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Liu J, Dai S, Liu L, Kuang H, Yan L, Cai Q, Shao Z, Wei W, Min Z, Tang W. A novel assisted reduction method in extra-articular fractures of the distal tibia treated with intramedullary nail. Front Med (Lausanne) 2024; 11:1444434. [PMID: 39131089 PMCID: PMC11310112 DOI: 10.3389/fmed.2024.1444434] [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: 06/05/2024] [Accepted: 07/15/2024] [Indexed: 08/13/2024] Open
Abstract
Background To explore the clinical efficacy and safety of Kirschner wires (KWs) as a blocking screw technique for extra-articular fractures of the distal tibia treated with intramedullary nails (IMNs). Methods Fifty-three patients were treated with KW-assisted IMN for extra-articular fractures of the distal tibia via the blocking screw technique or Poller screw (PS) technique. The operation time, number of fluoroscopies, number of blocking screws used, blood loss and time to union were compared between the two groups. Additionally, the functional outcomes of the two groups were compared using range of motion (ROM), visual analog scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS), and Lysholm scores. Results Compared with those in the PS group, the operation time in the KW group was significantly shorter, and the number of fluoroscopy procedures and amount of blood loss during KW surgery were also significantly lower (p = 0.014, 0.001, and 0.036, respectively). Regarding the functional outcomes, there were no significant differences in the ROM, VAS score, AOFAS score or Lysholm score between the two groups (p > 0.05). Conclusion In the treatment of extra-articular fractures of the distal tibia with nails, the use of KW as a blocking screw technique is safe and reliable.
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Affiliation(s)
- Jun Liu
- Department of Orthopaedic Surgery, The Third Hospital of Nanchang, Nanchang People's Hospital, Nanchang, Jiangxi, China
| | - Simin Dai
- Department of Emergency, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Lijin Liu
- Department of Orthopaedic Surgery, The Third Hospital of Nanchang, Nanchang People's Hospital, Nanchang, Jiangxi, China
| | - Hailin Kuang
- Department of Orthopaedic Surgery, The Third Hospital of Nanchang, Nanchang People's Hospital, Nanchang, Jiangxi, China
| | - Liang Yan
- Department of Orthopaedic Surgery, The Third Hospital of Nanchang, Nanchang People's Hospital, Nanchang, Jiangxi, China
| | - Qiangqiang Cai
- Department of Orthopaedic Surgery, The Third Hospital of Nanchang, Nanchang People's Hospital, Nanchang, Jiangxi, China
| | - Zongzuan Shao
- Department of Orthopaedic Surgery, The Third Hospital of Nanchang, Nanchang People's Hospital, Nanchang, Jiangxi, China
| | - Wenbo Wei
- Department of Orthopaedic Surgery, The Third Hospital of Nanchang, Nanchang People's Hospital, Nanchang, Jiangxi, China
| | - Zhihai Min
- Department of Orthopaedic Surgery, The Third Hospital of Nanchang, Nanchang People's Hospital, Nanchang, Jiangxi, China
| | - Wubing Tang
- Department of Orthopaedic Surgery, The Third Hospital of Nanchang, Nanchang People's Hospital, Nanchang, Jiangxi, China
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Gupta A, Negi DK, Thami T, Nishani M, Ghosh AK. Minimally Invasive Osteotomy for Correction of Post-Traumatic Tibia Internal Rotation Deformity: A Case Report. J Orthop Case Rep 2024; 14:25-29. [PMID: 38910987 PMCID: PMC11189091 DOI: 10.13107/jocr.2024.v14.i06.4490] [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: 03/10/2024] [Revised: 04/29/2024] [Indexed: 06/25/2024] Open
Abstract
Introduction Intramedullary nailing is a commonly performed surgery for tibia diaphysis fractures. However, in selected cases, this procedure can get complicated with rotational malalignment if not checked carefully intra-operatively. Case Report A 29 year-old male sustained polytrauma and was treated with intramedullary nailing for bilateral femur and right-side tibia fractures. Postoperatively, the patient noticed extreme in-toeing suggesting an internal rotation deformity, which caused great difficulty in walking. The patient was planned for a revision surgery to correct the internal rotation deformity, 6 months after the index surgery. A minimally invasive metaphyseal osteotomy was performed, away from his fracture site by drilling multiple holes. The distal locking bolts of the interlocking nail were removed, and two K wires used to achieve the desired correction angle. After rotating the distal fragment, locking bolts were reinserted in new holes. We kept the patient on our regular follow-up till he achieved sound union at the osteotomy site, after which we allowed him unrestricted activities. Conclusion The presence of an intramedullary nail can hence help the surgeon in correcting such isolated rotational deformities without getting into the hassle of implant removal to achieve the same.
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Affiliation(s)
- Ansh Gupta
- Department of Orthopedic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Kumar Negi
- Department of Orthopedic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Tarkik Thami
- Department of Orthopedic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manjunath Nishani
- Department of Orthopedic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Akash Kumar Ghosh
- Department of Orthopedic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Grand JG. Delayed Life-Threatening Hemorrhage Caused by Cranial Tibial Artery Pseudoaneurysm in Two Dogs. J Am Anim Hosp Assoc 2024; 60:74-80. [PMID: 38394694 DOI: 10.5326/jaaha-ms-7405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2023] [Indexed: 02/25/2024]
Abstract
Two adult dogs were presented at 25 and 30 days following tibial external skeletal fixator placement (case 1) and tibial plateau leveling osteotomy (case 2), respectively. Clinical signs at presentation for each of them included acute onset lethargy, non-weight-bearing lameness, and hemorrhage at the surgical site with large hematoma formation. On admission, emergency whole blood transfusion was required in case 2 with a preoperative packed cell volume of 13%. Both dogs were diagnosed with pseudoaneurysm of the cranial tibial artery based on color Doppler ultrasonography. Additionally, computed tomography angiography was performed in one dog. Surgical treatment of the dogs included ligation of the cranial tibial artery supplying the pseudoaneurysm and curettage of hematoma. The surgery was completed without complications in case 1, but case 2 experienced inadvertent rupture of pseudoaneurysm with significant blood loss, which required another whole blood transfusion during the procedure. Both dogs had excellent functional recovery with no recurrence of clinical signs. We hypothesized that pseudoaneurysms were primarily caused by trauma secondary to placement of surgical implants or osteotomy. For orthopedic surgeons, it is important to recognize clinical signs of a potential tibial arterial pseudoaneurysm, as early surgical intervention may prevent loss of limb or life.
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Garabano G, Jaime A, Alamino LP, Taleb JP, Rodriguez J, Pesciallo CA. Does the distal nail position impact the rates of misalignment and bone union in distal tibial fractures? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3365-3371. [PMID: 37127816 DOI: 10.1007/s00590-023-03566-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 04/23/2023] [Indexed: 05/03/2023]
Abstract
PURPOSE This retrospective study aimed to assess the impact of distal nail placement on misalignment and healing rates in distal tibial fractures. METHODS We reviewed all patients with distal tibial fracture treated with intramedullary nailing between 2015 and 2021, and a minimum follow-up of 12 months. Distal nail positioning was determined according to the Triantafillou zones. We related these positioning zones to misalignments (alignment ≥ 3°) and too bony union disorders (delayed union, non-union). RESULTS Out of the 62 patients included, 56 (90.3%) show bone union without additional procedure, 3 (4.8%) with dynamization, and 3 (4.8%) showed non-union. Twenty-one (33.8%) presented misalignment, with valgus in the coronal plane being the most frequent (76.19%). In patients with and without misalignment, the most frequent distal nail position was 2-2 in 47.6% and 80.5%, respectively (p = 0.01). In multivariate analysis, distal nail positioning in the 2-2 zone showed a significant protective effect against misalignment (OR 0.18; p = 0.018), while nail positioning in the 3-2 zone generated a significant risk of misalignment (OR 18.55; p = 0.009). CONCLUSION In intramedullary nailing of distal tibial fractures, distal positioning of the nail slightly lateral to the center of the talus in the coronal plane and slightly posterior in the sagittal plane (zone 2-2) allows high alignment percentages to be obtained. Positioning medial to this point in the coronal plane (zone 3) is associated with more significant misalignment and should be avoided.
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Affiliation(s)
- Germán Garabano
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina.
| | - Adrian Jaime
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Leonel Perez Alamino
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Juan Pablo Taleb
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Joaquin Rodriguez
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Cesar Angel Pesciallo
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
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Kotsarinis G, Wakefield SM, Kanakaris NK, Giannoudis PV. Stabilization of Tibial Fractures at Risk of Complications With the Bactiguard Intramedullary Nail: Early to Medium Results With a Novel Metal-Coated Device. J Orthop Trauma 2023; 37:S12-S17. [PMID: 37828696 DOI: 10.1097/bot.0000000000002688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate the safety and early clinical results from the use of a novel, noble metal-coated titanium tibial nail for the definite stabilization of tibial shaft fractures at risk of developing complications. DESIGN This is a retrospective case series with prospectively collected data. SETTING Level I Trauma Centre in the United Kingdom. PATIENTS AND INTERVENTION Thirty-one patients who were managed with the Bactiguard-coated Natural Nail and achieved a minimum of a 12-month follow-up. MAIN OUTCOME MEASUREMENTS The main outcomes of this study were the incidence of adverse events (related to implant safety), complications (particularly infection), and reinterventions. RESULTS Thirty-one patients with a mean age of 41.6 years were included in this study. Active heavy smokers or intravenous drug users were 25.8% and 9.7% of them were diabetic. Five fractures were open while 13 had concomitant soft-tissue involvement (Tscherne grade 1 or 2). Twenty-seven patients healed with no further intervention in a mean time of 3.3 months. Three patients developed nonunion and required further intervention. The overall union rate was 96.7%. One patient developed deep infection after union (infection incidence 3.2%). Six patients (6/31; [19.3%]) required reinterventions [2 for the treatment of nonunion, 3 for removal of screws soft-tissue irritation, and 1 for the management of infection). CONCLUSIONS The management of tibial shaft fractures with a noble metal-coated titanium tibial nail demonstrates encouraging outcomes. Further studies are desirable to gather more evidence in the performance of this innovative implant. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Georgios Kotsarinis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; and
| | - Sophia M Wakefield
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; and
| | - Nikolaos K Kanakaris
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; and
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; and
- NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
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Sandness BM, Perry KL, Bruce M. Single institution retrospective study evaluating the frequency of implant removal and associated risk factors following open fracture fixation in 80 cases (2010-2020). BMC Vet Res 2023; 19:119. [PMID: 37563636 PMCID: PMC10413701 DOI: 10.1186/s12917-023-03687-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 08/04/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Open fractures occur commonly in small animals and are characterised by contamination of the fracture site. While never quantified, it is believed that open fractures stabilised with internal implants are at a higher risk for requiring explantation. This retrospective study determines the frequency and risk factors for explantation following use of internal fixation. Medical records of client-owned dogs and cats with an open fracture, between 2010 and 2020 stabilised using internal implants, were included. Data retrieved included signalment, cause and characterisation of the fracture, comorbidities, preexisting infections, and all details related to anesthesia and surgery. Pre-, Peri- and post-operative antibiotic use were detailed. All cases were followed to clinical union. Postoperative complications, including requirement for implant removal were recorded and classified as major or minor. Associations between potential risk factors and need for explantation were assessed. RESULTS Of 80 cases, 72 (90%) were dogs and eight (10%) cats. Major complications were encountered in 23 (28.75%) cases and minor complications in 16 (20%) cases. Explantation was performed in 17 cases (21.25%). Out of 72 dogs, 13 required explantation (18%) whereas four of the eight cats needed implants removed (50%). Only diagnosis of postoperative infection was associated with an increased risk of explantation (RR 2.77; 95% CI 1.25; 6.15; p = 0.045). CONCLUSION Approximately 1 in 5 open fractures stabilised using internal fixation can be anticipated to require explantation, with cats potentially being at a higher risk than dogs. Cases diagnosed with postoperative infection are at a higher risk for requiring implant removal.
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Affiliation(s)
- Brea M Sandness
- Department of Small Animal Clinical Sciences, Michigan State University, 736 Wilson Road, East Lansing, MI, 48824-1314, USA
| | - Karen L Perry
- Department of Small Animal Clinical Sciences, Michigan State University, 736 Wilson Road, East Lansing, MI, 48824-1314, USA.
| | - Mieghan Bruce
- School of Veterinary Medicine and Centre for Biosecurity and One Health, Murdoch University, Murdoch, 6150, Australia
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Mortality and morbidity following operative management of tibial shaft fractures in octogenarians. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:299-304. [PMID: 35031851 DOI: 10.1007/s00590-021-03180-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/27/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE As the geriatric population continues to grow, the incidence of tibial shaft fractures in octogenarians is projected to increase. There is significant variation in the functional and physiologic status within the geriatric population. The purpose of this study is to compare the complications following operative treatment of tibial shaft fractures for patients who are 65- to79-year-old compared to patients who are 80- to 89-year-old. METHODS Data were collected through the National Surgical Quality Improvement Program database for the years 2007-2018. All isolated tibial shaft fractures that were treated with open reduction internal fixation (ORIF) or intramedullary nail (IMN) were identified. Patients were divided into a 65- to 79-year-old group and an 80-to 89-year-old group. Primary and secondary outcomes were studied and included 30-day mortality. Univariate and multivariate analyses were performed with a significance set at p < 0.05. RESULTS In total, 434 patients with tibial shaft fractures were included in the study. Of these, 333 were 65- to 79-year-old and 101 were 80- to 89-year-old (Table 1). On multivariate analysis, there was no significant difference in complication rates between the two cohorts. CONCLUSION After controlling for demographics and comorbidities, age was not independently associated with 30-day mortality or any other peri-operative complications between patients aged 80 to 89 and patients aged 65 to 79 following operative management of tibial shaft fractures. In appropriately selected octogenarian patients, operative management of tibial shaft fractures represents a relatively safe treatment modality that may promote early rehabilitation.
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Jobson J, Saad A, Jaly I, Singh R, Baloch K, Botchu R. Radiation exposure from fluoroscopy during tibia fracture intramedullary nailing - The effect of surgical experience. J Clin Orthop Trauma 2022; 34:102029. [PMID: 36263250 PMCID: PMC9573901 DOI: 10.1016/j.jcot.2022.102029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/30/2022] [Accepted: 09/18/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Jessica Jobson
- Department of Trauma & Orthopaedic Surgery, Queen Elizabeth Hospital Birmingham, UHB, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Ahmed Saad
- Department of Trauma & Orthopaedic Surgery, Queen Elizabeth Hospital Birmingham, UHB, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Ibrahim Jaly
- Department of Trauma & Orthopaedic Surgery, Queen Elizabeth Hospital Birmingham, UHB, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Ravneet Singh
- Department of Radiology, Queen Elizabeth Hospital Birmingham, UHB, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Khalid Baloch
- Department of Trauma & Orthopaedic Surgery, Queen Elizabeth Hospital Birmingham, UHB, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Rajesh Botchu
- Department of Radiology, Royal Orthopaedic Hospital, Birmingham, Bristol Rd S, Northfield, Birmingham, B31 2AP, UK
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Garabano G, Pereira S, Perez Alamino L, Ernst G, Pesciallo CA, Bidolegui F. The relevance of the number of distal locking planes and nail to canal ratio in bone healing after intramedullary nailing in tibial shaft fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03401-0. [PMID: 36208335 DOI: 10.1007/s00590-022-03401-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/28/2022] [Indexed: 05/19/2023]
Abstract
INTRODUCTION The objective of this retrospective study was to assess the effect of the nail to canal ratio and the number and configuration of distal locking screws in bone healing in tibial shaft fractures. METHODS We analyzed 223 consecutive tibial shaft fractures treated with reamed intramedullary nailing between January 2014 and December 2020. We recorded and evaluated the nail to canal ratio (NCR) and the number and configuration of distal locking screws. Median NCR was 0.87 (IQR 0.82-0.94). Ten (4.48%) fractures were treated with one distal locking screw, 173 (77.57%) with two, and 40 (17.93%) with three. Uniplanar fixation was used in 63 (28.25%), biplanar in 150 (67.26%), and triplanar in 10 (4.48%) cases. Uni-, bi-, and multivariate analyses were performed to compare patients who achieved bone union with those who did not. RESULTS Bone union was achieved in 195 (87.44%) patients. Uni- and bivariate analyses showed that bone union increased significantly with larger NCR (p = 0.0001) and a greater number of locking planes (p = 0.001) and distal screws (p = 0.046). NCR > 0.78 (OR 48.77 CI 95% 15.39-154.56; p = < 0.0001) and distal locking screw configuration (OR 2.91 CI 95% 1.12-9.91; p = 0.046) were identified as independent variables for union. CONCLUSION Our findings suggest that in tibial shaft fractures treated with intramedullary nailing, NCR should be equal to or greater than 0.79. Additionally, distal locking screws should be used with a biplanar or triplanar configuration.
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Affiliation(s)
- Germán Garabano
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina.
| | - Sebastian Pereira
- Orthopaedic and Trauma Surgery Department, Sirio - Libanes Hospital, Campana 4658, C1419, Buenos Aires, Argentina
| | - Leonel Perez Alamino
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Glenda Ernst
- Scientific Advisory Committee, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Cesar Angel Pesciallo
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Fernando Bidolegui
- Orthopaedic and Trauma Surgery Department, Sirio - Libanes Hospital, Campana 4658, C1419, Buenos Aires, Argentina
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Multimodal analgesia is superior to opiates alone after tibial fracture in patients with substance abuse history. OTA Int 2022; 5:e214. [PMID: 36569103 PMCID: PMC9782319 DOI: 10.1097/oi9.0000000000000214] [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: 06/13/2021] [Accepted: 05/08/2022] [Indexed: 12/27/2022]
Abstract
Objectives: To evaluate the effectiveness of multimodal analgesia in patients with a tibial shaft fracture. Design: Retrospective review. Setting: Large, urban, academic center. Patients: One hundred thirty-eight patients were evaluated before implementation of multimodal analgesia. Thirty-four patients were evaluated after implementation. All patients were treated operatively with internal fixation for their tibial shaft fracture. Patients with polytrauma were excluded. Intervention: Multimodal analgesia. Main Outcome Measures: Pain levels at rest and with movement were assessed. Morphine milligram equivalents (MMEs) dosed per patient were calculated each day. Length of stay was also documented. Results: After implementation of a multimodal analgesic program, there was a statistically significant decrease in pain score at rest (4.7-4.0, P = 0.034) and with movement (5.8-4.8, P = 0.007). MMEs dosed in the multimodal analgesic program correlated with pain score (R2 = 0.5), whereas before implementation of the program, MMEs dosed were not dependent on pain score (R2 = 0.007). Patients with a history of substance abuse had the most profound effect from this paradigm change. For those with a history of substance abuse, treatment of pain using a multimodal approach reduces MMEs dosed and length of stay (5.7-3.1 days, P = 0.016). Conclusions: Multimodal analgesia improves patient pain scores both at rest and during movement. In patients with a history of substance abuse, multimodal analgesia not only decreases pain but also decreases length of stay and MMEs dosed to levels consistent with someone who does not have a substance abuse history. Level of Evidence: Therapeutic Level III.
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11
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Jayaraju U, Rammohan R, Awad F, Kaur K, Brock J, Singhal A, Clewer G. Tibial Intramedullary Nailing by Suprapatellar Approach: Is It Quicker and Safer? Cureus 2022; 14:e29915. [PMID: 36348901 PMCID: PMC9633433 DOI: 10.7759/cureus.29915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 11/07/2022] Open
Abstract
Background With the increasingly accepted method of suprapatellar tibial nailing for tibial shaft fractures, we aimed to compare intraoperative and postoperative outcomes of infrapatellar (IP) vs suprapatellar (SP) tibial nails. Methods This is a retrospective cohort analysis of 34 SP tibial nails over three years vs 24 IP tibial nails over a similar time frame. We compared total radiation dose (TRD), patient positioning time (PPT), fracture healing and follow up time. Knee pain in the SP group was evaluated utilising the Hospital for Special Surgery (HSS) Knee Injury and Osteoarthritis Outcome Score (KOOS). Results Fifty-eight patients with a mean age of 43 years were included. Mean intraoperative radiation dose for SP nails was 61.78 cGy (range: 11.60-156.01 cGy) vs 121.09 cGy (range: 58.01-18.03 cGy) for IP nails (p < 0.05). Mean PPT for SP nails was 10 minutes vs 18 minutes for IP nails (p < 0.05). All fractures united in the SP group vs one non-union in the IP group. Mean follow up was 5.5 months vs 11 months in the IP and SP groups, respectively. Mean KOOS was 7 (range: 0-22) at six months for the SP group. Conclusion The semi-extended position (SP group) leads to reduced TRD because of ease of imaging. Patients showed improved outcomes with shorter follow up and fracture union in all patients (SP group). The KOOS revealed that SP nail patients had minimal pain and good knee function. This study establishes a management and patient-reported outcome measures (PROMs) baseline for ongoing evaluation of SP nails.
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Chandak R, Kekatpure AL, Agrawal R, Kekatpure A. Tibia Nailing Using Modular Stand: A Technical Note. Cureus 2022; 14:e24801. [PMID: 35686274 PMCID: PMC9170429 DOI: 10.7759/cureus.24801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2022] [Indexed: 11/15/2022] Open
Abstract
Interlocking nailing is a well-established procedure for managing unstable tibial shaft fractures. Closed reduction and internal fixation of the tibial shaft fractures require ease of intraoperative positioning, maneuvering, and biplane imaging.
We describe the use of an innovative modular tibia-nailing stand, which greatly enhances the ergonomics of the tibia nailing procedure.
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Rodríguez-Zamorano P, García-Coiradas J, Galán-Olleros M, Marcelo Aznar H, Alcobia-Díaz B, Llanos S, Valle-Cruz J, Marco F. [Translated article] Suprapatellar tibial nailing, why have we changed? Rev Esp Cir Ortop Traumatol (Engl Ed) 2022. [DOI: 10.1016/j.recot.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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14
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Aneja A, Marquez-Lara A, Luo TD, Teasdall RJ, Isla A, Albano A, Halvorson JJ, Carroll EA. Rethinking the Coronal Anatomic Axis of the Distal Tibia for Intramedullary Nail Placement: A Cadaveric Study. HSS J 2022; 18:284-289. [PMID: 35645644 PMCID: PMC9097000 DOI: 10.1177/15563316211008176] [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: 12/17/2020] [Accepted: 01/22/2021] [Indexed: 02/07/2023]
Abstract
Background: Recent studies have reported that targeting a center-center position at the distal tibia during intramedullary nailing (IMN) may result in malalignment. Although not fully understood, this observation suggests that the coronal anatomic center of the tibia may not correspond to the center of the distal tibia articular surface. Questions/Purposes: To identify the coronal anatomic axis of the distal tibia that corresponds to an ideal start site for IMN placement utilizing intact cadaveric tibiae. Methods: IMN placement was performed in 9 fresh frozen cadaveric tibiae. A guidewire was used to identify the ideal start site in the proximal tibia and an opening reamer allowed access to the canal. Each nail was then advanced without the use of a reaming rod until exiting the distal tibia plafond. Cadaveric and radiographic measurements were performed to determine the center of the nail exit site in the coronal plane. Results: Cadaveric and radiographic measurements identified the IMN exit site to correspond with the lateral 59.5% and 60.4% of the plafond, respectively. Conclusions: Tibial nails inserted using an ideal start site have an endpoint that corresponds roughly to the junction of the lateral and middle third of the plafond. Further studies are warranted to better understand the impact of IMN endpoint placement on the functional and radiographic outcomes of tibia shaft fractures.
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Affiliation(s)
- Arun Aneja
- Department of Orthopaedic Surgery, University
of Kentucky College of Medicine, Lexington, KY, USA,Arun Aneja, MD, PhD, Assistant Professor,
Department of Orthopaedic Surgery, University of Kentucky College of Medicine, 740 S.
Limestone, Suite K401, Lexington, KY 40536-0284, USA.
| | - Alejandro Marquez-Lara
- Department of Orthopaedic Surgery, Wake
Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - T. David Luo
- Department of Orthopaedic Surgery, Wake
Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Robert J. Teasdall
- Department of Orthopaedic Surgery, University
of Kentucky College of Medicine, Lexington, KY, USA
| | - Alexander Isla
- Department of Orthopaedic Surgery, University
of Kentucky College of Medicine, Lexington, KY, USA
| | - Ashley Albano
- Department of Orthopaedic Surgery, University
of Kentucky College of Medicine, Lexington, KY, USA
| | - Jason J. Halvorson
- Department of Orthopaedic Surgery, Wake
Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Eben A. Carroll
- Department of Orthopaedic Surgery, Wake
Forest Baptist Medical Center, Winston-Salem, NC, USA
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15
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Rodríguez-Zamorano P, García-Coiradas J, Galán-Olleros M, Marcelo Aznar H, Alcobia-Díaz B, Llanos S, Valle-Cruz J, Marco F. Enclavado de tibia suprapatelar, ¿por qué hemos cambiado? Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 66:159-169. [DOI: 10.1016/j.recot.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 08/18/2021] [Accepted: 09/07/2021] [Indexed: 10/19/2022] Open
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Tucker NJ, Hadeed MM, Mauffrey C, Parry JA. Native tibia valga: a potential source of varus malreduction during intramedullary tibial nail fixation of tibial shaft fractures. INTERNATIONAL ORTHOPAEDICS 2022; 46:1165-1173. [PMID: 35246719 DOI: 10.1007/s00264-022-05356-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/22/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine the effect of native tibia valga on intramedullary nail (IMN) fixation of tibial shaft fractures. METHODS Retrospective comparative cohort analysis of 110 consecutive patients with tibial shaft fractures undergoing IMN fixation at an urban level one trauma centre was performed. Medical records and radiographs were reviewed for demographics, tibia centre of rotation of angulation (CORA), nail starting point, incidence of varus malreduction, and nail/canal proportional fit. RESULTS Tibia valga (CORA of ≥ 3 degrees) was present in 37 (33.6%) patients. The anatomic nail starting point distance (in relation to the lateral tibial spine) was significantly greater in the tibia valga group (12.0 mm vs. 5.0 mm, mean difference: 7.1 mm, 95% CI: 5.8 to 8.3 mm, p < 0.0001). Varus malreduction was more common in the tibia valga group (10.8% vs. 1.4%, proportional difference: 9.4%, 95% CI: - 1.0 to 21.3%, p = 0.04). Varus malreduction in the tibia valga group was associated with a decreased nail width/inner canal width proportion on multivariate analysis (OR = 0.683, 95% CI: 0.468 to 0.995, p = 0.0004). CONCLUSION Native tibia valga is common, and the use of a standard coronal IMN starting point with poor nail fit can lead to iatrogenic varus malreduction. In patients with tibia valga, maximizing nail fit or utilization of a medial starting point should be considered.
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Affiliation(s)
- Nicholas J Tucker
- Department of Orthopedics, Denver Health Medical Center, Denver Health, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
| | - Michael M Hadeed
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Cyril Mauffrey
- Department of Orthopedics, Denver Health Medical Center, Denver Health, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Joshua A Parry
- Department of Orthopedics, Denver Health Medical Center, Denver Health, 777 Bannock St, MC 0188, Denver, CO, 80204, USA.
- University of Colorado School of Medicine, Aurora, CO, USA.
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Goyal ND, Gautam VK, Panchnadikar VM, Jeyaraman M, Valsangka N, Shringeri AS. Iatrogenic Anterior Tibial Artery Pseudoaneurysm - A Rare Case Report. J Orthop Case Rep 2021; 11:29-32. [PMID: 34790598 PMCID: PMC8576776 DOI: 10.13107/jocr.2021.v11.i07.2302] [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: 05/15/2021] [Revised: 06/04/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Interlocking tibia nail fixation for tibia shaft fracture treatment is one of the most commonest procedures performed in orthopedic trauma practices. We report one such case of a rare complication of anterior tibial artery (ATA) pseudo-aneurysm caused by the proximal coronal locking bolt performed by an unusual entry from lateral to medial side during shaft of tibia fracture fixation. Case Report: A 86- years old female sustained a road traffic accident and was diagnosed with a closed tibia shaft fracture of the right leg for which she underwent intramedullary interlocking nail IMIL nailing elsewhere. She presented to us three 3 weeks after primary surgery with persistent pain and swelling in the right leg proximally. We investigated and diagnosed her as having a pseudoaneurysm of the Anterior Tibial Artery on color Doppler and magnetic resonance imaging (MRI) angiography. The pseudoaneurysm of ATA was clipped without any complications. To avoid the rupture of the pseudoaneurysm during manipulation of nail and bolts, their positions were not changed as they were supporting the fracture well and the fracture was also not united at that time. Conclusion: Though Although interlocking nailing of tibia shaft fracture is a commonly performed procedure, it can lead to disastrous vascular complications if the procedure is not performed with utmost care. ATA injury by proximal locking bolts of the tibia nail mandates the need for reconsideration of the nail design with better screw hole positions. We recommend preferring standard AO manual instructions for proximal tibia locking bolt direction.
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Affiliation(s)
- Nishant D Goyal
- Department of Orthopaedics, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India
| | - Vinay Kumar Gautam
- Department of Orthopaedics, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India
| | - Vijay M Panchnadikar
- Department of Orthopaedics, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India
| | - Madhan Jeyaraman
- Department of Orthopaedics, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India
| | - Nikhil Valsangka
- Department of Orthopaedics, Clinical Fellow, Sant Parmanand Hospital, New Delhi, India
| | - Ajay Satish Shringeri
- Department of Orthopaedics, Sri Devaraj Urs Medical College, Kolar, Karnataka, India
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18
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Trompeter A, Williamson M, Bates P, Petersik A, Kelly M. Defining the Ideal "Nail Exit Path" of a Tibial Intramedullary Nail-A Computed Tomography Analysis of 860 Tibiae. J Orthop Trauma 2021; 35:e392-e396. [PMID: 33675627 DOI: 10.1097/bot.0000000000002098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To identify the ideal distal nail position in the distal tibia, using a computed tomography analysis. METHODS Three-dimensional models of 860 left tibiae were analyzed using the Stryker Orthopaedic Modeling and Analytics software (SOMA, Stryker, Kiel, Germany). The nail axis was defined by 7 center points at the middle of the inner cortical boundary. The point where this line fell relative to the center of the tibial plafond in both the anteroposterior and mediolateral planes was calculated. RESULTS The mean mediolateral offset of the tibial nail exit path was 4.4 ± 0.2 mm (95% confidence interval) lateral to the center of the tibial plafond. The mean anteroposterior offset of the tibial nail exit path was 0.6 ± 0.1 mm anterior to the center of the tibial plafond. CONCLUSIONS We have presented an anatomic study analyzing the ideal nail exit path using computed tomography scans of 860 tibiae. We defined that the ideal nail exit path of a tibial nail is lateral with respect to the center of the tibial plafond. This is supported by previous clinical studies and has significant implications for preventing malalignment when treating distal tibial fractures with intramedullary nailing.
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Affiliation(s)
- Alex Trompeter
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Mike Williamson
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Peter Bates
- Department of Trauma and Orthopaedics, The Royal London Hospital Barts Health NHS Trust, London, United Kingdom
| | | | - Michael Kelly
- Department of Trauma and Orthopaedics, North Bristol NHS Trust, Bristol, England
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19
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Peat F, Ordas-Bayon A, Krkovic M. Do Poller screws effect union in tibial shaft fractures treated with intramedullary nailing? Injury 2021; 52:3132-3138. [PMID: 33627250 DOI: 10.1016/j.injury.2021.02.040] [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: 11/18/2020] [Revised: 02/04/2021] [Accepted: 02/15/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Tibial shaft fractures are a commonly encountered challenge presented to orthopaedic trauma surgeons. Intramedullary nailing (IMN) is often the treatment of choice and whilst effective, complications of delayed and/or non-union can cause significant morbidity and necessitate additional operative procedures. The use of Poller screws during IMN are a recognised way of aiding fracture reduction, however the clinical benefits of this are debated. This study evaluated the outcome of tibial shaft fractures treated with IMN with or without the addition of Poller screws. METHODS Retrospective cohort study of all patients undergoing IMN following tibial shaft fractures over a 5-year period. 154 operated tibial shaft fractures were identified, with patients divided into 3 groups - Group 1: IM nailing alone, Group 2: IMN + 1 conventional Poller screw, or Group 3: IMN + 2 Poller screws placed Epicentrically across the fracture site. Data collected included demographics, length of stay, fracture type, position and AO classification grade, operative time, and operating surgeons' grade. Primary outcome measure was the incidence of delayed and/or non-union. Secondary outcomes were differences in rates of infection and additional orthopaedic procedures between the 3 groups. RESULTS Overall 139/154 fractures (90.3%) achieved a timely union. There was a statistically significant difference (p = 0.05) in fracture union between the 3 groups, with 75/88 fractures healing in group 1 (IMN alone) compared to 44/46 in Group 2 (IMN + 1 Poller screw) and 20/20 in group 3 (IMN + 2 Poller screws). There was no statistical difference in the incidence of superficial infection, (p = 0.95) additional procedures (p = 0.23) or deep infection (p = 0.65) between the 3 groups. CONCLUSION The addition of Poller screws appear to be a safe and effective adjunct in the treatment of tibial shaft fractures via IMN. Further prospective randomised trials are needed to fully elucidate both the role and potential benefits of Poller screw augmentation in acute lower limb fracture management.
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Affiliation(s)
- Fidel Peat
- Department of Trauma and Orthopaedic Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road CB2 0QQ Cambridge, Cambridgeshire, United Kingdom.
| | - Alejandro Ordas-Bayon
- Department of Trauma and Orthopaedic Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road CB2 0QQ Cambridge, Cambridgeshire, United Kingdom.
| | - Matija Krkovic
- Department of Trauma and Orthopaedic Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road CB2 0QQ Cambridge, Cambridgeshire, United Kingdom.
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20
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Evaluation of anatomical axis-joint center distance and anatomical axis-joint center ratio in distal femur and proximal tibia in coronal plane of Indian population. J Clin Orthop Trauma 2021; 21:101513. [PMID: 34367914 PMCID: PMC8326722 DOI: 10.1016/j.jcot.2021.101513] [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: 06/22/2021] [Revised: 07/12/2021] [Accepted: 07/18/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Radiographic evaluation of the anatomical geometry of the bone is important for executing reconstructive surgeries like deformity correction, limb lengthening and joint replacements. Various studies have been done in the past to define the anatomic placement of implant inside the bone. The aim of this study is to evaluate the distance between the anatomical axis and joint center of the distal femur (aJCD-f) and proximal tibia (aJCD-t) along with the ratio of anatomical axis-joint center distance of distal femur (aJCR-f) and proximal tibia (aJCR-t) of the skeletally mature individual of Indian population along with its application in day to day practice. METHODS Data is procured from the standard radiographs of the knee on large films. The anatomical axis is drawn on both sides of tibia and femur in a standard fashion. These lines intersect the horizontal drawn line at the intercondylar notch of femur and joint orientation line of the tibia. The aJCD-f, aJCD-t, aJCR-f, aJCR-t are then measured. Also the center of the inter-spinous distance of the tibia is measured from the anatomical axis (aSCD-t). RESULTS A total of 182 x-rays of skeletally mature individual were included with mean age of 46.35 ± 13.93 years. Of them 81 were males and 101 were females. There were 89 x-ray of left side and 93 x-ray of right side. The mean width of the femur at the intercondylar notch is found to be 76.78 mm (±7.40). The mean aJCD-f is found to be 3.87 mm (±2.44), aJCR-f to be 0.50 (±0.06). The mean width of the tibia is found to be 76.80 mm (±6.48). The aJCD-t is found to be 2.20 mm (±1.41), aJCR-t to be 0.50 (±0.03). The aSCD-t at the level of tibial spine is found to be -0.23 mm (±2.84). There was significant difference in the width of the femoral condyle of males 82.13 mm (±0.65) and females 72.48 mm (±0.55). Males showed mean aJCD-f of 3.59 mm (±2.42) and females showed 4.10 mm (±2.46). The aJCR-f is found to be significantly different between males 0.49 (±0.05) and females 0.51 (±0.07). There is significant difference between the width of the proximal tibia between males 80.83 mm (±0.68) and females 73.56 mm (±0.46). The aJCD-t of males and females is found to be 2.28 mm (±1.25) and 2.16 mm (±1.54) respectively. The aJCR-t is found to be significantly different between males 0.49 (±0.03) and females 0.50 (±0.04). While the mean distance of the anatomical axis from the lateral tibial spine is 0.23 mm lateral to the center of the inter-spinous distance and is found to be same in both males and females -0.23 mm (±2.84). CONCLUSION The coronal plane parameter like aJCD, aJCR of femur and tibia and aSCD-t of tibia can be a useful parameter to calculate in the 'real world' settings for reconstructive surgeries like deformity correction, nailing through the knee for femur and tibia as well as replacement surgeries around knee.
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21
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Williams KA, Thier ZT, Mathews CG, Locke MD. Physeal-Sparing Rigid Intramedullary Nailing in Adolescent Tibial Shaft Fractures: A Pilot Study. Cureus 2021; 13:e13893. [PMID: 33880249 PMCID: PMC8046697 DOI: 10.7759/cureus.13893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Purpose: Elastic stable intramedullary nailing (ESIN) and open reduction internal fixation (ORIF) are literature-supported operative treatments for displaced tibial shaft fractures in skeletally immature patients. Very little is written about rigid intramedullary nails (RIMNs) in adolescents. Our purpose is to describe a physeal-sparing, reamed, locked RIMN technique for adolescent tibial shaft fractures and report its safety. Methods: Adolescent patients with tibial shaft fractures indicated for operative intervention at one institution were retrospectively identified from 2011-2018. Patients were classified based on method of fracture fixation. Primary outcomes included fracture union, reoperation, and complication rates. Results: Thirteen patients were included in the RIMN arm, with an average age of 13.8 years. Two patients in the observational group underwent ESIN and seven patients underwent ORIF, with an average age of 11.5 years. Significant differences were found between time of immobilization (28 days vs 121 days), time to touch down weight bearing release (1 day vs 34 days), and hardware pain (2/13 vs 7/9). The RIMN group sustained fewer reoperations (2/13 vs 5/9). No differences were found in rates of complications or fixation failure between groups. Conclusions: Based on our small pilot study, RIMNs in adolescents should be considered as a potential treatment option when a physeal-sparing distal start point is utilized. Additionally, short-term follow-up suggests safety. Patients who underwent the RIMN procedure required fewer reoperations compared with the observational group. Overall, fracture healing was similar across the two groups. The benefits of RIMN include early immobilization and improved weight-bearing profile. Level of Evidence: IV.
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Affiliation(s)
- Kevin A Williams
- Orthopaedic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, USA
| | - Zachary T Thier
- Medical Education, Lincoln Memorial University DeBusk College of Osteopathic Medicine, Knoxville, USA
| | - Candler G Mathews
- Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Mark D Locke
- Orthopaedic Surgery, Prisma Health - University of South Carolina, Columbia, USA
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Packer TW, Naqvi AZ, Edwards TC. Intramedullary tibial nailing using infrapatellar and suprapatellar approaches: A systematic review and meta-analysis. Injury 2021; 52:307-315. [PMID: 32998824 DOI: 10.1016/j.injury.2020.09.047] [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: 05/31/2020] [Revised: 07/15/2020] [Accepted: 09/22/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intramedullary nailing of diaphyseal tibial fractures has become the gold standard method of fixation with high rates of union and low complication rates reported. The suprapatellar (SP) approach may have many advantages over the traditional infrapatellar (IP) approach. Controversy exists due to potential damage to the patellofemoral joint leading to persistent anterior knee pain. This systematic review and meta-analysis aims to evaluate the clinical and procedural outcomes of the SP approach in comparison to the traditional IP approach. METHOD In this PRISMA compliant systematic review and meta-analysis, five databases including MEDLINE, EMBASE, Web of Science, Cochrane Library and CINAHL were searched from inception until May 2020. Randomised controlled trials (RCTs) and comparative observational studies involving adults with tibial fractures treated with intramedullary nail fixation using either the suprapatellar or infrapatellar approach were included. Data extracted included demographics, functional knee scores, fluoroscopy exposure, insertional accuracy and adverse events. The primary outcome was validated functional knee scores. Risk of bias was calculated using the Cochrane risk of bias tool version 2 (RoB 2) and Newcastle-Ottawa Scale (NOS). RESULTS In total 16 studies were included consisting of 5 RCTs and 11 comparative observational studies. This included 1750 total operations with 810 in the SP group and 940 in the IP group. Meta-analysis was performed on the studies where appropriate data was reported. The SP approach demonstrated superior Lysholm scores (Mean Difference (MD) 5.63 [95% Confidence Interval (CI): 2.81 to 8.44]), reduced fluoroscopy times (MD -38.12 sec [95% CI: -47.96 to -28.28]) and increased entry point accuracy (Standard Mean Difference (SMD) -0.90 [95% CI: -1.22 to -0.59]). No differences in complication rates or blood loss were found. CONCLUSION Based on the data presented in this review, intramedullary nailing of the tibia using the SP approach demonstrates superior Lysholm knee scores, greater entry point accuracy and reduced fluoroscopy exposure with equivalent risk of developing complications when compared to the IP approach.
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Affiliation(s)
- Timothy W Packer
- Trauma and Orthopaedics Department, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, W2 1NY, UK..
| | - Ali Z Naqvi
- Trauma and Orthopaedics Department, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, W2 1NY, UK
| | - Thomas C Edwards
- Trauma and Orthopaedics Department, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, W2 1NY, UK.; MSk Lab, Imperial College London, London, UK
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Sperelakis I, Tsitoura E, Koutoulaki C, Mastrodimou S, Tosounidis TH, Spandidos DA, Antoniou KM, Kontakis G. Influence of reaming intramedullary nailing on MSC population after surgical treatment of patients with long bone fracture. Mol Med Rep 2020; 22:2521-2527. [PMID: 32705190 PMCID: PMC7411410 DOI: 10.3892/mmr.2020.11320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/09/2020] [Indexed: 11/22/2022] Open
Abstract
Reamed intramedullary nailing (RIN) is a surgical method of choice for treatment of diaphyseal fractures. This procedure affects the biological environment of bone tissue locally and systemically. This study investigated the influence of RIN on mesenchymal stem cells (MSCs) in patients with long bone fractures. The axis of C-X-C motif chemokine receptor 4 (CXCR4)/stromal cell-derived factor 1 (SDF-1) was selected since it is considered as major pathway for MSC homing and migration. Iliac crest bone marrow (IC-BM) samples and blood samples were collected at two different time points. One sample was collected before the RIN (BN) and the other immediately after RIN (AN). BM-MSCs were cultured and RT-qPCR was performed for CXCR4 mRNA levels and ELISA for the SDF-1 sera levels. The experimental study revealed that there was a correlation between the increase of SDF-1 levels in peripheral blood and a decrease in the levels of CXCR4 in MSCs in the IC-BM following RIN. The levels of SDF-1 showed a significant increase in the sera of patients after RIN. In conclusion, the present study is the first providing evidence of the effects of RIN on MSC population via the CXCR4/SDF-1 axis. The levels of serum SDF-1 factor were elevated after RIN while increased levels of SDF-1 in peripheral blood were inversely correlated with the mRNA levels of CXCR4 on BM-MSCs after RIN. Therefore, this study contributes to enlighten the systematic effects of RIN on the population of MSCs at a cellular level.
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Affiliation(s)
- Ioannis Sperelakis
- Department of Orthopedics and Traumatology, University of Crete School of Medicine, 71003 Heraklion, Greece
| | - Eliza Tsitoura
- Department of Respiratory Medicine, University General Hospital of Heraklion, Laboratory of Molecular and Cellular Pneumonology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Chara Koutoulaki
- Department of Respiratory Medicine, University General Hospital of Heraklion, Laboratory of Molecular and Cellular Pneumonology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Semeli Mastrodimou
- Department of Respiratory Medicine, University General Hospital of Heraklion, Laboratory of Molecular and Cellular Pneumonology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Theodoros H Tosounidis
- Department of Orthopedics and Traumatology, University of Crete School of Medicine, 71003 Heraklion, Greece
| | - Demetrios A Spandidos
- Laboratory of Clinical Virology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Katerina M Antoniou
- Department of Respiratory Medicine, University General Hospital of Heraklion, Laboratory of Molecular and Cellular Pneumonology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - George Kontakis
- Department of Orthopedics and Traumatology, University of Crete School of Medicine, 71003 Heraklion, Greece
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Lu K, Gao YJ, Wang HZ, Li C, Zhou TT, Qian RX, Shan HQ, Dong QR. A comparison of the use of a suprapatellar Chinese Aircraft-shaped Sleeve System versus suprapatellar intramedullary nailing for tibial shaft fractures: Outcomes over a one-year follow-up. Injury 2020; 51:1069-1076. [PMID: 32061356 DOI: 10.1016/j.injury.2020.01.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/06/2020] [Accepted: 01/20/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This study aimed to investigate the effectiveness and safety of the Chinese Aircraft-shaped Sleeve (CASS) system on the clinical outcomes of tibial intermedullary nailing using a suprapatellar approach for the treatment of tibial fractures in a cohort of adult Chinese patients over a minimum one-year follow-up. METHODS After institutional review board approval, skeletally mature patients with Orthopaedic Trauma Association (OTA) type 42 tibial shaft fractures were randomized into either a SP approach using CASS group or a conventional SP approach group after informed consent was obtained. The operations were performed by a single senior orthopaedic surgeon according to group assignments. A group of 33 patients were treated using the CASS system and the other group of 34 patients were treated using a conventional SP approach. Both groups fully complied with research requirements and completed 12 months of follow-up. Magnetic resonance images (MRI) were obtained for the evaluation of the patellofemoral joint (PFJ) and residual debris preoperatively, as well as one week and 12 months postoperatively. Radiographs were used to assess alignment and union, visual analog scores (VAS) were used to assess anterior knee pain, and range of motion (ROM) and the Lysholm knee scoring scales were used for evaluating the operated knee at the 12-month follow-up. RESULTS Differences in cartilage lesion changes observed by MRI between the two groups were statistically significant (P = 0.030 at 1 week postoperatively; P = 0.025 at 12 months postoperatively). No significant differences were evident with respect to debris residue, malalignments, nonunion, VAS, ROM and Lysholm knee scoring scale with the exception of stair climbing (P = 0.02). CONCLUSION Based on the data of this one-year clinical follow-up study, the SP approach using the CASS system offers the potential to benefit patients suffering from tibial shaft fractures, who will be treated with intramedullary nailing especially for smaller patients.
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Affiliation(s)
- Ke Lu
- Department of Orthopaedics, the Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, Jiangsu 215004, China; Department of Joint Surgery, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu 215300, China
| | - Yi-Jun Gao
- Department of Joint Surgery, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu 215300, China
| | - Hong-Zhen Wang
- Department of Joint Surgery, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu 215300, China
| | - Chong Li
- Department of Orthopaedics, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu 215300, China
| | - Ting-Ting Zhou
- Department of Radiology, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu 215300, China
| | - Rong-Xun Qian
- Department of Joint Surgery, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu 215300, China
| | - Hui-Qiang Shan
- Department of Orthopaedics, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu 215300, China
| | - Qi-Rong Dong
- Department of Orthopaedics, the Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, Jiangsu 215004, China.
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25
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Cain ME, Hendrickx LAM, Bleeker NJ, Lambers KTA, Doornberg JN, Jaarsma RL. Prevalence of Rotational Malalignment After Intramedullary Nailing of Tibial Shaft Fractures: Can We Reliably Use the Contralateral Uninjured Side as the Reference Standard? J Bone Joint Surg Am 2020; 102:582-591. [PMID: 31977824 DOI: 10.2106/jbjs.19.00731] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intramedullary (IM) nailing is the treatment of choice for most tibial shaft fractures. However, an iatrogenic pitfall may be rotational malalignment. The aims of this retrospective analysis were to determine (1) the prevalence of rotational malalignment using postoperative computed tomography (CT) as the reference standard; (2) the average baseline tibial torsion of uninjured limbs; and (3) based on that normal torsion, whether the contralateral, uninjured limb can be reliably used as the reference standard. METHODS The study included 154 patients (71% male and 29% female) with a median age of 37 years. All patients were treated for a unilateral tibial shaft fracture with an IM nail and underwent low-dose bilateral postoperative CT to assess rotational malalignment. RESULTS More than one-third of the patients (n = 55; 36%) had postoperative rotational malalignment of ≥10°. Right-sided tibial shaft fractures were significantly more likely to display external rotational malalignment whereas left-sided fractures were predisposed to internal rotational malalignment. The uninjured right tibiae were an average of 4° more externally rotated than the left (mean rotation and standard deviation, 41.1° ± 8.0° [right] versus 37.0° ± 8.2° [left]; p < 0.01). Applying this 4° correction to our cohort not only reduced the prevalence of rotational malalignment (n = 45; 29%), it also equalized the distribution of internal and external rotational malalignment between the left and right tibiae. CONCLUSIONS This study confirms a high prevalence of rotational malalignment following IM nailing of tibial shaft fractures (36%). There was a preexisting 4° left-right difference in tibial torsion, which sheds a different light on previous studies and current clinical practice and could have important implications for the diagnosis and management of tibial rotational malalignment. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Megan E Cain
- Department of Orthopaedics and Trauma Surgery, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Laurent A M Hendrickx
- Department of Orthopaedics and Trauma Surgery, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia.,Department of Orthopaedic Surgery, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - Nils Jan Bleeker
- Department of Orthopaedics and Trauma Surgery, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia.,Department of Orthopaedic Surgery, Universitair Medisch Centrum, Groningen, the Netherlands
| | - Kaj T A Lambers
- Department of Orthopaedics and Trauma Surgery, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia.,Department of Orthopaedic Surgery, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - Job N Doornberg
- Department of Orthopaedics and Trauma Surgery, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia.,Department of Orthopaedic Surgery, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - Ruurd L Jaarsma
- Department of Orthopaedics and Trauma Surgery, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
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Intramedullary nailing as an alternative to plate fixation in patients with distal fibular fracture. Orthop Traumatol Surg Res 2020; 106:149-154. [PMID: 31812634 DOI: 10.1016/j.otsr.2019.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 07/19/2019] [Accepted: 10/07/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND We examined whether the intramedullary nailing (IMN) can be used as an alternative modality to the plate fixation (PF) in patients with distal fibular fracture with displaced fragments. PATIENTS AND METHODS The eligible patients of two treatment arms (IMN group: n=30 and the group: n=31) were evaluated at 3, 6, 9 and 12 months postoperatively, for which functional outcome measures include differences in the American Orthopaedic Foot and Ankle Society Scores (AOFAS) and the Olerud Molander Ankle Scores (OMAS) between the two groups. In addition, radiological outcome measures include differences in radiological outcome scores at 12 months between the two groups. Differences in the percentage of frequency of postoperative complications between the two groups served as safety outcome measures. RESULTS At 3 months, the AOFAS and OMAS were significantly higher in the IMN group as compared with the PF group (p<0.0001 and p=0.0177, respectively). At 6 months, the AOFAS were significantly higher in the IMN group as compared with the PF group (p=0.0255). But there were no significant differences in the OMAS between the two groups (p=0.1077). At 9 and 12 months, there were no significant differences in the AOFAS and OMAS between the two groups (p=0.4334 and 0.3227, respectively at 9 months and p=0.8731 and 0.7610, respectively, at 12 months). These results indicate that the IMN group achieved a faster recovery as compared with the PF group. At 12 months, the radiological outcome scores were 3.67±0.60 in the IMN group and 3.71±0.52 in the PF group (p=0.7816). All the patients of each group achieved a bony union at 12 months. At 12 months, the percentage of frequency of postoperative complications was significantly lower in the IMN group as compared with the PF group (p=0.0227). CONCLUSIONS The IMN might be considered as an alternative surgical modality to the PF in patients with distal fibular fracture with displaced fragments. But further large-scale, multi-center studies are warranted to establish our results.
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Cui Y, Hua X, Schmidutz F, Zhou J, Yin Z, Yan SG. Suprapatellar versus infrapatellar approaches in the treatment of tibia intramedullary nailing: a retrospective cohort study. BMC Musculoskelet Disord 2019; 20:573. [PMID: 31779596 PMCID: PMC6883512 DOI: 10.1186/s12891-019-2961-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 11/20/2019] [Indexed: 01/29/2023] Open
Abstract
Background Tibial shaft fractures are routinely managed with intramedullary nailing (IMN). An increasingly accepted technique is the suprapatellar (SP) approach. The purpose of this study was to compare the clinical and functional outcomes of knee joint after tibia IMN through an suprapatellar (SP) or traditional infrapatellar (IP) approach. Methods Retrospective analysis was performed in patients with tibial shaft fractures that were treated with IMN through a SP or IP approach between 01/01/2014 and 31/12/2016. The clinical and functional outcomes of the knee were assessed with the Hospital for Special Surgery (HSS) Knee Score. Secondary outcomes included the operation time and intraoperative blood loss. Results A total of 50 patients/fractures (26 IP and 24 SP) with a minimum follow-up of 15 months were evaluated. All fractures were OTA 42. No significant differences were found between the two groups in age, gender, side of fractures, operation time, intra-operative blood loss, and follow-up time. No significant difference was seen in HSS score (P = 0.62) between them. Sub analysis of all the HSS components scores revealed no significant differences between pain (P = 0.57), the stand and walk (P = 0.54), the need for walking stick (P = 0.60) and extension lag (P = 0.60). The other HSS components showed full scores (IP 10 vs. SP 10) in both approaches, including muscle force, flexion deformity and stability components. The range of motion (ROM) component score was superior in the IP group (P = 0.04) suggesting a higher ROM. Conclusions Both SP and IP approach results in equivalent overall HSS knee scores. However, for the HSS component, the IP approach was superior to SP approach regarding the ROM.
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Affiliation(s)
- Yiliang Cui
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xingyi Hua
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Florian Schmidutz
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University of Munich (LMU), Munich, Germany.,BG Trauma Center, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Jian Zhou
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zongsheng Yin
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Shuang G Yan
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China.
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A novel adjustable locking plate (ALP) for segmental bone fracture treatment. Injury 2019; 50:1612-1619. [PMID: 31455505 DOI: 10.1016/j.injury.2019.08.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 08/15/2019] [Accepted: 08/19/2019] [Indexed: 02/02/2023]
Abstract
A novel Ti6Al4V adjustable locking plate (ALP) is designed to provide enhanced bone stability for segmental bone fractures and to allow precise positioning of disconnected segments. The design incorporates an adjustable rack and pinion mechanism to perform compression, distraction and segment transfer during plate fixation surgery. The aim of this study is to introduce the advantages of the added feature and computationally characterize the biomechanical performance of the proposed design. Structural strength of the novel plate is analyzed using numerical methods for 4-point bending and fatigue properties, following ASTM standards. An additional mechanical failure finite element test is also conducted on the rack and pinion to reveal how much torque can be safely applied to the mechanism by the surgeon. Simulation results predict that the new design is sufficiently strong to not fail under regular anatomical loading scenarios with close bending strength and fatigue life properties to clinically used locking compression plates. The novel ALP design is expected to be a good candidate for addressing problems regarding fixation of multi-fragmentary bone fractures.
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Xu H, Gu F, Xin J, Tian C, Chen F. A meta-analysis of suprapatellar versus infrapatellar intramedullary nailing for the treatment of tibial shaft fractures. Heliyon 2019; 5:e02199. [PMID: 31517106 PMCID: PMC6734195 DOI: 10.1016/j.heliyon.2019.e02199] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 05/16/2019] [Accepted: 07/29/2019] [Indexed: 12/28/2022] Open
Abstract
Background Whether the optimal treatment for tibial shaft fractures is suprapatellar intramedullary nailing or infrapatellar approach is controversial. Materials and methods PubMed, Embase, Cochrane, Web of science and CNKI, Wan fang Chinese databases were retrieved from their establishment to April 26, 2017. Seven studies (three randomized and four clinical controlled trials) were included in the final analysis. This meta-analysis included 683 patients with tibial shaft fracture (suprapatellar: 341; infrapatellar: 342). Results There was significant difference between suprapatellar and infrapatellar approach surgery in the incidence of knee pain (P = 0.003). The malalignment of the sagittal and coronal plane in suprapatellar surgery was more serious than in the infrapatellar approach (sagittal plane: P < 0.00001; coronal plane:P = 0.07). The infrapatellar approach surgery was more time-consuming than suprapatellar surgery (P = 0.01), with no significant difference in knee function score (P = 0.35). Conclusions Suprapatellar intramedullary nailing reduced the incidence of knee pain and the average malalignment of fractures compared to infrapatellar intramedullary nailing. It also reduced the operation time and fluoroscopy time. The results of the study should be interpreted with caution due to the heterogeneity of the study designs.
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Affiliation(s)
- Heng Xu
- Department of Orthopaedics, Zhejiang Veterans Hospital, No. 309, Shuang Yuan Road, Nanhu District, Jiaxing, Zhejiang, China
| | - Fushun Gu
- Department of Orthopaedics, The Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, NO. 816 Zhenli Road, Hebei District, 300150, Tianjin, China
| | - Jindang Xin
- Department of Orthopaedics, The Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, NO. 816 Zhenli Road, Hebei District, 300150, Tianjin, China
| | - Chengguang Tian
- Graduate School of Tianjin University of Traditional Chinese Medicine, NO. 312 West Anshan Road, Nankai District, 300193, Tianjin, China
| | - Fei Chen
- Graduate School of Tianjin University of Traditional Chinese Medicine, NO. 312 West Anshan Road, Nankai District, 300193, Tianjin, China
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Valsamis EM, Iliopoulos E, Williams R, Trompeter A. Suprapatellar tibial nailing: a learning curve analysis. Eur J Trauma Emerg Surg 2019; 46:1107-1113. [PMID: 31256209 DOI: 10.1007/s00068-019-01177-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/20/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE The suprapatellar approach for intramedullary nailing of tibial fractures is gaining popularity with reported improved patient outcomes when compared to infrapatellar techniques. The aim of this study was to investigate the learning curve of the suprapatellar technique using radiation exposure as an outcome measure. METHODS Data were analysed from a prospectively collected database over a 3-year period at a Major Trauma Centre in the United Kingdom. 83 study patients with an acute isolated extra-articular fracture of the tibia treated with intramedullary tibial nailing were included. Cases requiring additional intra-operative procedures were excluded. Four consultant trauma surgeons with no previous experience of the suprapatellar technique used this approach for 40 consecutive operations. Six consultant trauma surgeons used the infrapatellar approach for 43 patients and acted as a control group. Patient demographics, fluoroscopy time and radiation dose area product (DAP) were collected for each operation. A segmented linear regression modelling method was employed to analyse learning. RESULTS Fluoroscopy time and DAP per surgeon showed no evidence of a learning curve when using a suprapatellar tibial nailing technique in group or individual analysis. Fluoroscopy time and DAP were stationary in the infrapatellar group analysis, confirming the absence of time-dependent trends over the study period. CONCLUSIONS Consultant trauma surgeons experienced no significant learning-related increase in radiation exposure when introducing a suprapatellar technique for intramedullary nailing of uncomplicated tibial fractures. Future work is required to investigate the effects of learning on other outcome measures.
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Affiliation(s)
- Epaminondas Markos Valsamis
- Trauma and Orthopaedics Department, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton, BN2 5BE, UK.
| | - Efthymios Iliopoulos
- Trauma and Orthopaedics Department, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - Rachel Williams
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - Alex Trompeter
- Trauma and Orthopaedics Department, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
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Williamson M, Iliopoulos E, Williams R, Trompeter A. Intra-operative fluoroscopy time and radiation dose during suprapatellar tibial nailing versus infrapatellar tibial nailing. Injury 2018; 49:1891-1894. [PMID: 30017180 DOI: 10.1016/j.injury.2018.07.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/15/2018] [Accepted: 07/04/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fractures of the tibial shaft are routinely managed with intramedullary nailing. An increasingly accepted technique is the suprapatellar extended leg method. The aim of this study was to investigate whether the suprapatellar tibial nailing technique offers shorter intraoperative fluoroscopy times and lower radiation doses when compared to the traditional infrapatellar technique. STUDY DESIGN AND METHODS Data from 200 consecutive intramedullary tibial nailing operations in our level 1 Major Trauma Centre were retrospectively collected from a prospective database (January 2014-December 2017). Only acute diaphyseal nailing procedures were included. The operations were performed by seven senior trauma consultants experienced in both suprapatellar and infrapatellar tibial nailing. The operations were divided into two groups: infrapatellar and suprapatellar. Intraoperative radiation time and dose data were collected. RESULTS A total of 90 cases were included and analysed. The majority of the patients were male (82%). 37 operations were infrapatellar and 53 were suprapatellar. Independent samples t-test revealed lower radiation time and dose for the suprapatellar group. The infrapatellar group had a mean radiation time of 129.7 ± 56.6 s versus 94.4 ± 47.9 s for the suprapatellar group. The infrapatellar group had a mean radiation dose (Dose Area Product) 53.6 ± 34.2 cGY cm2 versus 38.2 ± 26.7 cGY cm2 for the suprapatellar group. The difference in mean radiation time and mean radiation dose were both significant (p = 0.002 and p = 0.02 respectively). CONCLUSIONS Suprapatellar tibial nailing is an increasingly accepted technique in the management of tibial fractures. It is shown here that amongst surgeons experienced in both suprapatellar and infrapatellar nailing techniques, the suprapatellar approach trends towards lower use of intra-operative fluoroscopy as measured by time and dose and thus potentially lower radiation exposure to the operating surgeon, assistants and patient.
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Affiliation(s)
- M Williamson
- Trauma & Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| | - E Iliopoulos
- Trauma & Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| | - R Williams
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| | - A Trompeter
- Trauma & Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
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Bleeker NJ, Cain M, Rego M, Saarig A, Chan A, Sierevelt I, Doornberg JN, Jaarsma RL. Bilateral Low-Dose Computed Tomography Assessment for Post-Operative Rotational Malalignment After Intramedullary Nailing for Tibial Shaft Fractures: Reliability of a Practical Imaging Technique. Injury 2018; 49:1895-1900. [PMID: 30097311 DOI: 10.1016/j.injury.2018.07.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/05/2018] [Accepted: 07/26/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study is to evaluate the intra- and inter-observer reliability of low-dose protocolled bilateral postoperative Computed Tomography (CT)-assessment of rotational malalignment after intramedullary nailing (IMN) of tibial shaft fractures. MATERIALS AND METHODS 156 patients were prospectively included with tibial shaft fractures that were treated with IMN in a Level-I Trauma Centre. All patients underwent post-operative bilateral low-dose CT-assessment (effective dose of 0.03784 - 0.05768 mGy) as per hospital protocol. Four observers performed the validated reproducible measurements of tibial torsion in degrees, based on standardized techniques. The Intra-Class Coefficient (ICC) was calculated to evaluate intra- and inter-observer reliability. The intra- and inter-observer reliability was categorized according to Landis and Koch. RESULTS Intra-observer reliability for quantification of rotational malalignment on post-operative CT after IMN of tibial shaft fractures was excellent with 0.95 (95% CI = 0.92-0.97). The overall inter-observer reliability was 0.90 (95% CI = 0.87-0.92), also excellent according Landis and Koch. CONCLUSION Firstly, bilateral post-operative low-dose -similar radiation exposure as plain chest radiographs- CT assessment of tibial rotational alignment is a reliable diagnostic imaging modality to assess rotational malalignment in patients following IMN of tibial shaft fractures and it allows for early revision surgery. Secondly, it may contribute to our understanding of the incidence-, predictors- and clinical relevance of post-operative tibial rotational malalignment in patients treated with IMN for a tibial shaft fracture, and facilitates future studies on this topic.
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Affiliation(s)
- Nils Jan Bleeker
- Research Fellow, Department of Orthopaedics and Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, Australia.
| | - Megan Cain
- Flinders Medical Centre, Department of Orthopaedics and Trauma Surgery, Adelaide, Australia.
| | - Mariana Rego
- Flinders Medical Centre, Flinders University, Adelaide, Australia.
| | - Aimane Saarig
- Research Fellow, Department of Orthopaedics and Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, Australia; Academisch Medisch Centrum Amsterdam, University of Amsterdam, The Netherlands.
| | - Andrew Chan
- Flinders Medical Centre, Flinders University, Adelaide, Australia.
| | | | - Job N Doornberg
- Postdoc Fellow, Deparment of Orthopaedic Surgery, Academisch Medisch Centrum Amsterdam, The Netherlands; Orthopaedic Trauma Fellow, Flinders Medical Centre, Adelaide, Australia; Associate Professor, Flinders University, Adelaide, Australia.
| | - Ruurd L Jaarsma
- Consultant Orthopaedic Surgeon, Department of Orthopaedics and Trauma Surgery, Flinders Medical Centre, Adelaide, Australia; Professor of Orthopaedics and Trauma Surgery, Flinders University, Adelaide, Australia.
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Minimally Invasive Treatment for Tibial Malrotation after Locked Intramedullary Nailing. Case Rep Orthop 2018; 2018:4190670. [PMID: 30210886 PMCID: PMC6126075 DOI: 10.1155/2018/4190670] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 07/16/2018] [Accepted: 07/22/2018] [Indexed: 11/23/2022] Open
Abstract
Rotational malreduction is a potential complication of intramedullary nailing for tibial shaft fractures. We experienced a symptomatic case of a 24° externally rotated malunion that we treated with minimally invasive corrective osteotomy. A 49-year-old man sustained a tibial shaft spiral fracture with a fibula fracture. He had been initially treated elsewhere with a reamed statically locked intramedullary nail. Bone union had been obtained, but he complained of asymmetry of his legs, difficulty walking and running, and the inability to ride a bicycle. We decided to perform corrective osteotomy in a minimally invasive fashion. After a 1 cm incision was made at the original fracture site, osteotomy for the affected tibia was performed with an osteotome after multiple efforts at drilling around the nail with the aim of retaining it. Fibula osteotomy was also performed at the same level. Two Kirschner wires that created an affected rotational angle between the fragments were inserted as a guide for correction. The distal locking screws were removed. Correct rotation was regained by matching the two wires in a straight line. Finally, the distal locking screws were inserted into new holes. The patient obtained bony union and has returned to his preinjury activities with no symptoms.
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Ozcan C, Turkmen I, Sokucu S. Comparison of three different approaches for anterior knee pain after tibia intramedullary nailing. Eur J Trauma Emerg Surg 2018; 46:99-105. [PMID: 30039307 DOI: 10.1007/s00068-018-0988-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 07/17/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The aim of this study was to compare anterior knee pain and functional outcomes in patients who underwent intramedullary tibial nailing using transpatellar, medial parapatellar or suprapatellar nail entry methods. METHODS We retrospectively reviewed patients who underwent tibial fracture repair in our clinic between January 2010 and March 2017. After applying the exclusion criteria, 58 patients were included in the study. Patients were divided into 3 groups based on the nailing approach: medial parapatellar, transpatellar or suprapatellar. Age, body mass index, follow-up duration, Kujala Score, Lysholm Knee Score, anterior knee pain, length of hospitalization and surgical duration were assessed. RESULTS Of the 58 patients studied, 21 underwent a transpatellar (TP) approach, 16 a medial parapatellar (MP) approach, and 21 a suprapatellar (SP) approach. The mean Kujala Score of patients who had the TP approach was 80 ± 7.15 (72-93) and the average Lysholm Knee Score was 80.23 ± 8.74 (70-95). There was no statistically significant difference between Kujala Scores (p = 0.38) or Lysholm Knee Scores (p 0.06) among the groups; similarly, no statistically significant difference was found among the three groups in terms of anterior knee pain, length of hospitalization or surgical duration (p > 0.05). CONCLUSION The suprapatellar tibia nailing method is as safe and reliable as transpatellar and medial parapatellar methods in terms of effect on postoperative anterior knee pain and functional outcomes. LEVEL OF EVIDENCE Level 3 case-control study.
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Affiliation(s)
- Cagri Ozcan
- Department of Orthopaedics and Traumatology, SBU Umraniye Training and Research Hospital, Elmalikent mh, Umraniye, 34764, Istanbul, Turkey.
| | - Ismail Turkmen
- Department of Orthopaedics and Traumatology, SBU Umraniye Training and Research Hospital, Elmalikent mh, Umraniye, 34764, Istanbul, Turkey
| | - Sami Sokucu
- Department of Orthopaedics and Traumatology, Istanbul Aydın University Medical Park Florya Hospital, Akasya Sk, Kucukcekmece, 34295, Istanbul, Turkey
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Yang L, Sun Y, Li G. Comparison of suprapatellar and infrapatellar intramedullary nailing for tibial shaft fractures: a systematic review and meta-analysis. J Orthop Surg Res 2018; 13:146. [PMID: 29898758 PMCID: PMC6001044 DOI: 10.1186/s13018-018-0846-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/28/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Optimal surgical approach for tibial shaft fractures remains controversial. We perform a meta-analysis from randomized controlled trials (RCTs) to compare the clinical efficacy and prognosis between infrapatellar and suprapatellar intramedullary nail in the treatment of tibial shaft fractures. METHODS PubMed, OVID, Embase, ScienceDirect, and Web of Science were searched up to December 2017 for comparative RCTs involving infrapatellar and suprapatellar intramedullary nail in the treatment of tibial shaft fractures. Primary outcomes were blood loss, visual analog scale (VAS) score, range of motion, Lysholm knee scores, and fluoroscopy times. Secondary outcomes were length of hospital stay and postoperative complications. We assessed statistical heterogeneity for each outcome with the use of a standard χ2 test and the I2 statistic. The meta-analysis was undertaken using Stata 14.0. RESULTS Four RCTs involving 293 participants were included in our study. The present meta-analysis indicated that there were significant differences between infrapatellar and suprapatellar intramedullary nail regarding the total blood loss, VAS scores, Lysholm knee scores, and fluoroscopy times. CONCLUSION Suprapatellar intramedullary nailing could significantly reduce total blood loss, postoperative knee pain, and fluoroscopy times compared to infrapatellar approach. Additionally, it was associated with an improved Lysholm knee scores. High-quality RCTs were still required for further investigation.
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Affiliation(s)
- Liqing Yang
- Department of orthopedics, Shengjing Hospital of China Medical University, Shenyang, 110004 China
| | - Yuefeng Sun
- Department of orthopedics, Shengjing Hospital of China Medical University, Shenyang, 110004 China
| | - Ge Li
- Department of orthopedics, Shengjing Hospital of China Medical University, Shenyang, 110004 China
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Abstract
Open fractures of the lower extremity are the most common open long bone injuries, yet their management remains a topic of debate. This article discusses the basic tenets of management and the subsequent impact on clinical outcome. These include the rationale for initial debridement, antimicrobial cover, addressing the soft-tissue injury and definitive skeletal management. The classification of injury severity continues to be a useful tool in guiding treatment and predicting outcome and prognosis. The Gustilo-Anderson classification continues to be the mainstay, but the adoption of severity scores such as the Ganga Hospital score may provide additional predictive utility. Recent literature has challenged the perceived need for rapid debridement within 6 hours and the rationale for prolonged antibiotic therapy in the open fracture. The choice of definitive treatment must be decided against known efficacy and injury severity/type. Recent data demonstrate better outcomes with internal fixation methods in most open tibial fractures, but external fixation continues to be an appropriate choice in more severe injuries. The incidence of infection and non-union has decreased with new treatment approaches but continues to be a source of significant morbidity and mortality. Assessment of functional outcome using various measures has been prevalent in the literature, but there is limited consensus regarding the best measures to be used.
Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170072
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Affiliation(s)
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, University of Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, UK
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Intramedullary nailing in opening wedge high tibial osteotomy-in vitro test for validation of a method of fixation. INTERNATIONAL ORTHOPAEDICS 2018; 42:1835-1843. [PMID: 29392383 DOI: 10.1007/s00264-018-3790-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/18/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE Opening wedge high tibial osteotomy (HTO) as a treatment in unicompartimental osteoarthritis of the knee can significantly relieve pain and prevent or at least delay an early joint replacement. The fixation of the osteotomy has undergone development and refinements during the last years. The angle-stable plate fixator is currently one of the most commonly used plates in HTOs. The angular stable fixation between screws and the plate offers a high primary stability to retain the correction with early weight-bearing protocols. This surgical technique is performed as a standard of care and generally well tolerated by the patients. Nevertheless, some studies observed that many patients complained about discomfort related to the implant. METHODS Therefore, the stability of two different intramedullary nails, a short implant used in humeral fractures and a long device used in tibial fractures for stabilization in valgus HTOs, was investigated as an alternative fixation technique. The plate fixator was defined as reference standard. Nine synthetic tibia models were standardly osteotomized and stabilized by one of the fixation devices. Axial compression was realized using a special testing machine and two protocols were performed: a multi-step fatigue test and a load-to-failure test. RESULTS Overall motion, medial, and lateral displacements were documented. Fractures always occurred at the lateral cortex. Axial cyclic loading up to 800 N was tolerated by all implants without failure. The tibia nail provided highest fatigue strength under the load-to-failure conditions. CONCLUSIONS The results suggest that intramedullary nailing might be used as an alternative concept in HTO.
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"Clothesline technique" for proximal tibial shaft fracture fixation using conventional intramedullary nail: a simple, useful, and inexpensive technique to prevent fracture malalignment. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:721-725. [PMID: 29362975 DOI: 10.1007/s00590-018-2131-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 12/31/2017] [Indexed: 10/18/2022]
Abstract
Treatment of proximal tibial shaft fractures is always challenging. Despite the development of modern techniques, the literature still shows high complication rates, especially regarding proximal fragment malalignment. It is well known that knee position in flexion during tibial nailing is responsible for extension and valgus deformities of the proximal fragment. Unlike in tibial shaft fractures, nails do not reduce proximal tibial fractures due to the medullary canal width. This study aims to describe a simple, useful, and inexpensive technique to prevent valgus and extension deformities when treating proximal tibial fractures using conventional nails: the so-called clothesline technique.
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