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Wen Y, Zhu D, Wang Q, Song B, Feng W. External fixator as a safe method in the treatment of distal tibial fractures in children. J Pediatr Orthop B 2024; 33:233-239. [PMID: 37040653 DOI: 10.1097/bpb.0000000000001088] [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: 04/13/2023]
Abstract
OBJECTIVE The objective of this study is to evaluate the functional and radiological results of external fixator application in the treatment of distal tibial metaphyseal diaphyseal junction (MDJ) fractures in children and to analyze differences between stable and unstable fractures. METHODS Medical records of children with distal tibial MDJ fracture confirmed by imaging from January 2015 to November 2021 were retrospectively analyzed. Patients were divided into stable and unstable groups and parameters, including clinical and imaging data and Tornetta ankle score were compared. RESULTS Twenty-five children, comprising 13 with stable and 12 with unstable fractures, were included in our study. The mean age was 7 years (range, 2-13.1 years), and there were 17 males and 8 females. All children had closed reduction, and the basic clinical data of the two groups were comparable. Stable fractures showed shorter intraoperative fluoroscopy, operation, and fracture healing times than unstable fractures. No significant difference in Tornetta ankle score was observed. Twenty-two patients had excellent ankle score, and three had a good ankle score, for a combined incidence of 100%. Two patients in the stable fracture group and one in the unstable fracture group developed a pin site infection, and one patient with unstable fracture showed a length discrepancy (discrepancy<1 cm). CONCLUSION External fixator is safe and effective for the treatment of distal tibial MDJ fractures, whether the fracture is stable or not. It has the advantages of minimally invasive, excellent ankle function score, few major complications, needless auxiliary cast fixation, and early functional exercise and weight bearing. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Yuwei Wen
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Makaram NS, Sheppard J, Leow JM, Oliver WM, Keating JF. Outcome Following Intramedullary Nailing of Tibial Diaphyseal Fractures: Suprapatellar Nail Insertion Results in Superior Radiographic Parameters But No Difference in Mid-Term Function. J Bone Joint Surg Am 2024; 106:397-406. [PMID: 38100599 DOI: 10.2106/jbjs.23.00421] [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: 12/17/2023]
Abstract
BACKGROUND The primary aim of this study was to compare the radiographic parameters (nail insertion-point accuracy [NIPA] and fracture malalignment) of patients who had undergone tibial intramedullary nailing via the suprapatellar (SP) and infrapatellar (IP) approaches. The secondary aims were to compare clinical outcomes and patient-reported outcomes (PROs) between these approaches. METHODS All adult patients with an acute tibial diaphyseal fracture who underwent intramedullary nailing at a single level-I trauma center over a 4-year period (2017 to 2020) were retrospectively identified. The nailing approach (SP or IP) was at the treating surgeon's discretion. Intraoperative and immediate postoperative radiographs were reviewed to assess NIPA (mean distance from the optimal insertion point) and malalignment (≥5°). Medical records and radiographs were reviewed to evaluate the rates of malunion, nonunion, and other postoperative complications. The Oxford and Lysholm Knee Scores (OKS and LKS) and patient satisfaction (0 = completely dissatisfied, 100 = completely satisfied) were obtained via a postal survey at a minimum of 1 year postoperatively. RESULTS The cohort consisted of 219 consecutive patients (mean age, 48 years [range, 16 to 90 years], 51% [112] male). There were 61 patients (27.9%) in the SP group and 158 (72.1%) in the IP group. The groups did not differ in baseline demographic or injury-related variables. SP nailing was associated with superior coronal NIPA (p < 0.001; 95% confidence interval [CI] for IP versus SP, 1.17 to 3.60 mm) and sagittal NIPA (p < 0.001; 95% CI, 0.23 to 0.97 mm) and with a reduced rate of malalignment (3% [2 of 61] versus 11% [18 of 158] for IP; p = 0.030). PROs were available for 118 of 211 patients (56%; 32 of 58 in the SP group and 86 of 153 in the IP group) at a mean of 3 years (range, 1.2 to 6.5 years). There was no difference between the SP and IP groups in mean OKS (36.5 versus 39.6; p = 0.246), LKS (71.2 versus 73.5; p = 0.696), or satisfaction scores (81.4 versus 79.9; p = 0.725). CONCLUSIONS Compared with IP nailing, SP nailing of tibial shaft fractures was associated with superior NIPA and a reduced rate of intraoperative malalignment but not of malunion at healing. However, the superior NIPA may not be clinically important. Furthermore, there were no differences in PROs at mid-term follow-up. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - James Sheppard
- University of Edinburgh Medical School, Edinburgh, Scotland, United Kingdom
| | - Jun M Leow
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - William M Oliver
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - John F Keating
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
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Lin X, Zhang C, Yang Y, Yang W, Wang X, Lu H, Liu Q. Comparative experimental study of the biomechanical properties of retrograde tibial nailing and distal tibia plate in distal tibia fracture. Front Bioeng Biotechnol 2024; 12:1322043. [PMID: 38444646 PMCID: PMC10912641 DOI: 10.3389/fbioe.2024.1322043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 02/06/2024] [Indexed: 03/07/2024] Open
Abstract
Objective: A biomechanical comparative analysis was conducted to evaluate the retrograde tibial nailing (RTN) and distal tibia plate techniques for the treatment of distal tibia fractures. Methods: Fourteen fresh adult tibia specimens were selected, consisting of seven males and seven females aged 34-55 years. The specimens were randomly divided into two groups (Group A and Group B) using a numerical table method, with seven specimens in each group. Group A underwent internal fixation of distal tibial fractures using RTN, while Group B received internal fixation using a plate. The axial compression properties of the specimens were tested in the neutral positions under pressures of 100, 200, 300, 400, and 500 N. Additionally, the torsional resistance of the two groups was assessed by subjecting the specimens to torques of 1.0, 2.0, 3.0, 4.0, and 5.0 N m. Results: At pressures of 400 and 500 N, the axial compression displacement in Group A (1.11 ± 0.06, 1.24 ± 0.05) mm was significantly smaller than that in Group B (1.21 ± 0.08, 1.37 ± 0.11) mm (p = 0.023, 0.019). Moreover, at a pressure of 500 N, the axial compression stiffness in Group A (389.24 ± 17.79) N/mm was significantly higher than that of the control group (362.37 ± 14.44) N/mm (p = 0.010). When subjected to torques of 4 and 5 N m, the torsion angle in Group A (2.97° ± 0.23°, 3.41° ± 0.17°) was significantly smaller compared to Group B (3.31° ± 0.28°, 3.76° ± 0.20°) (p = 0.035, 0.004). Furthermore, at a torque of 5 N m, the torsional stiffness in Group A (1.48 ± 0.07) N m/° was significantly higher than that in Group B (1.36 ± 0.06) N·m/° (p = 0.003). Conclusion: The results obtained from the study demonstrate that the biomechanical performance of RTN outperforms that of the distal tibial plate, providing valuable biomechanical data to support the clinical implementation of RTN.
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Affiliation(s)
- Xuping Lin
- Department of Spinal Surgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
- Department of Orthopedic Surgery, The Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, China
| | - Cong Zhang
- Department of Orthopedic Surgery, The Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, China
| | - Yanfang Yang
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Wencheng Yang
- Department of Spinal Surgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Xiaomeng Wang
- Department of Spinal Surgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Haichuan Lu
- Department of Spinal Surgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Qingjun Liu
- Department of Orthopedic Surgery, The Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, China
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Alam MA, Shirazi AF, Alaradi H. Association of Fracture Location and Pattern With Nonunion or Malunion in Tibia Fractures Managed With Intramedullary Nailing: A Retrospective Study. Cureus 2023; 15:e49156. [PMID: 38130567 PMCID: PMC10733781 DOI: 10.7759/cureus.49156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Background and objective Extra-articular fractures of the tibia are common orthopedic injuries that are frequently treated with rigid intramedullary nailing. Fracture location and pattern may increase the risk of nonunion or malunion in fractures managed with intramedullary nails. This study aimed to assess the relationship between fracture pattern and location with malunion and nonunion. The primary objective was to evaluate the influence of fracture location and pattern on adverse clinical outcomes such as nonunion, delayed union, and malunion in tibial shaft fractures that are treated operatively with rigid intramedullary nails. Methodology This was a retrospective cross-sectional study conducted on patients operated in a tertiary care center in the Kingdom of Bahrain. The study included patients who sustained tibia shaft fractures and were subsequently operated with intramedullary of the tibia. The primary endpoint was the rate of adverse outcomes associated with fracture patterns. Fracture characteristics were to determine which fracture patterns healed well with intramedullary nailing and which fractures ended up with malunion or nonunion and would likely benefit from additional measures to augment the nail fixation and help encourage union. Results One hundred and eighty-nine patients were included in the study. The level of associated fibula fracture was significantly associated with an increased risk of nonunion and malunion (P = 0.0034, P = 0.001). The presence of a concomitant distal fibula fracture in association with tibia fractures increased the odds of nonunion (odds ratio [OR] = 4.871, P = 0.033, confidence interval [CI] = 1.133-20.948). Conclusions The level and pattern of some tibia and fibula fractures were associated with nonunion, malunion, and delayed union. Further studies with more robust follow-up are needed to examine these findings in greater detail.
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Affiliation(s)
- Mahmood A Alam
- Orthopaedics and Trauma, Salmaniya Medical Complex, Manama, BHR
| | - Ahmed F Shirazi
- Orthopaedics and Trauma, Salmaniya Medical Complex, Manama, BHR
| | - Hasan Alaradi
- Orthopaedics and Trauma, Salmaniya Medical Complex, Manama, BHR
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Zhang J, Lu V, Zhou AK, Stevenson A, Thahir A, Krkovic M. Predictors for infection severity for open tibial fractures: major trauma centre perspective. Arch Orthop Trauma Surg 2023; 143:6579-6587. [PMID: 37418004 PMCID: PMC10541339 DOI: 10.1007/s00402-023-04956-1] [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: 02/14/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Open diaphyseal tibial fractures are the most common long-bone fractures and require a rapid approach to prevent devastating complications. Current literature reports the outcomes of open tibial fractures. However, there is no robust, up-to-date research on the predictive indicators of infection severity in a large open tibial fracture patient cohort. This study investigated the predictive factors of superficial infections and osteomyelitis in open tibial fractures. MATERIALS AND METHODS A retrospective analysis of the tibial fracture database was carried out from 2014 to 2020. Criteria for inclusion was any tibial fracture including tibial plateau, shaft, pilon or ankle, with an open wound at the fracture site. Exclusion criteria included patients with a follow-up period of less than 12 months and who are deceased. A total of 235 patients were included in our study, of which 154 (65.6%), 42 (17.9%), and 39 (16.6%) developed no infection, superficial infection, or osteomyelitis, respectively. Patient demographics, injury characteristics, fracture characteristics, infection status and management details were collected for all patients. RESULTS On multivariate modelling, patients with BMI > 30 (OR = 2.078, 95%CI [1.145-6.317], p = 0.025), Gustilo-Anderson (GA) type III (OR = 6.120, 95%CI [1.995-18.767], p = 0.001), longer time to soft tissue cover (p = 0.006) were more likely to develop a superficial infection, and patients with wound contamination (OR = 3.152, 95%CI [1.079-9.207], p = 0.036), GA-3 (OR = 3.387,95%CI [1.103-10.405], p = 0.026), longer to soft tissue cover (p = 0.007) were more likely to develop osteomyelitis. Univariate analysis also determined that risk factors for superficial infection were: BMI > 35 (OR = 6.107, 95%CI [2.283-16.332], p = 0.003) and wound contamination (OR = 2.249, 95%CI [1.015-5.135], p = 0.047); whilst currently smoking (OR = 2.298, 95%CI [1.087-4.856], p = 0.025), polytrauma (OR = 3.212, 95%CI [1.556-6.629], p = 0.001), longer time to definitive fixation (p = 0.023) were for osteomyelitis. However, none of these reached significance in multivariate analysis. CONCLUSION Higher GA classification is a significant risk factor for developing superficial infection and osteomyelitis, with a stronger association with osteomyelitis, especially GA 3C fractures. Predictors for superficial infection included BMI and time to soft tissue closure. Time to definitive fixation, time to soft tissue closure, and wound contamination were associated with osteomyelitis.
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Affiliation(s)
- James Zhang
- Department of Trauma and OrthopaedicsAddenbrooke’s Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK
| | - Victor Lu
- Department of Trauma and OrthopaedicsAddenbrooke’s Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK
| | - Andrew Kailin Zhou
- Department of Trauma and OrthopaedicsAddenbrooke’s Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK
| | - Anna Stevenson
- Department of Trauma and OrthopaedicsAddenbrooke’s Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP UK
| | - Azeem Thahir
- Department of Trauma and OrthopaedicsAddenbrooke’s Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
| | - Matija Krkovic
- Department of Trauma and OrthopaedicsAddenbrooke’s Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
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O'Neill CN, Hooper N, Wait J, Satalich J, Cinats D, Toney C, Perdue P, Satpathy J. No Difference in Short-Term Complications following Treatment of Closed Tibial Shaft Fractures with Intramedullary Nailing versus Plate Fixation. Adv Orthop 2023; 2023:1627225. [PMID: 37868630 PMCID: PMC10586916 DOI: 10.1155/2023/1627225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/30/2023] [Accepted: 10/06/2023] [Indexed: 10/24/2023] Open
Abstract
Objectives Tibial shaft fractures are treated with both intramedullary nailing (IMN) and plate fixation (ORIF). Using a large national database, we aimed to explore the differences in thirty-day complication rates between IMN and ORIF. Methods Patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had undergone either tibial IMN or ORIF for closed fractures from 2010 to 2018 were identified using current procedural terminology (CPT) codes. After excluding all patients with open fractures, the propensity score was matching. Univariate and multivariate logistic regressions were used to identify risk factors associated with the thirty-day incidence of complications in the two cohorts. Results A total of 5,400 patients were identified with 3,902 (72.3%) undergoing IMN and 1,498 (27.7%) ORIF. After excluding any ICD-10 diagnosis codes not pertaining to closed, traumatic tibial shaft fractures, 2,136 IMN and 621 ORIF cases remained. After matching, the baseline demographics were not significantly different between the cohorts. Following matching, the rate of any adverse event (aae) did not differ significantly between the IMN (7.08% (n = 44)) and ORIF (8.86% (n = 55)) cohorts (p=0.13). There was also no significant difference in operative time (IMN = 98.5 min, ORIF = 100 min; p=0.3) or length of stay (IMN = 3.7 days, ORIF = 3.3 days; p=0.08) between the cohorts. Conclusion There were no significant differences in short-term complications between cohorts. These are important data for the surgeon when considering surgical management of closed tibial shaft fractures.
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Affiliation(s)
- Conor N. O'Neill
- Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Nicholas Hooper
- Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Jacob Wait
- Virginia Commonwealth University Health System, Richmond, VA, USA
| | - James Satalich
- Virginia Commonwealth University Health System, Richmond, VA, USA
| | - David Cinats
- Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Clarence Toney
- Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Paul Perdue
- Virginia Commonwealth University Health System, Richmond, VA, USA
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Kumar D, Mittal A, Singh J, Kumar H, Singh PP, Kumar A, Singhania A, Kant R. Anterolateral and Medial Locking Compression Plates for the Management of Distal Tibial Fractures: A Comparative Prospective Study. Cureus 2023; 15:e44235. [PMID: 37772222 PMCID: PMC10523109 DOI: 10.7759/cureus.44235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Open/close reduction (OR/CR) and internal fixation (IF) of displaced fractures of distal tibia with either a medial or anterolateral plate is a commonly performed procedure. Anterolateral plating avoids an incision along the medial subcutaneous border of tibia and has been shown to have reduced risk of wound complications. The aim of our study was to determine the functional outcome of these fractures treated with anterolateral and medial distal tibial locking compression plates. METHODS This was a prospective study that included 60 patients with distal tibial fractures (close or grade I open injury) divided into two groups with 30 patients in each where one group was treated with OR/CR and IF using an anterolateral distal tibial locking plate (Group A) and the other using a medial distal tibial locking plate (Group B). The duration of surgery and intraoperative blood loss and time to union were recorded for all the patients. Functional evaluation was done at one year in terms of pain, function and alignment using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and complications, if any, were noted. RESULTS Both the groups were comparable in terms of age, gender, time of presentation, AO classification and presence of wound. The mean duration of surgery as well as the intraoperative blood loss were more in the anterolateral plate group than in the medial plate group, but the difference was statistically insignificant. Ten patients (33%) with medial plates had symptomatic hardware and 7 (23.3%) underwent removal while only 3 (10%) patients in the anterolateral plate group had similar complaints and none had to undergo removal. Two patients with anterolateral plate and one with medial plate had malunion. The mean time to fracture union as well as the rate of infection was less and the functional outcome at one year was better in the group treated with anterolateral plates as compared to the one with medial plates, but the difference again was not statistically significant for all the parameters. CONCLUSION With reduced risk of soft tissue complications and by obviating the need for implant removal, anterolateral plates can prove to be a better alternative to the medial plates especially in elderly patients in the management of these fractures.
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Affiliation(s)
- Dinesh Kumar
- Department of Orthopaedics, Uttar Pradesh University of Medical Sciences, Etawah, IND
| | - Ankit Mittal
- Department of Orthopaedics, Uttar Pradesh University of Medical Sciences, Etawah, IND
| | - Jasveer Singh
- Department of Orthopaedics, Uttar Pradesh University of Medical Sciences, Etawah, IND
| | - Harish Kumar
- Department of Orthopaedics, Uttar Pradesh University of Medical Sciences, Etawah, IND
| | - Prashant P Singh
- Department of Orthopaedics, Uttar Pradesh University of Medical Sciences, Etawah, IND
| | - Akash Kumar
- Department of Orthopaedics, Uttar Pradesh University of Medical Sciences, Etawah, IND
| | - Ashish Singhania
- Department of Orthopaedics, Uttar Pradesh University of Medical Sciences, Etawah, IND
| | - Ravi Kant
- Department of Orthopaedics, Uttar Pradesh University of Medical Sciences, Etawah, IND
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Darden C, Pujari A, Stocchi C, Forsh D. Distal Tibial Metaphyseal Malunion Treated with Clamshell Osteotomy: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00038. [PMID: 37556575 DOI: 10.2106/jbjs.cc.23.00072] [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: 08/11/2023]
Abstract
CASE Here, we describe a case of a 49-year-old female patient with a history of hypertension and polysubstance use disorder presenting with a distal tibial metaphyseal malunion treated with a clamshell osteotomy. Her follow-up was 2.5 years long. CONCLUSION Malunions in the tibial diaphysis and distal metaphysis can cause significantly increased joint reaction forces and altered gait mechanics leading to cosmetic dissatisfaction and decreased quality of life for these patients. Correction of these deformities can improve patient satisfaction and quality of life, along with decrease the risk of early arthritis. The clamshell osteotomy, although initially described to treat diaphyseal long bone malunions, can safely be performed for treatment of complex periarticular metaphyseal malunions.
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Megerian MF, Schimizzi GV, Barth KA, LaValva SM, Klinger CE, Dziadosz DR, Ricci WM, Campbell ST. Distal Tibia Apex Posterior Angulation: A Normal Anatomic Variant Related to Hindfoot Alignment With Side-to-Side Symmetry. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202306000-00009. [PMID: 37319362 PMCID: PMC10566894 DOI: 10.5435/jaaosglobal-d-23-00076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/17/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES The sagittal plane of the distal tibia has not been well-described. This study sought to characterize sagittal plane morphology, determine symmetry from side to side, and identify differences based on hindfoot alignment. METHODS One hundred twelve bilateral lateral weight-bearing ankle radiographs were retrospectively evaluated (224 ankles). Hindfoot alignment was classified as neutral, planus, or cavus using the Meary angle. The angle between the diaphyseal and distal tibia axes was measured, and the apex location relative to the plafond was recorded. RESULTS A mean distal tibia apex posterior angulation (DTAPA) of 2.0° (range -2° to 7°, SD = 2.06°) was located 8.0 cm proximal to the plafond. No difference was observed from side to side in DTAPA magnitude (P = 0.36) or location (P = 0.90). Planus alignment was associated with a significantly greater DTAPA (3.05°) as compared with neutral (1.89°) (P = 0.002) and cavus (1.25°) (P < 0.001) alignment. CONCLUSION The distal tibia has an apex posterior angulation, suggesting that the true anatomic axis of the tibia terminates just posterior to the plafond center. Hindfoot alignment is related to distal tibia morphology. DTAPA symmetry indicates that contralateral imaging can be used to guide reconstruction of patient-specific anatomy and alignment. Knowledge of the DTAPA may help mitigate sagittal malalignment during distal tibia fracture surgery.
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Affiliation(s)
- Mark F. Megerian
- From the Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY (Megerian, Schimizzi, Dr. Barth, Dr. LaValva, Klinger, Dr. Dziadosz, and Dr. Ricci); the Case Western Reserve University School of Medicine, Cleveland, OH (Megerian); and the Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA (Dr. Campbell)
| | - Gregory V. Schimizzi
- From the Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY (Megerian, Schimizzi, Dr. Barth, Dr. LaValva, Klinger, Dr. Dziadosz, and Dr. Ricci); the Case Western Reserve University School of Medicine, Cleveland, OH (Megerian); and the Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA (Dr. Campbell)
| | - Kathryn A. Barth
- From the Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY (Megerian, Schimizzi, Dr. Barth, Dr. LaValva, Klinger, Dr. Dziadosz, and Dr. Ricci); the Case Western Reserve University School of Medicine, Cleveland, OH (Megerian); and the Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA (Dr. Campbell)
| | - Scott M. LaValva
- From the Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY (Megerian, Schimizzi, Dr. Barth, Dr. LaValva, Klinger, Dr. Dziadosz, and Dr. Ricci); the Case Western Reserve University School of Medicine, Cleveland, OH (Megerian); and the Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA (Dr. Campbell)
| | - Craig E. Klinger
- From the Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY (Megerian, Schimizzi, Dr. Barth, Dr. LaValva, Klinger, Dr. Dziadosz, and Dr. Ricci); the Case Western Reserve University School of Medicine, Cleveland, OH (Megerian); and the Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA (Dr. Campbell)
| | - Daniel R. Dziadosz
- From the Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY (Megerian, Schimizzi, Dr. Barth, Dr. LaValva, Klinger, Dr. Dziadosz, and Dr. Ricci); the Case Western Reserve University School of Medicine, Cleveland, OH (Megerian); and the Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA (Dr. Campbell)
| | - William M. Ricci
- From the Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY (Megerian, Schimizzi, Dr. Barth, Dr. LaValva, Klinger, Dr. Dziadosz, and Dr. Ricci); the Case Western Reserve University School of Medicine, Cleveland, OH (Megerian); and the Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA (Dr. Campbell)
| | - Sean T. Campbell
- From the Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY (Megerian, Schimizzi, Dr. Barth, Dr. LaValva, Klinger, Dr. Dziadosz, and Dr. Ricci); the Case Western Reserve University School of Medicine, Cleveland, OH (Megerian); and the Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA (Dr. Campbell)
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Hague M, Texeira D, Anderson T, Williamson M, Trompeter A. Nailing distal tibial fractures: does entry technique affect distal alignment? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:61-66. [PMID: 34727267 DOI: 10.1007/s00590-021-03148-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/11/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE In treating distal third tibial fractures, restoration of the axial alignment and therefore accurate reduction of the distal fragment minimise the risk of tibiotalar joint malalignment. The aim of this study is to investigate whether there was a difference in accuracy of reduction and axial alignment, when nailing distal third tibial fractures using either the suprapatellar or the infrapatellar tibial nailing entry technique. METHODS This retrospective cohort study compared alignment of intramedullary nails performed for distal third tibial fractures between 2015 and 2018 through the suprapatellar and infrapatellar approach at a UK Level 1 trauma centre. It compared a consecutive series of 74 suprapatellar nails and 51 infrapatellar nails, with radiographic assessment of tibial alignment in the antero-posterior and sagittal planes. It included inter- and intra-observer analyses of radiographic measurements. RESULTS In the coronal plane, mean malalignment in the suprapatellar technique group was 2.8 ± 0.7° and 4.7 ± 0.9° in the infrapatellar technique group (P < 0.01). In the sagittal plane, mean malalignment in the suprapatellar technique group was 4.0 ± 0.8° and 3.5 ± 0.9° in the infrapatellar technique group (P = 0.42). Intra- and inter-observer analysis showed strongly positive correlations between observers. CONCLUSIONS We suggest that the suprapatellar technique may improve coronal plane alignment when intramedullary nailing distal tibial fractures. There was no significant difference in alignment in the sagittal plane. We conclude that the suprapatellar technique may be superior in preventing malalignment when treating distal third tibial fractures, potentially improving clinical outcome.
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Affiliation(s)
- Matthew Hague
- Epsom and St Helier University Hospitals NHS Trust, London, UK.
| | | | | | - Mike Williamson
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Alex Trompeter
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK
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Jose RS, Vivek K, Bava NK, Moosa MS. Functional outcome of intramedullary interlocking nailing versus minimally invasive percutaneous plate osteosynthesis in distal tibia fracture. JOURNAL OF ORTHOPAEDIC DISEASES AND TRAUMATOLOGY 2023. [DOI: 10.4103/jodp.jodp_56_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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12
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Lu K, Wu ZQ, Wang HZ, Qian RX, Li C, Gao YJ. The semi-extended infrapatellar intramedullary nailing of distal tibia fractures: a randomized clinical trial. J Orthop Traumatol 2022; 23:53. [PMID: 36443615 PMCID: PMC9705656 DOI: 10.1186/s10195-022-00674-3] [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: 08/13/2022] [Accepted: 10/30/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Malalignment is a common event during the intramedullary nailing (IMN) of distal tibia fractures (DTFs). Although it is reported that the semi-extended IMN techniques such as suprapatellar (SP) and parapatellar (PP) approaches may be superior in preventing malalignment, the application of these techniques is concerning owing to the intra-articular involvement. We thus developed an extra-articular semi-extended infrapatellar (SEIP) approach which utilizes the infrapatellar (IP) space while maintaining the knee in a semi-extended position. However, there are no studies on the safety and efficacy of SEIP in treating DTFs. Therefore, in this study, the SEIP technique was examined, particularly in terms of the potential alignment improvement of DTFs, and this technique was compared with the traditional hyperflexed infrapatellar (HFIP) procedure. MATERIALS AND METHODS This randomized clinical trial (RCT) compared IMN malalignment while correcting extraarticular and nondisplaced intra-articular DTFs between April 2018 and June 2021 using the HFIP and SEIP techniques at a level I trauma center in China. The study participants were clinically and radiographically examined for at least 12 months of follow-ups. Intraoperative fluoroscopy time, operation time, blood loss, hospitalization duration, functional ankle score, and complications were assessed as well. RESULTS Among the 88 recruited participants, 45 (51%) underwent traditional HFIP IMN and 43 (49%) underwent SEIP IMN. Malalignment occurred in 9 patients (20.0%) from the HFIP cohort and in 2 patients (4.7%) from the SEIP cohort (P value = 0.030). In addition, the SEIP IMN technique significantly reduced the intraoperative fluoroscopy time, operation time, and improved the postoperative ankle function compared to the HFIP IMN technique. However, the intraoperative blood loss, hospitalization duration, infection, delay union, and nonunion remained the same between the two cohorts. CONCLUSIONS In summary, we demonstrated that the SEIP IMN provides markedly enhanced alignment of extraarticular and nondisplaced intra-articular DTFs compared to the traditional HFIP IMN procedure. The described technique represents an effective option for IMN of DTFs. LEVEL OF EVIDENCE Level 2. Trial registration The Chinese Clinical Trial Registry, ChiCTR2100043673. Registered 26 February 2021, retrospectively registered, http://www.chictr.org.cn/showprojen.aspx?proj=122263.
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Affiliation(s)
- Ke Lu
- Department of Orthopaedics, Affiliated Kunshan Hospital of Jiangsu University, No. 91 West of Qianjin Road, Suzhou, 215300, Jiangsu, China
| | - Zhi-Qiang Wu
- Department of Orthopaedics, Affiliated Kunshan Hospital of Jiangsu University, No. 91 West of Qianjin Road, Suzhou, 215300, Jiangsu, China
| | - Hong-Zhen Wang
- Department of Orthopaedics, Affiliated Kunshan Hospital of Jiangsu University, No. 91 West of Qianjin Road, Suzhou, 215300, Jiangsu, China
| | - Rong-Xun Qian
- Department of Orthopaedics, Affiliated Kunshan Hospital of Jiangsu University, No. 91 West of Qianjin Road, Suzhou, 215300, Jiangsu, China
| | - Chong Li
- Department of Orthopaedics, Affiliated Kunshan Hospital of Jiangsu University, No. 91 West of Qianjin Road, Suzhou, 215300, Jiangsu, China
| | - Yi-Jun Gao
- Department of Orthopaedics, Affiliated Kunshan Hospital of Jiangsu University, No. 91 West of Qianjin Road, Suzhou, 215300, Jiangsu, China.
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13
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John M, Mir HR. Extreme nailing and immediate weight bearing constructs in fractures of the distal tibia. OTA Int 2022; 5:e180. [PMID: 37781481 PMCID: PMC10538524 DOI: 10.1097/oi9.0000000000000180] [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: 10/05/2021] [Accepted: 12/18/2021] [Indexed: 10/03/2023]
Abstract
Extraarticular fractures of the distal tibia can present as difficult but manageable lower extremity injuries. Historically, these injuries have been fixed in a myriad of ways. Early management with intramedullary nailing had higher complication rates due to the unique anatomical and biomechanical features of the distal tibia. Modern improvements in intramedullary nailing surgical techniques and implant design have significantly decreased complication rates and led to improvement in patient outcomes. Many surgeons protect weight bearing postoperatively, but recent literature suggests that patients may safely weight bear immediately following intramedullary fixation. This article reviews technique and implant design changes that have facilitated immediate safe weight bearing following intramedullary nailing of extraarticular distal tibia fractures.
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Affiliation(s)
- Mitchell John
- University of South Florida, Department of Orthopaedic Surgery
| | - Hassan R Mir
- University of South Florida, Department of Orthopaedic Surgery
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL
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14
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Brodke DJ, Upfill-Brown A, Devana SK, Eichenlaub EK, Mahoney JM, Orbach MR, Bucklen BS, Kelley BV, Mayer EN, Shi BY, Lee C. A Critical Analysis of Lateral Versus Central Endpoint in Distal Tibia Nailing: Does It Affect Alignment? J Orthop Trauma 2022; 36:400-405. [PMID: 34999627 PMCID: PMC10371388 DOI: 10.1097/bot.0000000000002345] [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: 01/04/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the effect of a traditional "center-center" end point for distal tibia nailing in comparison with a lateral-of-center end point on fracture malalignment in a cadaver model. METHODS Nine matched pairs of human cadaveric lower-extremity specimens were used to model the effect of nail end point on fracture alignment in extra-articular distal tibia fractures. After simulation of the fracture through a standardized osteotomy, 1 member of each pair was fixed with an intramedullary nail using a "center-center" end point, whereas a lateral-of-center end point was used for the other member of the pair. Specimens were stripped of soft tissue, and digital calipers were used to measure fracture translation and gap medially, laterally, anteriorly, and posteriorly. Coronal plane angulation at each fracture was measured on the final mortise image. RESULTS The average coronal angulation was 7.0 degrees of valgus (with a SD of 4.1) in central-end point specimens versus 0.2 degrees of valgus (SD = 1.5) in lateral-end point specimens ( P < 0.001). Lateral-end point specimens also demonstrated significantly less fracture gap medially (mean 0.2 vs. 3.1 mm for central-end point specimens, P < 0.001), anteriorly (mean 0.1 vs. 1.3 mm, P = 0.003), and posteriorly (mean 0.3 vs. 2.2 mm, P = 0.003). Lateral-end point specimens also showed less lateral translation (mean 0.6 vs. 1.6 mm, P = 0.006). CONCLUSIONS Lateral-of-center nail end points may help surgeons restore native alignment in extra-articular distal tibia fractures and avoid valgus malalignment.
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Affiliation(s)
- Dane J Brodke
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Alexander Upfill-Brown
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Sai K Devana
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Emily K Eichenlaub
- Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc, Audubon, PA; and
| | - Jonathan M Mahoney
- Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc, Audubon, PA; and
| | - Mattan R Orbach
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA
| | - Brandon S Bucklen
- Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc, Audubon, PA; and
| | - Benjamin V Kelley
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Erik N Mayer
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Brendan Y Shi
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Christopher Lee
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
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15
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He M, Liu J, Deng X, He M. Controlling the angle between the distal locking screw and tibiotalar joint tangent helps to reduce the occurrence of misalignment of distal tibial fractures treated with intramedullary nail fixation. BMC Musculoskelet Disord 2022; 23:671. [PMID: 35836214 PMCID: PMC9281126 DOI: 10.1186/s12891-022-05641-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Studies have shown that on the coronal plane, whether the direction of the distal locking screw is parallel to the tangent line of the tibiotalar joint can be used to determine whether there is varus or valgus deformity after the treatment of distal tibial fractures with intramedullary nail (IMN) fixation. However, there has been no statistical analysis of the included angle on the coronal plane, and there have been no reports on whether there is a relationship between the direction of the distal locking screw on the sagittal plane or the included angle of the tangent line of the tibiotalar joint and the postoperative alignment of distal tibial fractures treated with IMN fixation. OBJECTIVE Our aim was to evaluate the relationship between the angles formed by the distal locking screw and the tibiotalar joint tangent (ADTTs) on the sagittal and coronal planes and postoperative alignment in the treatment of distal tibial fractures with IMN fixation. METHODS We performed a retrospective analysis of 100 patients with distal tibial fractures treated with IMN fixation using the suprapatellar approach. On the coronal and sagittal planes, the ADTTs were arranged from small to large and divided into 4 groups, namely, groups A, B, C and D. One-way ANOVA was used to compare the lateral distal tibial angle (LDTA) and anterior distal tibial angle (ADTA) among all groups, and the chi-square test was used to compare the incidence of postoperative tibial misalignment among all groups. Univariate analysis was performed using chi-square tests to identify factors that might be associated with dislocation, including fibular open reduction and internal fixation (ORIF), limited open reduction, ADTT, IMN diameter, injury mechanism, open vs. closed fracture, comminution, and fibular fracture level. Then, the statistically significant variables in the univariate analysis were included in a multivariate logistic regression equation to evaluate the independent factors related to misalignment. RESULTS On the coronal plane, the ADTTs of groups A, B, C and D were < 0°, 0°-1.3°, 1.3°-2.7° and > 2.7°, respectively. The mean LDTAs of groups B and C (0°-1.3° and 1.3°-2.7°), group A (< 0°) and group D (> 2.7°) were 89.5 ± 1.6°, 92.0 ± 3.2° and 85.8 ± 3.5°, respectively (P < 0.01). Deformity greater than 5° were more likely in groups A and D than groups B and C [14 of 50 (28%) vs. 1 of 50 (2%), P < 0.001]. On the sagittal plane, the ADTTs of groups A, B, C and D were < 8.9°, 8.9°-10.4°, 10.4°-11.7° and > 11.8°, respectively. The average ADTAs of groups B and C (8.9°-10.4° and 10.4°-11.7°), group A (< 8.9°) and group D (> 11.8°) were 80.4 ± 1.3°, 83.1 ± 3.7° and 77.9 ± 2.5°, respectively (P < 0.01). Deformity greater than 5° was more likely in groups A and D than groups B and C [13 of 50 (26%) vs. 0 of 50 (0%), P < 0.001]. An ADTT of 0°-2.7° on the coronal plane and 8.9°-11.7° on the sagittal plane (OR: 0.08, P = 0.02) and limited open reduction (OR: 0.21, P < 0.01) were independent factors that reduced the likelihood of misalignment. CONCLUSION The alignment of distal tibial fractures after surgery is sensitive to the ADTT and use of limited open reduction. Controlling the ADTT between 0° and 2.7° on the coronal plane and between 8.9° and 11.7° on the sagittal plane is helpful to reduce the occurrence of misalignment after the treatment of distal tibial fractures by IMN fixation.
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Affiliation(s)
- Miao He
- Department of Orthopaedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), No. 1 Jiankang Road, Chongqing, 400010, China
| | - Jian Liu
- Department of Orthopaedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), No. 1 Jiankang Road, Chongqing, 400010, China
| | - Xu Deng
- Department of Orthopaedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), No. 1 Jiankang Road, Chongqing, 400010, China
| | - Miao He
- Department of Orthopaedic Surgery, Chongqing Emergency Medical Center (Chongqing University Central Hospital), No. 1 Jiankang Road, Chongqing, 400010, China.
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16
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Novoa-Sierra B, Estrems-Diaz V, Bertó-Martí X, Fuentes-Real S, Hernandez-Ferrando L. [Translated article] Metaphysary fractures of the distal tibia: Comparative analysis of the results obtained by means of a blocked plate and intramedular nail. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022. [DOI: 10.1016/j.recot.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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17
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Fracturas metafisarias de tibia distal: analisis comparativo de los resultados obtenidos mediante placa bloqueada y clavo intramedular. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 66:298-305. [DOI: 10.1016/j.recot.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/25/2021] [Accepted: 03/05/2022] [Indexed: 11/23/2022] Open
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18
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Chun DI, Min TH, Kang EM, Yu W, Won SH, Cho J, Yi Y. Comparison of Radiological and Clinical Outcomes in Patients Treated with Standard Plating versus Intramedullary Nailing in Distal Tibial Fracture. Orthop Surg 2022; 14:536-542. [PMID: 35106932 PMCID: PMC8927007 DOI: 10.1111/os.13210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To evaluate clinical and radiological outcomes including hindfoot alignment after plate vs intramedullary nailing (IMN) for distal tibia fracture and to define radiologic parameters that influence changes in hindfoot alignment. Methods Among 92 patients with distal tibia metaphyseal fractures treated from 2002 to 2015, 39 cases of intramedullary nailing and 53 cases of standard plate osteosynthesis were performed. Union rate and complication rate were compared in both groups. Radiographic measurements including hindfoot angulation, moment arm, calcaneal pitch angle, and Meary angle were evaluated at a minimum of 1‐year follow‐up. Hindfoot alignment changes after surgery were compared between both groups using student t‐test. Correlation and regression were analyzed between fracture alignment parameters and hindfoot alignment. Results All patients ultimately healed, with an average union period of 26 weeks in both groups. The AOFAS and VAS scores were not significantly different between the two groups. Complications were similar between the two groups. Hindfoot alignment angle, calcaneal pitch, and Meary angle showed no significant differences between the groups. The hindfoot moment arm increased with valgus in the IMN group. A low correlation was detected between angulation at the fracture site in the coronal view and hindfoot alignment (angulation and moment arm) changes (R = 0.38). A significantly high correlation was noted only between transverse rotation and hindfoot alignment changes (R = 0.79). Conclusions Rotation in the transverse plane notably influenced changes in hindfoot alignment. And this suggests that patients with distal tibia fracture should be closely monitored for hindfoot alignment changes caused by intraoperative transverse rotation regardless of the fixation method.
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Affiliation(s)
- Dong-Il Chun
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Tae-Hong Min
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Eun Myeong Kang
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Woojin Yu
- Department of Orthopaedic Surgery, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, South Korea
| | - Sung Hun Won
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Jaeho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon-si, South Korea
| | - Young Yi
- Department of Orthopaedic Surgery, Seoul Foot and Ankle Center, Inje University, Seoul, South Korea
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Greenfield J, Appelmann P, Wunderlich F, Mehler D, Rommens PM, Kuhn S. Retrograde tibial nailing of far distal tibia fractures: a biomechanical evaluation of double- versus triple-distal interlocking. Eur J Trauma Emerg Surg 2021; 48:3693-3700. [PMID: 34859267 PMCID: PMC9532294 DOI: 10.1007/s00068-021-01843-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/14/2021] [Indexed: 01/08/2023]
Abstract
Objectives Retrograde tibial nailing using the Distal Tibia Nail (DTN) is a novel surgical option in the treatment of distal tibial fracture. Its unique retrograde insertion increases the range of surgical options in far distal fractures of the tibia beyond the use of plating. The aim of this study was to assess the feasibility of the DTN for far distal tibia fractures where only double rather than triple-distal locking is possible due to fracture localisation and morphology. Methods Six Sawbones® were instrumented with a DTN and an AO/OTA 43-A3 fracture simulated. Samples were tested in two configurations: first with distal triple locking, second with double locking by removing one distal screw. Samples were subjected to compressive (350 N, 600 N) and torsional (± 8 Nm) loads. Stiffness construct and interfragmentary movement were quantified and compared between double and triple-locking configurations. Results The removal of one distal screw resulted in a 60–70% preservation of compressive stiffness, and 90% preservation of torsional stiffness for double locking compared to triple locking. Interfragmentary movement remained minimal for both compressive and torsional loading. Conclusions The DTN with a distal double locking can, therefore, be considered for far distal tibia fractures where nailing would be preferred over plating.
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Affiliation(s)
- Julia Greenfield
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Philipp Appelmann
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Felix Wunderlich
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Dorothea Mehler
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Pol Maria Rommens
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Sebastian Kuhn
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany. .,Department of Digital Medicine, Medical School OWL, Bielefeld University, Universitätsstr. 25, 33615, Bielefeld, Germany.
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Rates and timing of short-term complications following operative treatment of tibial shaft fractures. OTA Int 2021; 4:e158. [PMID: 34765906 PMCID: PMC8575429 DOI: 10.1097/oi9.0000000000000158] [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: 06/05/2021] [Accepted: 10/04/2021] [Indexed: 10/31/2022]
Abstract
Introduction Tibial shaft fractures are a relatively common injury in orthopaedic surgery, with management options including intramedullary nail (IMN) fixation or open reduction internal fixation (ORIF) with plate osteosynthesis. Using a large national database, we sought to compare the prevalence and timing of short-term complications following either IMN or ORIF for tibial shaft fractures. Methods The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients undergoing IMN or ORIF for the treatment of tibial shaft fracture between 2012 and 2018. Multivariate Poisson hurdle regression models were utilized to determine predictors of postoperative complications as well as the timing of postoperative complications. Results A total of 4963 tibial shaft fracture were identified, with 3601 patients undergoing IMN (72.6%) and 1362 undergoing ORIF (27.4%). Patients undergoing IMN had a lower mean age of 48.8 compared with 53.9 for plate osteosynthesis (P < .001). IMN patients were also more likely to be male (53.5%) compared with ORIF patients (44.2%, P < .001). In multivariate analysis, ORIF patients were significantly more likely to experience surgical site complications, including dehiscence, superficial, and deep infections (OR 2.04, P = .003). There was no difference in probability of VTE between constructs; however, patients who underwent ORIF were diagnosed with VTE earlier than those who underwent IMN (relative rate 0.50, P < .001). There was no difference between ORIF and IMN with regard to probability or timing of subsequent blood transfusion, major complications, or return to the operating room. Many patient factors, such as higher American Society of Anesthesiologists score, congestive heart failure, and hypertension, were independently associated with an increased risk of postoperative complications. Conclusions Postoperative complications within 30 days are common after the surgical treatment of tibial shaft fractures. The risk of developing specific complications and the timing of these complications vary depending on numerous factors, including potentially modifiable risk factors such as the method of fixation or operative time, as well as nonmodifiable risk factors such as medical comorbidities.
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KUMBARACI M, SAVRAN A. Comparison of minimally invasive plate osteosynthesis and intramedullary nailing in the treatment of distal extraarticular tibial fractures. EGE TIP DERGISI 2021. [DOI: 10.19161/etd.990612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Large Individual Bilateral Differences in Tibial Torsion Impact Accurate Contralateral Templating and the Evaluation of Rotational Malalignment. J Orthop Trauma 2021; 35:e277-e282. [PMID: 33878071 DOI: 10.1097/bot.0000000000002041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine individual bilateral differences (IBDs) in tibial torsion in a diverse population. METHODS Computed tomography scans of uninjured bilateral tibiae were used to determine tibial torsion and IBDs in torsion using 4 measurement methods. Age, sex, and self-identified race/ethnicity were also recorded for each subject. Mean tibial torsion and IBDs in torsion were compared in the overall cohort and when stratified by sex and race/ethnicity. Simple and multiple linear regression models were used to correlate demographic variables with tibial torsion and IBDs in torsion. RESULTS One hundred ninety-five patients were evaluated. The mean tibial torsion was 27.5 ± 8.3 degrees (range -3 to 47.5 degrees). The mean IBD in torsion was 5.3 ± 4.0 degrees (range 0-23.5 degrees, P < 0.001). 12.3% of patients had IBDs in torsion of ≥10 degrees. In the regression analysis, patients who identified as White had greater average torsion by 4.4 degrees compared with Hispanic/Latinx patients (P = 0.001), whereas age and sex were not significantly associated with absolute torsion. Demographics were not associated with significant differences in IBDs in torsion. CONCLUSIONS Tibial torsion varies considerably and individual side-to-side differences are common. Race/ethnicity was associated with differences in the magnitude of tibial torsion, but no factors were associated with bilateral differences in torsion. The results of this study may be clinically significant in the context of using the uninjured contralateral limb to help establish rotational alignment during medullary nail stabilization of diaphyseal tibia fractures. In addition, these findings should be considered in the evaluation of tibia rotational malalignment. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Wang W, Zhu Y, Hu X, Jin C, Wang X. Treatment of Distal Metaphyseal Tibial Fractures with Anterolateral Plates or with Anterolateral-Medial Plates: A Retrospective Series. J Foot Ankle Surg 2021; 60:36-41. [PMID: 33218860 DOI: 10.1053/j.jfas.2019.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 10/20/2019] [Accepted: 11/17/2019] [Indexed: 02/03/2023]
Abstract
Distal metaphyseal tibial fractures (3-5 cm from the joint with zones of comminution or <3 cm from the joint) are challenging to fix and are associated with many complications. The study objective was to evaluate the functional outcomes and complications after treating distal metaphyseal tibial fractures using anatomical anterolateral tibia locking plates or anterolateral-medial plates. This retrospective study included 57 patients with distal metaphyseal tibial fractures. Thirty patients were treated by open reduction internal fixation with anterolateral plates; 27 patients were treated with anterolateral-medial plates. Patients were followed at regular intervals. The time to fracture union and complications were recorded. We evaluated the stage of fracture healing using the Radiographic Union Score for Tibial fractures. The patients treated with anterolateral plates had significantly higher rates of loss of reduction and malunion than those treated with anterolateral-medial plates (p = .02 and p = .002, respectively). There were no significant differences in the radiographic union scores (p = .22), non-union (p = .17), incision necrosis (p = .91), or infection (p = .94) between the 2 groups. The functional outcomes were assessed using the American Orthopedic Foot and Ankle Society hindfoot-ankle score at the 12-month follow-up. The mean hindfoot-ankle scores were 90.9 ± 5.0 (range 79 to 100, median 90) and 92.3 ± 5.1 (range 82 to 100, median 92) for the anterolateral plates and anterolateral-medial plates, respectively (p = .29). For distal metaphyseal tibial fractures, anterolateral-medial plates may be worthwhile for reducing loss of reduction and malunion.
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Affiliation(s)
- Wenjuan Wang
- Surgeon, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yanhui Zhu
- Surgeon, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xiaopeng Hu
- Surgeon, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Chen Jin
- Surgeon, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.
| | - Xiang Wang
- Surgeon, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.
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Uemi R, Takegami Y, Sakai R, Todoroki K, Kawasaki N, Imagama S. Early versus delayed weight bearing after intramedullary nailing for tibial shaft fracture: A multicenter, propensity score-matched study, the TRON study. Injury 2021; 52:1583-1586. [PMID: 33441252 DOI: 10.1016/j.injury.2020.12.023] [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: 09/08/2020] [Revised: 12/05/2020] [Accepted: 12/13/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this multicenter study was to assess the differences in the rates of implant failure and bone union by X-ray examination, and walking ability between an early weight-bearing group (EWB) and a non-weight-bearing group (NWB) following treatment with intramedullary nailing (IMN) for tibial shaft fractures with a propensity score-matching method. MATERIAL AND METHODS We collected data from 336 patients with tibia fractures that were treated surgically. We excluded patients lost to follow-up and polytrauma patients. Finally, 263 patients were included who were divided into two groups, the early weight-bearing (EWB) group, in which partial weight-bearing walking within four weeks was encouraged, and a non-weight-bearing (NWB) group, in which no weight bearing was allowed for more than four weeks. To adjust for baseline differences between groups, a propensity score algorithm was used to match the EWB group with the NWB group in a 1:1 ratio of 75 cases each. After matching, we compared the rate of implant failure, the rate of bone union at six months and one year after surgery, and walking ability at the last follow-up between the two groups. RESULT Implant failure occurred in 0 of 75 patients in the EWB group vs. 1 of 75 in the NWB group (P = 1.0). Delayed bone union at six months occurred in 20 of 75 (26%) vs. 13 of 75 (17%) patients, and that at one year occurred in 5 of 75 (6.7%) vs. 3 of 75 (4%) patients. The median New Mobility Score was 9 (4-9) vs. 9 (0-9) points. CONCLUSIONS There were no statistically significant differences in the rate of implant failure, the rates of the bone union at six months and one year after surgery, and walking ability between the EWB group and NWB group. We suggest that instruction in early weight-bearing after IMN nailing for tibial shaft fracture may not be harmful.
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Affiliation(s)
- Ryota Uemi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Risa Sakai
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Kazunori Todoroki
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Narumi Kawasaki
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
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Hollensteiner M, Sandriesser S, Hackl S, Augat P. Custom-made polyurethane-based synthetic bones mimic screw cut-through of intramedullary nails in human long bones. J Mech Behav Biomed Mater 2021; 117:104405. [PMID: 33621867 DOI: 10.1016/j.jmbbm.2021.104405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 10/05/2020] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
Intramedullary nails are considered the gold standard for the treatment of tibial shaft fractures. Thereby, the screw-bone interface is considered the weakest link. For biomechanical evaluation of osteosyntheses synthetic bones are often used to overcome the disadvantages of human specimens. However, commercially available synthetic bones cannot adequately mimic the local mechanical properties of human bone. Thus, the aim of this study was to develop and evaluate novel cortical bone surrogate materials that mimic human tibial shafts in the screw-loosening mechanisms of intramedullary nails. Bone surrogates, based on two different polyurethanes, were developed and shaped as simple tubes with varying cortical thicknesses to simulate the diaphyseal cortex of human tibiae. Fresh frozen human tibiae and commercially available synthetic bones with similar cortical thickness were used as references. All specimens were treated with a nail dummy and bicortical locking screws to simulate treatment of a distal tibia shaft fracture. The nail-bone construct was loaded in a combined axial-torsional-sinusoidal loading protocol to simulate the physiological load during human gait. The loads to failure as well as the number of load cycles were evaluated. Furthermore, the cut-through length of the screws was analysed by additional micro computed -tomography images of the tested specimens. The failure load of custom made synthetic bone tubes with 6 mm cortical thickness (3242 ± 136 N) was in accordance with the failure load of human samples (3300 ± 307 N, p = 0.418) with a similar cortical thickness of 4.9 ± 1.4 mm. Commercially available synthetic bones with similar cortical thickness of 4.5 ± 0.7 mm were significantly stronger (4575 ± 795 N, p = 0.008). Oval-shaped migration patterns were "cut" into the cortices by the screws due to the cyclical loading. The cut-through length of the self-developed synthetic bones with 6 mm cortices (0.8 ± 0.6 mm, p = 0.516) matched the cut-through of the human tibiae (0.7 ± 0.6 mm). The cut-through of commercially available epoxy-based synthetic bones deviated from the human reference (0.2 ± 0.1 mm, p < 0.001). The results of this study indicate that the novel bone surrogates realistically mimic the failure and screw migration behaviour in human tibiae. Thus, they offer a new possibility to serve as substrate for biomechanical testing. The use of commercially available surrogates is discouraged for biomechanical testing as there is a risk of drawing incorrect conclusions.
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Affiliation(s)
- Marianne Hollensteiner
- Institute for Biomechanics, BG Unfallklinik Murnau and Paracelsus Medical University Salzburg, Prof. Küntscher Str. 8, 82418, Murnau, Germany.
| | - Sabrina Sandriesser
- Institute for Biomechanics, BG Unfallklinik Murnau and Paracelsus Medical University Salzburg, Prof. Küntscher Str. 8, 82418, Murnau, Germany
| | - Simon Hackl
- Institute for Biomechanics, BG Unfallklinik Murnau and Paracelsus Medical University Salzburg, Prof. Küntscher Str. 8, 82418, Murnau, Germany; Department of Trauma Surgery, BG Unfallklinik Murnau, Prof. Küntscher Str. 8, 82418, Murnau, Germany
| | - Peter Augat
- Institute for Biomechanics, BG Unfallklinik Murnau and Paracelsus Medical University Salzburg, Prof. Küntscher Str. 8, 82418, Murnau, Germany
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Extreme Nailing or Less Invasive Plating of Lower Extremity Periarticular Fractures. Orthop Clin North Am 2021; 52:111-121. [PMID: 33752832 DOI: 10.1016/j.ocl.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Periarticular fractures of the lower extremity can be difficult injuries to stabilize effectively. Modern advances in technique and implant design now allow many of these fractures to be fixed with an extreme intramedullary nail. When nailing is not possible, less invasive plating through percutaneous incisions is a reliable option. The decision to perform extreme nailing is multifactorial and is based on the fracture pattern, the condition of the soft tissues, the medical condition of the patient, and the importance of earlier or immediate weightbearing.
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Bleeker NJ, van de Wall BJM, IJpma FFA, Doornberg JN, Kerkhoffs GMMJ, Jaarsma RL, Knobe M, Link BC, Babst R, Beeres FJP. Plate vs. nail for extra-articular distal tibia fractures: How should we personalize surgical treatment? A meta-analysis of 1332 patients. Injury 2021; 52:345-357. [PMID: 33268081 DOI: 10.1016/j.injury.2020.10.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/06/2020] [Accepted: 10/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Treatment for distal diaphyseal or metaphyseal tibia fractures is challenging and the optimal surgical strategy remains a matter of debate. The purpose of this study was to compare plate fixation with nailing in terms of operation time, non-union, time-to-union, mal-union, infection, subsequent re-interventions and functional outcomes (quality of life scores, knee- and ankle scores). METHODS A search was performed in PubMed/Embase/CINAHL/CENTRAL for all study designs comparing plate fixation with intramedullary nailing (IMN). Data were pooled using RevMan and presented as odds ratios (OR), risk difference (RD), weighted mean difference (WMD) or weighted standardized mean difference (WSMD) with a 95% confidence interval (95%CI). All analyzes were stratified for study design. RESULTS A total of 15 studies with 1332 patients were analyzed, including ten RCTs (n = 873) and five observational studies (n = 459). IMN leads to a shorter time-to-union (WMD: 0.4 months, 95%CI 0.1 - 0.7), shorter time-to-full-weightbearing (WMD: 0.6 months, 95%CI 0.4 - 0.8) and shorter operation duration (WMD: 15.5 min, 95%CI 9.3 - 21.7). Plating leads to a lower risk for mal-union (RD: -10%, OR: 0.4, 95%CI 0.3 - 0.6), but higher risk for infection (RD: 8%, OR: 2.4, 95%CI 1.5 - 3.8). No differences were detected with regard to non-union (RD: 1%, OR: 0.7, 95%CI 0.3 - 1.7), subsequent re-interventions (RD: 4%, OR: 1.3, 95%CI 0.8 - 1.9) and functional outcomes (WSMD: -0.4, 95%CI -0.9 - 0.1). The effect estimates of RCTs and observational studies were equal for all outcomes except for time to union and mal-union. CONCLUSION Satisfactory results can be obtained with both plate fixation and nailing for distal extra-articular tibia fractures. However, nailing is associated with higher rates of mal-union and anterior knee pain while plate fixation results in an increased risk of infection. This study provides a guideline towards a personalized approach and facilitates shared decision-making in surgical treatment of distal extra-articular tibia fractures. The definitive treatment should be case-based and aligned to patient-specific needs in order to minimize the risk of complications.
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Affiliation(s)
- N J Bleeker
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland.
| | - B J M van de Wall
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
| | - F F A IJpma
- Dept. of Trauma Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
| | - J N Doornberg
- Dept. of Orthopaedic Trauma Surgery, Flinders Medical Centre, Adelaide, Australia
| | - G M M J Kerkhoffs
- Dept. of Orthopaedic Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - R L Jaarsma
- Dept. of Orthopaedic Trauma Surgery, Flinders Medical Centre, Adelaide, Australia
| | - M Knobe
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
| | - B C Link
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
| | - R Babst
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
| | - F J P Beeres
- Dept. of Orthopaedic and Trauma Surgery, Lucerner Kantonsspital, Lucerne, Switzerland
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Abstract
AIMS The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols. METHODS A biomechanical model of distal metaphyseal tibial fractures was created using a fourth-generation composite bone model. Three fracture patterns were tested: spiral, oblique, and multifragmented. Each fracture extended to within 4 cm to 5 cm of the plafond. The models were nearly-anatomically reduced and stabilized with an intramedullary nail and three distal locking screws. Cyclic loading was performed to simulate normal gait. Loading was completed in compression at 3,000 N at 1 Hz for a total of 70,000 cycles. Displacement (shortening, coronal and sagittal angulation) was measured at regular intervals. RESULTS The spiral and oblique fracture patterns withstood simulated weight-bearing with minimal displacement. The multifragmented model had early implant failure with breaking of the distal locking screws. The spiral fracture model shortened by a mean of 0.3 mm (SD 0.2), and developed a mean coronal angulation of 2.0° (SD 1.9°) and a mean sagittal angulation of 1.2° (SD 1.1°). On average, 88% of the shortening, 74% of the change in coronal alignment, and 75% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. The oblique fracture model shortened by a mean of 0.2 mm (SD 0.1) and developed a mean coronal angulation of 2.4° (SD 1.6°) and a mean sagittal angulation of 2.6° (SD 1.4°). On average, 44% of the shortening, 39% of the change in coronal alignment, and 79% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. CONCLUSION For spiral and oblique fracture patterns, simulated weight-bearing resulted in a clinically acceptable degree of displacement. Most displacement occurred early in the test period, and the rate of displacement decreased over time. Based on this model, we offer evidence that early weight-bearing appears safe for well reduced oblique and spiral fractures, but not in multifragmented patterns that have poor bone contact. Cite this article: Bone Joint J 2021;103-B(2):294-298.
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Affiliation(s)
- Michael M Hadeed
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Hans Prakash
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Seth R Yarboro
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - David B Weiss
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
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May minimally invasive plate osteosynthesis be an alternative to intramedullary nailing in selected spiral oblique and spiral wedge tibial shaft fractures? Jt Dis Relat Surg 2021; 31:494-501. [PMID: 32962581 PMCID: PMC7607957 DOI: 10.5606/ehc.2020.75052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objectives
This study aims to compare intramedullary nailing (IMN) and minimally invasive plate osteosynthesis (MIPO) treatment methods in Arbeitsgemeinschaft für Osteosynthesefragen (AO) 42A1 & 42B1 selected tibial shaft fractures. Patients and methods
Fifty-one patients (31 males, 20 females; mean age 43.5±14.2 years; range, 18 to 81 years) operated for AO 42A1 or AO 42B1 tibial shaft fractures between January 2006 and January 2012 were retrospectively evaluated. Twenty-three of these patients were treated with MIPO and 28 with IMN. Patients were compared in terms of union time, return to work, infection, malunion, hospital stay, and sixth month and two-year Lower Extremity Functional Scale (LEFS) values. Results
There was no difference between the MIPO and IMN groups in terms of demographic data, etiology, and fracture patterns. The mean follow-up time was 37.8±8.8 months in MIPO group and 35.9±8.7 months in IMN group. Union time (p=0.575), return to work (p=0.155), infection (p=0.643), malunion (p=0.471), and hospital stay (p=0.538) were all similar between groups. Although the LEFS value was higher in IMN group in sixth month (p=0.026), the two-year LEFS value was similar between groups (p=0.085). Conclusion Results of the study showed that both treatment methods are similar regarding clinical and functional outcomes. According to these results, MIPO can be recommended as an alternative to IMN in tibial shaft fractures formed as spiral oblique and spiral wedge.
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Reduction techniques for intramedullary nailing of tibial shaft fractures: a comparative study. OTA Int 2021; 4:e095. [PMID: 33937718 PMCID: PMC8016605 DOI: 10.1097/oi9.0000000000000095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 10/14/2020] [Indexed: 12/04/2022]
Abstract
Objectives: To assess the impact of various reduction techniques on postoperative alignment following intramedullary nail (IMN) fixation of tibial shaft fractures. Design: Retrospective comparative study. Setting: Level I trauma center. Patients: Four hundred twenty-eight adult patients who underwent IMN fixation of a tibial shaft fracture between 2008 and 2017. Intervention: IMN fixation with use of one or more of the following reduction techniques: manual reduction, traveling traction, percutaneous clamps, provisional plating, or blocking screws. Main outcome measures: Immediate postoperative coronal and sagittal plane alignment, measured as deviation from anatomic axis (DFAA); coronal and sagittal plane malalignment (defined as DFAA >5° in either plane). Results: Four hundred twenty-eight patients met inclusion criteria. Manual reduction (MR) alone was used in 11% of fractures, and adjunctive reduction aids were used for the remaining 89%. After controlling for age, BMI, and fracture location, the use of traveling traction (TT) with or without percutaneous clamping (PC) resulted in significantly improved coronal plane alignment compared to MR alone (TT: 3.4°, TT+PC: 3.2°, MR: 4.5°, P = .007 and P = .01, respectively). Using TT+PC resulted in the lowest rate of coronal plane malalignment (13% vs 39% with MR alone, P = .01), and using any adjunctive reduction technique resulted in decreased malalignment rates compared to MR (24% vs 39%, P = .02). No difference was observed in sagittal plane alignment between reduction techniques. Intraclass correlation coefficient (ICC) results indicated excellent intraobserver reliability on both planes (both ICC>0.85), good inter-observer reliability in the coronal plane (ICC = 0.7), and poor inter-observer reliability in the sagittal plane (ICC = 0.05). Conclusions: The use of adjunctive reduction techniques during IMN fixation of tibia fractures is associated with a lower incidence of coronal plane malalignment when compared to manual reduction alone. Level of evidence: Therapeutic Level III.
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Comparison of Infrapatellar and Suprapatellar Approaches for Intramedullary Nail Fixation of Tibia Fractures. J Orthop Trauma 2021; 35:e45-e50. [PMID: 32658019 DOI: 10.1097/bot.0000000000001897] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess clinical, radiographic, and functional outcomes after intramedullary nail (IMN) fixation of tibia fractures with an infrapatellar approach compared to a suprapatellar approach. DESIGN Retrospective chart review. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Two hundred four patients with 208 tibia fractures treated with intramedullary nailing between 2008 and 2018. METHODS A retrospective chart review of tibia fractures was conducted. The clinical and functional outcomes of tibia fractures treated with IMN were compared between groups treated with an infrapatellar approach versus a suprapatellar approach. Multivariate models were created to control for confounding demographic, comorbidity, and injury-related confounders. MAIN OUTCOME MEASUREMENTS Outcome measures included nonunion, malunion, and infection. Subjective functional patient outcomes were assessed using pain interference and physical function Patient-Reported Outcome Measurements Systems scores. RESULTS There were 101 patients treated with infrapatellar nailing (49%) and 107 patients treated with suprapatellar nailing (51%). On multivariate analysis, suprapatellar nailing was independently associated with decreased risk of malunion (adjusted odds ratio, 0.165; 95% confidence interval, 0.054-0.501; P = 0.001) and decreased risk of postoperative knee pain (adjusted odds ratio, 0.272; 95% confidence interval, 0.083-0.891; P = 0.032). There was no difference in the rate of nonunion (P = 0.44), infection (P = 0.45), or Patient-Reported Outcome Measurements Systems pain interference or physical function scores. CONCLUSIONS Suprapatellar IMN fixation of tibial shaft fractures is independently associated with lower risk of malunion and postoperative knee pain compared to the infrapatellar approach. However, there are no functional differences between approaches. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
As the biologically friendly and biomechanically sound technique of intramedullary fixation has been increasingly applied to distal tibia diaphyseal fractures, challenges with the technique have emerged. Malalignment, most often valgus and recurvatum, is more common than with mid-diaphyseal patterns, given the lack of endosteal fit, and this can be challenging to prevent. Key technical steps can ensure success. These include recognition and initial fixation of intra-articular fracture planes, the use of percutaneous clamps, a slightly lateral terminal nail position, and the use of blocking wires or screws to prevent malalignment after nail passage. With thorough preoperative planning and early recognition of troublesome patterns, a variety of techniques can be applied to obtain and maintain a stable reduction throughout the procedure.
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Factors associated with subsequent surgical procedures after intramedullary nailing for tibial shaft fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:43-50. [PMID: 32656669 PMCID: PMC7815567 DOI: 10.1007/s00590-020-02733-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/01/2020] [Indexed: 11/13/2022]
Abstract
Introduction The reported rate of subsequent surgery after intramedullary nailing (IMN) of tibial shaft fractures (TSFs) is as high as 21%. However, most studies have not included the removal of symptomatic implant in these rates. The purpose of this study was to evaluate the subsequent surgery rate after IMN of TSFs, including the removal of symptomatic implants. Secondly, this study aimed to assess what factors are associated with subsequent surgery (1) to promote fracture and wound healing and (2) for the removal of symptomatic implants. Methods One-hundred and ninety-one patients treated with IMN for TSFs were retrospectively included. The rate of subsequent surgery was determined. Bi- and multivariable analysis was used to identify variables associated with subsequent surgery. Results Approximately half of patients (46%) underwent at least one subsequent surgical procedure. Forty-eight (25%) underwent a subsequent surgical procedure to promote fracture or wound healing. Age (P < 0.01), multi-trauma (P < 0.01), open fracture (P < 0.001) and index surgery during weekdays (P < 0.05) were associated with these procedures. Thirty-nine patients (20%) underwent a subsequent surgical procedure for removal of symptomatic implants. There was a significantly lower rate of implant removal in ASA II (11%) and ASA III–IV (14%) patients compared to ASA I patients (29%) (P < 0.05). Conclusions Patients treated with IMN for TSFs should be consented that about one-in-two patients will undergo an additional surgical procedure. Half of these procedures are required to promote wound or fracture healing; the other half are for symptomatic implant removal. Level of evidence Therapeutic level-IV.
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Kariya A, Jain P, Patond K, Mundra A. Outcome and complications of distal tibia fractures treated with intramedullary nails versus minimally invasive plate osteosynthesis and the role of fibula fixation. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:1487-1498. [PMID: 32621141 DOI: 10.1007/s00590-020-02726-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/25/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Distal tibia fractures have been managed conservatively as well surgically. A large number of implants have been used for surgical management of these fractures. No treatment method or implant has been proven to be superior to others. In this prospective comparative study, the complications and outcome of distal tibia fractures managed with intramedullary nails and minimally invasive plate osteosynthesis has been compared. Further, the role of fibula fixation in these fractures has been evaluated. MATERIALS AND METHOD One hundred and fifty-four patients of distal tibia fractures with concomitant fibula fractures were randomized into 4 treatment groups based on predetermined inclusion criteria. Functional outcome in these groups was compared based on AOFAS score at 1 year. Intra-operative, post-operative parameters as well as radiological alignment, complications and the need for reoperation were also compared in these groups. RESULT The functional outcome in all four treatment groups was similar. The duration of surgery and radiation exposure was higher with minimally invasive plate osteosynthesis. There was no improvement in outcome with plating of fibula. However, fixation of fibula improved the rotational alignment in distal tibia fractures. CONCLUSION Although there is no difference in outcome of distal tibia fractures with either nailing or minimally invasive plating, nailing is recommended for closed displaced extraarticular fractures. Fixation of fibula should not be done routinely but should be reserved only for a few specific fracture patterns.
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Affiliation(s)
- Ankur Kariya
- Department of Orthopaedics, MGIMS, Sewagram, Wardha, 442 102, India.
| | - Pramod Jain
- Department of Orthopaedics, MGIMS, Sewagram, Wardha, 442 102, India
| | - Kisan Patond
- Department of Orthopaedics, MGIMS, Sewagram, Wardha, 442 102, India
| | - Anuj Mundra
- Department of Community Medicine, MGIMS, Sewagram, Wardha, 442 102, India
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Hendrickx LAM, Virgin J, van den Bekerom MPJ, Doornberg JN, Kerkhoffs GMMJ, Jaarsma RL. Complications and subsequent surgery after intra-medullary nailing for tibial shaft fractures: Review of 8110 patients. Injury 2020; 51:1647-1654. [PMID: 32360087 DOI: 10.1016/j.injury.2020.04.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 04/13/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Intramedullary nailing of tibial shaft fractures has been common practice for decades. Nevertheless, complications occur frequently, and subsequent surgery is often required. To improve our understanding on how we may improve trauma care for patients with tibial shaft fractures, this study systematically reviewed all currently available evidence to assess the incidence of complications and rate of re-operations following intramedullary nailing of traumatic tibial fractures. METHODS Trip Database, Medline, Scopus and Cochrane Library were searched on September 7th, 2018. Searches were limited to English studies published after January 1st, 1998. Studies were included if authors included more than 50 patients treated with intramedullary nailing for traumatic tibial fractures. Inclusion of studies and critical appraisal of the evidence was performed by two independent authors. Incidence of complications and rate of re-operations were reported with descriptive statistics. RESULTS Fifty-one studies involving 8110 patients treated with intramedullary nailing for traumatic tibial fractures were included. Mean age of patients was 37.5 years. The most frequent complication was anterior knee pain (23%), followed by non-union (11%). Eighteen percent of patients required at least one subsequent surgery. The most frequent indication of subsequent surgery was screw removal due to pain or discomfort (9%). Dynamization of the nail to promote union was reported in 8% of the cases. Nail revision and bone-grafting to promote union were applied in 4% and 2% respectively. DISCUSSION & CONCLUSION Patients treated with intramedullary nailing for tibial fractures need to be consented for high probability of adverse events as anterior knee pain, subsequent surgical procedures and bone healing problems are relatively common. However, based on current data it remains difficult to identify specifiers and determinants of an individual patient with specific fracture characteristics at risk for complications. Future studies should aim to establish patient specific risks models for complications and re-operations, such that clinicians can anticipate them and adjust and individualize treatment strategies.
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Affiliation(s)
- Laurent A M Hendrickx
- Department of Orthopaedic & Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, SA, 5042, Australia; Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands.
| | - James Virgin
- Department of Orthopaedic & Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, SA, 5042, Australia
| | | | - Job N Doornberg
- Department of Orthopaedic & Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, SA, 5042, Australia; Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | - Gino M M J Kerkhoffs
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | - Ruurd L Jaarsma
- Department of Orthopaedic & Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, SA, 5042, Australia
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Dai J, Wang X, Zhang F, Zhu L, Zhen Y. Treatment of distal metaphyseal tibia fractures using an external fixator in children. Medicine (Baltimore) 2019; 98:e17068. [PMID: 31490405 PMCID: PMC6738966 DOI: 10.1097/md.0000000000017068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Current treatment of pediatric distal metaphyseal tibial/fibular fractures is challenging due to poor skin and soft tissue coverage and limited blood supply to the distal tibia area in children. It remains unknown whether the SK combined external fixator (made by Double Medical Technology Inc., China) is effective for the treatment of distal metaphyseal tibia/fibula fractures in children. HYPOTHESIS We hypothesized that SK combined external fixator could achieve satisfying outcomes for pediatric distal metaphyseal tibia/fibula fractures. PATIENTS AND METHODS A total of 19 pediatric patients with a median age of 6 years (range: 3.8-12.0 years), who had distal tibia/fibula metaphyseal fractures and attended our hospital between January 2017 and November 2017, were evaluated. All patients with tibia fracture had closed reduction and percutaneously fixed SK combined external fixators. Radiographs were taken at an average of every 4 weeks to evaluate the healing of the fracture. Complications were recorded, and the stability of the pin clamp and rod were also checked. Follow-up was conducted for up to 13 months. All patients provided informed consent for publication of the case. RESULTS All patients achieved a satisfactory clinical outcome at the final follow-up. Weight-bearing exercises were started at post-operative 2 weeks. Bone union was obtained at 8 weeks post-operation on average. No delayed healing or nonunion was observed, although one case of pin site infection and three cases of pin clamp loosening occurred. DISCUSSION Three-dimensional SK combined external fixators are light, easy to apply, minimally invasive, and result in low rates of complications. They provide excellent stability for pediatric distal tibia/fibula metaphyseal fractures. LEVEL OF EVIDENCE IV.
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Abstract
OBJECTIVES To assess the relationship between the distal nail target and postoperative alignment for distal tibia fractures treated with intramedullary nailing. DESIGN Retrospective cohort study. SETTING A single level 1 trauma center. PATIENTS/PARTICIPANTS One hundred thirty distal tibia fractures treated with intramedullary nailing over a 10-year period. MAIN OUTCOME MEASUREMENTS Malalignment >5 degrees. RESULTS Thirty-eight cases (29.2%) of malalignment >5 degrees included valgus (19 cases, 14.6%), procurvatum (13 cases, 10.0%), recurvatum (1 case, 0.8%), and combined valgus with procurvatum (5 cases, 3.8%). Medially directed nails demonstrated relative valgus (mean lateral distal tibia angle 86.4 vs. 89.4 degrees, P < 0.01) and more frequent coronal malalignment (24 of 78, 30.8% vs. 0 of 52, 0%, P < 0.01). Anteriorly directed nails demonstrated relative procurvatum (mean anterior distal tibia angle 82.8 vs. 80.9 degrees, P < 0.01) and more frequent sagittal malalignment (15 of 78, 19.2% vs. 3 of 52, 5.8%, P = 0.03). Malalignment was less common for nails targeting the central or slightly posterolateral plafond (0 of 30, 0% vs. 38 of 100, 38%), P < 0.01. Multivariate analysis demonstrated the distal nail target (P = 0.03), fracture within 5 cm of the plafond (P = 0.01), as well as night and weekend surgery (P = 0.03) were all independently associated with malalignment. CONCLUSIONS Alignment of distal tibia fractures is sensitive to both injury and treatment factors. Nails should be targeted centrally or slightly posterolaterally to minimize malalignment. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Nada AA, Romeih M, El-Rosasy M. Fixator-assisted Percutaneous Plate Fixation of Complex Diaphyseal Tibial Fractures. Strategies Trauma Limb Reconstr 2019; 14:25-28. [PMID: 32559264 PMCID: PMC7001593 DOI: 10.5005/jp-journals-10080-1422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aim The purpose of this study is to evaluate the results of indirect reduction and fixation of comminuted diaphyseal tibial fractures using temporary simplified external fixator and plate osteosynthesis through a limited incision approach with special consideration of the duration of surgery and rate of complications. Materials and methods In this prospective case series study, 41 cases of comminuted diaphyseal tibial fractures were included. Twenty-two were closed fractures, 15 grade I open fractures, and four were grade II open fractures. Patients were evaluated clinically according to the lower extremity functional scale (LEFS). Results Of the 41 cases, 38 were followed up for at least 1 year. Using the LEFS, final scores ranged from 67–80 (mean 75). Union was achieved in all cases except one which united after bone grafting. The mean time to radiological healing was 12 weeks. Operative time from skin incision to closure ranged between 65 minutes and 100 minutes (mean of 80 minutes). There were four cases of superficial infection. Conclusion Treatment of comminuted tibial fractures through use the of a simplified external fixator to aid and maintain the reduction of comminuted tibial fractures whilst limited incisions are then used for minimally-invasive plate osteosynthesis in an effective and time-saving method with a low complication rate. How to cite this article Nada AA, Romeih M, El-Rosasy M. Fixator-assisted Percutaneous Plate Fixation of Complex Diaphyseal Tibial Fractures. Strategies Trauma Limb Reconstr 2019;14(1):25–28.
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Affiliation(s)
- Abdullah A Nada
- Department of Orthopedics, Tanta University, Tanta, Gharbia, Egypt
| | - Mohamed Romeih
- Department of Orthopedics, Tanta University, Tanta, Gharbia, Egypt
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Goh EL, Chidambaram S, Eigenmann D, Ma S, Jones GG. Minimally invasive percutaneous plate osteosynthesis versus intramedullary nail fixation for closed distal tibial fractures: a meta-analysis of the clinical outcomes. SICOT J 2018; 4:58. [PMID: 30560779 PMCID: PMC6298240 DOI: 10.1051/sicotj/2018055] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 11/19/2018] [Indexed: 11/14/2022] Open
Abstract
Introduction: Minimally invasive percutaneous plate osteosynthesis (MIPPO) has emerged as a viable alternative for the treatment of distal tibial fractures. However, the clinical outcomes of this procedure compared to intramedullary (IM) nail fixation have yet to be established. The present meta-analysis aims to compare the clinical outcomes following MIPPO and IM nail fixation for closed distal tibial fractures. Methods: MEDLINE and EMBASE databases were searched from date of inception to 10th April 2017. Randomized controlled trials (RCTs) comparing MIPPO with IM nail fixation for closed and Gustilo Grade I distal tibial fractures were included. Outcomes assessed included time to union, complications and functional outcomes. Quality and risk of bias of the RCTs were assessed using the Cochrane Collaboration Tool. Results: Five RCTs comprising 497 patients were included. MIPPO was associated with a longer time to union (MD: 1.08, 95% CI: 0.26, 1.90, p = 0.010, I2 = 84%) and increased risk of wound complications (RR: 1.58, 95% CI: 1.01, 2.46, p = 0.04, I2 = 0%). Both MIPPO and IM nail fixation had comparable risks of malunion, delayed union, non-union and deep infections, with similar functional outcomes. Discussion: Compared to IM nail fixation, a MIPPO fixation technique for distal tibial fractures is associated with a longer time to fracture union and an increased risk of wound complications. Neither technique demonstrates a clear advantage with regard to risk of malunion/non-union, or functional outcome. Assuming equivalent surgical expertise with both techniques, the results suggest that IM nail fixation is the treatment modality of choice for these challenging fractures.
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Affiliation(s)
- En Lin Goh
- Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Swathikan Chidambaram
- Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Denise Eigenmann
- Department of General Surgery, Cantonal Hospital Lucerne, Spitalstrasse, 6000 Lucerne, Switzerland
| | - Shaocheng Ma
- Biomechanics Research Group, Imperial College London, South Kensington Campus, 774, 7th Floor, City and Guilds Building, London SW7 2AZ, UK
| | - Gareth G Jones
- MSK Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London W6 8PR, UK
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Connors JC, Hardy MA, Ehredt DJ, Coyer MA. The Use of Pediatric Flexible Intramedullary Nails for Minimally Invasive Fibular Fracture Fixation. J Foot Ankle Surg 2018; 57:844-849. [PMID: 29661673 DOI: 10.1053/j.jfas.2017.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Indexed: 02/03/2023]
Abstract
Fibular fractures in the setting of an unstable ankle joint require surgical fixation; however, several factors contradict open surgical correction. Severe soft tissue compromise can delay adequate fracture reduction and preclude the standard incisional approach. The soft tissue envelope in the setting of obesity, diabetes, and/or peripheral vascular disease further complicates definitive treatment. Poorly timed open fixation can lead to delayed healing of the incision site, with wound breakdown and the potential for hardware failure. Proximal fibular fractures are also at unique risk of neurovascular compromise with open reduction and internal fixation. Surgical fixation has now focused on minimizing the soft tissue insult using percutaneous techniques in the comorbid patient. We present a case that highlights a minimally invasive technique that provides dynamic stable internal fixation of fibular fractures with the use of flexible pediatric intramedullary nails, typically used in long bone fractures of children.
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Affiliation(s)
- James C Connors
- Assistant Professor, Division of Foot and Ankle Surgery and Biomechanics, Kent State University College of Podiatric Medicine, Independence, OH.
| | - Mark A Hardy
- Division Head and Associate Professor, Division of Foot and Ankle Surgery and Biomechanics, Kent State University College of Podiatric Medicine, Independence, OH
| | - Duane J Ehredt
- Assistant Professor, Division of Foot and Ankle Surgery and Biomechanics, Kent State University College of Podiatric Medicine, Independence, OH
| | - Michael A Coyer
- Attending, Private Practice, Orange County Foot and Ankle Surgeon, Irvine, CA
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Abstract
Plate fixation has historically been the preferred surgical treatment method for periarticular fractures of the lower extremity. This trend has stemmed from difficulties with fracture reduction and concerns of inadequate fixation with intramedullary implants. However, the body of literature on management of periarticular fractures of the lower extremities has expanded in recent years, indicating that intramedullary nailing of distal femur, proximal tibia, and distal tibia fractures may be the preferred method of treatment in some cases. Intramedullary nailing reliably leads to excellent outcomes when performed for appropriate indications and when potential difficulties are recognized and addressed.
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Terminal position of a tibial intramedullary nail: a computed tomography (CT) based study. Eur J Trauma Emerg Surg 2018; 46:1077-1083. [DOI: 10.1007/s00068-018-1000-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 08/20/2018] [Indexed: 11/27/2022]
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Treatment of distal tibial fractures: prospective comparative study evaluating two surgical procedures with investigation for predictive factors of unfavourable outcome. INTERNATIONAL ORTHOPAEDICS 2018; 43:201-207. [PMID: 30135986 DOI: 10.1007/s00264-018-4121-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/15/2018] [Indexed: 12/23/2022]
Abstract
PURPOSE The aim of this study is to compare clinical and radiological outcome of intramedullary nailing (IMN) and locked plate (LP) in patients affected by fracture of the distal tibia (DTF). We performed also an analysis to identify predictive factors of unfavourable outcome. METHODS Data about patients with DTF treated at our first level trauma centre between 2008 and 2017 were collected. Patients were divided in group 1 (IMN) and group 2 (LP). The inclusion criteria were age at least 18 years at the time of diagnosis and unilateral DTF (closed or Gustilo 1). Demographic variables and data related to surgical procedure and hospitalization were registered. X-ray at follow-up was reviewed to identify malunions and nonunions. Clinical outcome was evaluated using scores and registering any complication. RESULTS One hundred two patients were included in group 1 and 81 in group 2. In group 2 were documented higher operating time and hospitalization. The mean union time was 20.2 weeks for IMN and 24.8 weeks for LP group (p = 0.271). The rate of infections and wound complications was higher in group 2 while malunion and anterior knee pain were more frequent in group 1. No difference in scores for clinical outcome was documented after six months. The full-weight bearing time was significantly longer in the LP group (p = 0.019). At multivariate analysis, no variables showed a predictive power for unfavourable outcome. CONCLUSIONS Clinical and radiological results of LP and IMN appear similar. No predictive factors of unfavourable outcome were identified.
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Shukla R, Jain N, Jain RK, Patidar S, Kiyawat V. Minimally Invasive Plate Osteosynthesis Using Locking Plates for AO 43-Type Fractures: Lessons Learnt From a Prospective Study. Foot Ankle Spec 2018; 11:236-241. [PMID: 28814102 DOI: 10.1177/1938640017726134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Managing fractures of distal tibia is still a subject of debate for orthopaedic surgeons in terms of both, reduction and fixation. Subcutaneous location and soft tissue anatomy predisposes it to angular and rotational instability as well as other bony and soft tissue complexities. Minimally invasive plating offers many advantages over conventional open techniques. It causes minimal soft tissue dissection and surgical trauma to the bone. Minimally invasive plate osteosynthesis(MIPO) maintains biological configuration of distal tibia and fracture hematoma and also provides a construct, which is biomechanically more stable. OBJECTIVES Evaluation of results of MIPO in management of distal tibia fractures considering radiological union, ankle function restoration, and complications. MATERIALS AND METHODS In our study, 25 closed distal one-third tibia fracture with/without articular extension were taken, fulfilling the inclusion criteria (AO classification: 10, 43A1; 3, 43A2; 2, 43B1; 4, 43B2; and 6, 43C1). MIPO with locking plates was the treatment undertaken. Patients were followed up for 18 months prospectively. RESULTS Average injury-hospital interval was 11.16 hours and average injury-operation interval was 2.44 days. All fractures showed radiological union at an average duration of 20.5 weeks (14-28 weeks). Olerud and Molander score was used for evaluation at 3, 6, and 18 months. One patient had union with valgus angulation >5° but there was no nonunion. There was 1 superficial postoperative wound infection. CONCLUSION Our study shows that plating with MIPO is an effective treatment for closed distal one-third tibia fractures, considering union time and complications rate. Younger age promotes early union and functional recovery. LEVELS OF EVIDENCE Therapeutic, Level II: Prospective.
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Affiliation(s)
- Rajeev Shukla
- Department of Orthopedics, Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India
| | - Nikhil Jain
- Department of Orthopedics, Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India
| | - Ravi Kant Jain
- Department of Orthopedics, Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India
| | - Shravan Patidar
- Department of Orthopedics, Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India
| | - Vivek Kiyawat
- Department of Orthopedics, Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India
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Chandrakant KA, Martand BC. Distal Tibia Metaphyseal Fractures: Which is Better, Intra-medullary Nailing or Minimally Invasive Plate Osteosynthesis? JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2018. [DOI: 10.1016/j.jotr.2017.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Introduction Tibia fractures are the most common long bone fractures encountered by the orthopedic surgeons and distal tibia fractures have the second highest incidence of all tibia fractures after the middle third of tibia the distal tibial fractures are unique and are considered as most challenging fractures to treat due to its proximity to the ankle joint and its superficial nature. The objective of this study is to compare two osteosynthesis systems developed for surgical treatment of distal tibia fractures: the intramedullary nailing and the MIPPO technique. Methods The study was conducted between Jan 2011 to Dec 2012. 63 patients with extra-articular distal tibia fracture treated with intramedullary nailing and MIPPO technique were reviewed retrospectively and clinical outcome was evaluated according to American Orthopaedic Foot and Ankle Score. Results 31 patients were treated with intramedullary nail & 32 with MIPPO technique. Fibular fixation was done in cases where fibular fracture was at or below the level of tibial fractures. We found no difference in terms of time for fracture union, mal-union, non-union, duration of surgery and amount of blood loss. But there was significant difference in terms of infection and duration of hospital stay. Also weight bearing was possible much earlier in intramedullary group as compared to the MIPPO group. Conclusion Thus we conclude that intramedullary nailing is better choice of implant in patients with extra- articular distal tibia fractures & helps in early weight bearing and ambulation of patient with fewer complications.
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Costa ML, Achten J, Hennings S, Boota N, Griffin J, Petrou S, Maredza M, Dritsaki M, Wood T, Masters J, Pallister I, Lamb SE, Parsons NR. Intramedullary nail fixation versus locking plate fixation for adults with a fracture of the distal tibia: the UK FixDT RCT. Health Technol Assess 2018; 22:1-148. [PMID: 29785926 DOI: 10.3310/hta22250] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The best treatment for fractures of the distal tibia remains controversial. Most of these fractures require surgical fixation, but the outcomes are unpredictable and complications are common. OBJECTIVES To assess disability, quality of life, complications and resource use in patients treated with intramedullary (IM) nail fixation versus locking plate fixation in the 12 months following a fracture of the distal tibia. DESIGN This was a multicentre randomised trial. SETTING The trial was conducted in 28 UK acute trauma centres from April 2013 to final follow-up in February 2017. PARTICIPANTS In total, 321 adult patients were recruited. Participants were excluded if they had open fractures, fractures involving the ankle joint, contraindication to nailing or inability to complete questionnaires. INTERVENTIONS IM nail fixation (n = 161), in which a metal rod is inserted into the hollow centre of the tibia, versus locking plate fixation (n = 160), in which a plate is attached to the surface of the tibia with fixed-angle screws. MAIN OUTCOME MEASURES The primary outcome measure was the Disability Rating Index (DRI) score, which ranges from 0 points (no disability) to 100 points (complete disability), at 6 months with a minimum clinically important difference of 8 points. The DRI score was also collected at 3 and 12 months. The secondary outcomes were the Olerud-Molander Ankle Score (OMAS), quality of life as measured using EuroQol-5 Dimensions (EQ-5D), complications such as infection, and further surgery. Resource use was collected to inform the health economic evaluation. RESULTS Participants had a mean age of 45 years (standard deviation 16.2 years), were predominantly male (61%, 197/321) and had experienced traumatic injury after a fall (69%, 223/321). There was no statistically significant difference in DRI score at 6 months [IM nail fixation group, mean 29.8 points, 95% confidence interval (CI) 26.1 to 33.7 points; locking plate group, mean 33.8 points, 95% CI 29.7 to 37.9 points; adjusted difference, 4.0 points, 95% CI -1.0 to 9.0 points; p = 0.11]. There was a statistically significant difference in DRI score at 3 months in favour of IM nail fixation (IM nail fixation group, mean 44.2 points, 95% CI 40.8 to 47.6 points; locking plate group, mean 52.6 points, 95% CI 49.3 to 55.9 points; adjusted difference 8.8 points, 95% CI 4.3 to 13.2 points; p < 0.001), but not at 12 months (IM nail fixation group, mean 23.1 points, 95% CI 18.9 to 27.2 points; locking plate group, 24.0 points, 95% CI 19.7 to 28.3 points; adjusted difference 1.9 points, 95% CI -3.2 to 6.9 points; p = 0.47). Secondary outcomes showed the same pattern, including a statistically significant difference in mean OMAS and EQ-5D scores at 3 and 6 months in favour of IM nail fixation. There were no statistically significant differences in complications, including the number of postoperative infections (13% in the locking plate group and 9% in the IM nail fixation group). Further surgery was more common in the locking plate group (12% in locking plate group and 8% in IM nail fixation group at 12 months). The economic evaluation showed that IM nail fixation provided a slightly higher quality of life in the 12 months after injury and at lower cost and, therefore, it was cost-effective compared with locking plate fixation. The probability of cost-effectiveness for IM nail fixation exceeded 90%, regardless of the value of the cost-effectiveness threshold. LIMITATIONS As wound dressings after surgery are clearly visible, it was not possible to blind the patients to their treatment allocation. This evidence does not apply to intra-articular (pilon) fractures of the distal tibia. CONCLUSIONS Among adults with an acute fracture of the distal tibia who were randomised to IM nail fixation or locking plate fixation, there were similar disability ratings at 6 months. However, recovery across all outcomes was faster in the IM nail fixation group and costs were lower. FUTURE WORK The potential benefit of IM nail fixation in several other fractures requires investigation. Research is also required into the role of adjuvant treatment and different rehabilitation strategies to accelerate recovery following a fracture of the tibia and other long-bone fractures in the lower limb. The patients in this trial will remain in longer-term follow-up. TRIAL REGISTRATION Current Controlled Trials ISRCTN99771224 and UKCRN 13761. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 25. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matthew L Costa
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.,Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.,Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Juul Achten
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.,Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susie Hennings
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Nafisa Boota
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - James Griffin
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Stavros Petrou
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Mandy Maredza
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Melina Dritsaki
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Thomas Wood
- Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - James Masters
- Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.,Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Sarah E Lamb
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.,Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nick R Parsons
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
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Maredza M, Petrou S, Dritsaki M, Achten J, Griffin J, Lamb SE, Parsons NR, Costa ML. A comparison of the cost-effectiveness of intramedullary nail fixation and locking plate fixation in the treatment of adult patients with an extra-articular fracture of the distal tibia: economic evaluation based on the FixDT trial. Bone Joint J 2018; 100-B:624-633. [PMID: 29701091 DOI: 10.1302/0301-620x.100b5.bjj-2017-1329.r2] [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] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to compare the cost-effectiveness of intramedullary nail fixation and 'locking' plate fixation in the treatment of extra-articular fractures of the distal tibia. Patients and Methods An economic evaluation was conducted from the perspective of the United Kingdom National Health Service (NHS) and personal social services (PSS), based on evidence from the Fixation of Distal Tibia Fractures (UK FixDT) multicentre parallel trial. Data from 321 patients were available for analysis. Costs were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality adjusted life year (QALY) gained, and net monetary benefit. Sensitivity analyses were conducted to test the robustness of cost-effectiveness estimates. Results Mean NHS and PSS costs were significantly lower for patients treated with an intramedullary nail than for those treated with a locking plate (-£970, 95% confidence interval (CI) -1685 to -256; p = 0.05). There was a small increase in QALYs gained in the nail fixation group (0.01, 95% CI -0.03 to 0.06; p = 0.52). The probability of cost-effectiveness for nail fixation exceeded 90% at cost-effectiveness thresholds as low as £15 000 per additional QALY. The cost-effectiveness results remained robust to several sensitivity analyses. Conclusion This trial-based economic evaluation suggests that nail fixation is a cost-effective alternative to locking plate fixation. Cite this article: Bone Joint J 2018;100-B:624-33.
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Affiliation(s)
- M Maredza
- Clinical Trials Unit, Warwick Medical School, The University of Warwick, Coventry, UK
| | - S Petrou
- Clinical Trials Unit, Warwick Medical School, The University of Warwick
| | - M Dritsaki
- Oxford Trauma,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - J Achten
- Oxford Trauma,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - J Griffin
- Clinical Trials Unit, Warwick Medical School, The University of Warwick, Gibbet Hill Campus, Coventry, UK
| | - S E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - N R Parsons
- Clinical Trials Unit, Warwick Medical School, The University of Warwick
| | - M L Costa
- Oxford Trauma,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, and Clinical Trials Unit, Warwick Medical School, The University of Warwick, Coventry, UK and University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Bisaccia M, Cappiello A, Meccariello L, Rinonapoli G, Falzarano G, Medici A, Vicente CI, Piscitelli L, Stano V, Bisaccia O, Caraffa A. Nail or plate in the management of distal extra-articular tibial fracture, what is better? Valutation of outcomes. SICOT J 2018; 4:2. [PMID: 29469802 PMCID: PMC5822878 DOI: 10.1051/sicotj/2017058] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 11/14/2017] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Distal tibial fractures are the most common long bone fractures. Several studies focusing on the methods of treatment of displaced distal tibial fractures have been published. To date, locked plates, intramedullary nails and external fixation are the three most used techniques. The aim of our study was to compare intramedullary nail (IMN) and locked plate (LP) for treatment of this kind of fracture. MATERIALS AND METHODS We collected data on 81 patients with distal tibial fractures (distance from the joint between 40 and 100 mm) and we divided into two groups: IMN and LP. We compared in the 2 groups the mean operation time, the mean union time, the infection rate the rate of malunion and nonunion, the full weight bearing time. RESULTS No patient in the two groups developed a nonunion. None of the patients obtained a fair or poor outcome. Overall 52 patients obtained an excellent result (69.3%) and 23 obtained a good result (30.6%). DISCUSSION Our study results indicate a superiority of IMN over LP in terms of lower rates of infections and statistically significant shorter time to full weight bearing. Whereas LP appeared to be advantageous over IMN in terms of leading to a better anatomical and fixed reductions of the fracture and a lower rate of union complications. The two treatments achieved comparable results in terms of operation time, hospital stay, union time and functional outcomes.
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Affiliation(s)
- Michele Bisaccia
- Department of Orthopaedics and Traumatology, "S.M. Misericordia Hospital", University of Perugia, Perugia, Italy
| | - Andrea Cappiello
- Department of Orthopaedics and Traumatology, "S.M. Misericordia Hospital", University of Perugia, Perugia, Italy
| | - Luigi Meccariello
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
| | - Giuseppe Rinonapoli
- Department of Orthopaedics and Traumatology, "S.M. Misericordia Hospital", University of Perugia, Perugia, Italy
| | - Gabriele Falzarano
- Department of Medical and Surgical Sciences and Neuroscience, Section of Orthopedics and Traumatology, University of Siena, University Hospital "Santa Maria alle Scotte", Siena, Italy
| | - Antonio Medici
- Department of Medical and Surgical Sciences and Neuroscience, Section of Orthopedics and Traumatology, University of Siena, University Hospital "Santa Maria alle Scotte", Siena, Italy
| | - Cristina Ibáñez Vicente
- Department of Orthopaedics and Traumatology, "S.M. Misericordia Hospital", University of Perugia, Perugia, Italy
| | - Luigi Piscitelli
- Department of Orthopaedics and Traumatology, "S.M. Misericordia Hospital", University of Perugia, Perugia, Italy
| | - Verdiana Stano
- Department of Civil Engineering and Computer Engineering, Faculty of Medical Engineering, University of Rome Tor Vergata, Rome, Italy
| | - Olga Bisaccia
- Department of Radiology, "San Donato Hospital" University of Milano, Milano, Italy
| | - Auro Caraffa
- Department of Orthopaedics and Traumatology, "S.M. Misericordia Hospital", University of Perugia, Perugia, Italy
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A Prospective Randomized Study on Operative Treatment for Simple Distal Tibial Fractures-Minimally Invasive Plate Osteosynthesis Versus Minimal Open Reduction and Internal Fixation. J Orthop Trauma 2018; 32:e19-e24. [PMID: 28834822 DOI: 10.1097/bot.0000000000001007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the radiologic and clinical results of minimally invasive plate osteosynthesis (MIPO) and minimal open reduction and internal fixation (ORIF) for simple distal tibial fractures. DESIGN Randomized prospective study. SETTING Three level 1 trauma centers. PATIENTS Fifty-eight patients with simple and distal tibial fractures were randomized into a MIPO group (treatment with MIPO; n = 29) or a minimal group (treatment with minimal ORIF; n = 29). These numbers were designed to define the rate of soft tissue complication; therefore, validation of superiority in union time or determination of differences in rates of delayed union was limited in this study. INTERVENTION Simple distal tibial fractures treated with MIPO or minimal ORIF. MAIN OUTCOME MEASUREMENTS The clinical outcome measurements included operative time, radiation exposure time, and soft tissue complications. To evaluate a patient's function, the American Orthopedic Foot and Ankle Society ankle score (AOFAS) was used. Radiologic measurements included fracture alignment, delayed union, and union time. RESULTS All patients acquired bone union without any secondary intervention. The mean union time was 17.4 weeks and 16.3 weeks in the MIPO and minimal groups, respectively. There was 1 case of delayed union and 1 case of superficial infection in each group. The radiation exposure time was shorter in the minimal group than in the MIPO group. Coronal angulation showed a difference between both groups. The American Orthopedic Foot and Ankle Society ankle scores were 86.0 and 86.7 in the MIPO and minimal groups, respectively. Minimal ORIF resulted in similar outcomes, with no increased rate of soft tissue problems compared to MIPO. CONCLUSIONS Both MIPO and minimal ORIF have high union rates and good functional outcomes for simple distal tibial fractures. Minimal ORIF did not result in increased rates of infection and wound dehiscence. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Mukherjee S, Arambam MS, Waikhom S, Santosha, Masatwar PV, Maske RG. Interlocking Nailing Versus Plating in Tibial Shaft Fractures in Adults: A Comparative Study. J Clin Diagn Res 2017; 11:RC08-RC13. [PMID: 28571220 DOI: 10.7860/jcdr/2017/25577.9746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/06/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Tibial diaphyseal fractures are the commonest long bone fractures in adults, most commonly managed by intramedullary interlocking nailing. However, several meta-analysis show that locking plate osteosynthesis is equally effective in managing tibial diaphyseal fractures and are associated with less number of complications. AIM To compare the results of fixation of tibial fractures following plating and nailing in terms of union, patient satisfaction and complications. MATERIALS AND METHODS A hospital based non randomized clinical trial was performed from September 2013 to August 2016 where closed or open diaphyseal or metaphyseo- diaphyseal fractures of the tibia (closed or open Gustilo Anderson type 1 through 3B) were included. Simple sequential allocation was used for allotting the patients to two groups, one for interlocking nailing and other for plating. The patients were followed up for clinical, radiographic and functional results. RESULTS Forty patients with 41 involved limbs completed follow up for one year. The duration of surgery and average blood loss during surgery was 75.45±3.03 minutes and 165.00±5.31 ml respectively in case of nailing and 85.05±2.54 minutes and184.29±5.33 ml respectively in case of plating and their difference was statistically significant. In our study union was achieved in less than 20 weeks in 29 (70.8%) of the patients and 25-30 weeks in nine (22%) cases. The average time of union in our study was 19.55±0.69 weeks in case of interlocking nailing and 20.38±1.39 weeks in case of plating and there was no statistically significant difference between the two. However, there is statistically significant difference in the functional score in between the two groups in terms of Lower Extremity Functional Score (LEFS). Delayed union in one case of nailing and two cases of plating, valgus malunion in one case of nailing and joint stiffness in two cases each of nailing and plating were the major complications observed. CONCLUSION There was no difference between the two modalities in terms of fracture union. Complications were lesser but more serious in case of plating. Patient satisfaction was more with plating.
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Affiliation(s)
- Sagnik Mukherjee
- Postgraduate Trainee, Department of Orthopaedics, Regional Institute of Medical Sciences, Imphal, Manipur, India
| | - Mahendra Singh Arambam
- Professor, Department ofOrthopaedics, Regional Institute of Medical Sciences, Imphal, Manipur, India
| | - Sanjib Waikhom
- Associate Professor, Department of Orthopaedics, Regional Institute of Medical Sciences, Imphal, Manipur, India
| | - Santosha
- Postgraduate Trainee, Department of Orthopaedics, Regional Institute of Medical Sciences, Imphal, Manipur, India
| | - Pranav Vitthal Masatwar
- Postgraduate Trainee, Department of Orthopaedics, Regional Institute of Medical Sciences, Imphal, Manipur, India
| | - Rohan Gautam Maske
- Postgraduate Trainee, Department of Orthopaedics, Regional Institute of Medical Sciences, Imphal, Manipur, India
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