corrected to a maximum of 4 degrees in all planes. Four patients had positive intraoperative cultures, and only 2 required removal of the nail after achieving union to control infection. There were no signs of chronic osteomyelitis in these 2 patients at the date of the last follow-up visit; 5.5 years and 2 years following nail removal.

CONCLUSIONS

Reamed, locked intramedullary nailing is a reliable and safe procedure in the treatment of nonunions in the distal one-fourth of the tibia, even in the setting of prior infection or external fixation. It allows for excellent correction of deformity, which is an essential component of the procedure.

Effect of fibular plate fixation on rotational stability of simulated distal tibial fractures treated with intramedullary nailing

BACKGROUND

The effect of an intact fibula on rotational stability after a distal tibial fracture has, to the best of our knowledge, not been clearly defined. We designed a cadaver study to clarify our clinical impression that fixation of the fibula with a plate increases rotational stability of distal tibial fractures fixed with a Russell-Taylor intramedullary nail.

METHODS

Seven matched pairs of embalmed human cadaveric legs and sixteen fresh-frozen human cadaveric legs, including one matched pair, were tested. To simulate fractures, 5-mm transverse segmental defects were created at the same level in the tibia and fibula, 7 cm proximal to the ankle joint in each bone. The tibia was stabilized with a 9-mm Russell-Taylor intramedullary nail that was statically locked with two proximal and two distal screws. Each specimen was tested without fibular fixation as well as with fibular fixation with a six-hole semitubular plate. A biaxial mechanical testing machine was used in torque control mode with an initial axial load of 53 to 71 N applied to the tibial condyle. Angular displacement was measured in 0.56-N-m torque increments to a maximal torque of 4.52 N-m (40 in-lb).

RESULTS

Initially, significantly less displacement (p < or = 0.05) was produced in the specimens with fibular plate fixation than in those without fibular plate fixation. The difference in angular displacement between the specimens treated with and without plate fixation was established at the first torque data point measured but did not increase as the torque was increased. No significant difference in the rotational stiffness was found between the specimens treated with and without plate fixation after measurement of the second torque data point (between 1.68 and 4.48 N-m).

CONCLUSIONS

Fibular plate fixation increased the initial rotational stability after distal tibial fracture compared with that provided by tibial intramedullary nailing alone. However, there was no difference in rotational structural stiffness between the specimens treated with and without plate fixation as applied torque was increased.