The morphological and morphometric analysis of the variant patterns of the tricipital aponeurosis: a new anatomical classification with possible clinical implications.

BACKGROUND: Tricipital aponeurosis (TA) has gained attraction as a constant and reliable landmark to identify the location of radial nerve in the setting of fracture distal humeri. The aponeurosis itself shows variant anatomical patterns. In this study, we intend to provide a comprehensive description and functional classification of observed anatomical variations with possible clinical implications. MATERIALS AND METHODS: Sixty arms belonging to 30 adult cadavers were studied. TA was examined grossly to document variations in its shape and classified accordingly. Subsequently, length and breadth of TA were measured. The distance of the radial nerve (RN) from the point of confluence and from the lateral border of TA was also measured (tricepso-radial distance [TRD]). These distances were correlated with the different patterns of TA obtained. RESULTS: Based on the shape of the proximal apex of TA or point of confluence and frequency of their occurrence, we propose a new classification of 4 patterns for the TA anatomy. Pattern I: classically seen as the triangular proximal apex (76.67%); pattern II: tongue shaped or blunt proximal apex (18.33%); pattern III: bifurcated or dual proximal apex (3.33%); pattern IV: as the absence of TA (1.67%). The mean of length and breadth of TA was 16.58 ± 2.05 cm and 3.61 ± 0.61 cm, respectively. The mean distance of RN from point of confluence and lateral border of TA was 3.57 ± 0.19 cm and 2.04 ± 0.56 cm, respectively. The length, breadth of TA and TRD differs amongst the different patterns of TA. CONCLUSIONS: Anatomical variations in the shape and size of TA are frequently encountered. The proposed, hitherto undescribed, classification may make operating surgeon aware of these morphological variations and help prevent iatrogenic injury to RN. Such classification is simple and unique; however, its success relies upon universal acceptance.

Innervation of digital joints: an anatomical overview.

INTRODUCTION: The innervation of the digital joints as well as the anatomical relationships of the articular branches is present in this anatomical work to determine the technical feasibility of a selective and efficient denervation of the digital joints. MATERIALS AND METHODS: A study of 40 distal interphalangeal (DIP), 40 proximal interphalangeal (PIP), 50 metacarpophalangeal (MCP), 10 interphalangeal (IP) of the thumb, and 10 trapezo-metacarpophalangeal (TMC) joints was performed on ten hands. Under magnification and a proper surgical approach, we collected the course, the source origin, the number of articular nerve branches, and their caliber. RESULTS: In total, 118 nerve branches arising from the proper palmar digital nerves were found on 10 DIP of each dissected long finger (n = 40). A total of 226 nerve branches were found on 10 PIPs of each long finger (n = 40), of which 204 branches (90.3%) had a palmar origin. Dorsal innervation was found for the ring and little finger, originating from the dorso-ulnar digital nerve. 212 branches were found on 10 MCP of long fingers (n = 40), including 87 branches of palmar origin (41.1%), 107 branches of dorsal origin (50.4%), and 18 branches of the motor branch of the ulnar nerve (8.5%). 42 articular branches directed to the TMC joint (n = 10) were found. 13 branches (31%) originated from the anterior sensory branch of the radial nerve, 13 branches (31%) originated from the lateral cutaneous nerve of the forearm, 5 branches (12%) originated from the palmar cutaneous branch of the median nerve, and 11 (26%) branches originated from the thenar branch of the median nerve. The involvement of the sensory anterior branch of the radial nerve was always present for the innervation of each TMC. DISCUSSION AND CONCLUSION: Our research shows that finger joints receive their primary innervation from small branches of the digital nerves with the exception of the MCP joint and the TMC joint. To obtain an efficient and a selective digital denervation for articular pain relief, it is necessary to plan the best surgical approach and it is crucial to recognize the articular nervous branch localization and source.

The position of the upper limb during shoulder arthroscopy does not affect the distance between axillary nerve and glenoid.

PURPOSE: The segment of the axillary nerve (AxN) near the glenoid rim is at risk of iatrogenic lesion during arthroscopic procedures. We hypothesize that the distance between the AxN and the glenoid rim is not modified by the patient's positioning. The primary objective was to compare the position of the AxN with the inferior glenoid rim in lateral decubitus or in beach chair and positions of the upper limb. METHODS: Sixteen shoulders were dissected in beach chair position with the shoulder in neutral rotation. Needle one was placed in the axillary nerve where it was the closest with the inferior glenoid rim. In lateral decubitus with traction and 70° of abduction needle two was placed in the AxN at the closest with the inferior glenoid rim. The glenoid rim was marked with a needle at 6 o'clock. In beach chair position, the distance between needle one and the glenoid needle was measured for six positions. In lateral decubitus, measures were done for two positions of abduction. In lateral decubitus with 70° of abduction, the distance between needle two and the glenoid needle was also measured. RESULTS: The mean distance between AxN and the inferior glenoid rim was 14.4 mm in reference position in beach chair. The results showed the absence of difference between the positions during surgery except for lateral decubitus with 70° of abduction. CONCLUSION: Our study showed that the position of the shoulder during arthroscopic procedures cannot take away the AxN from the inferior glenoid rim. LEVEL OF EVIDENCE: Level IV-basic science study.

Vascularization of the superficial circumflex iliac perforator flap (SCIP flap): an anatomical study.

INTRODUCTION: The superficial circumflex iliac artery perforator flap (SCIP) has gained widespread popularity as local or free flap to cover soft tissue defects. However, there are numerous anatomical variations in terms of size, location and reliability of its perforators This cadaveric study aimed to focus on the anatomical bases of this flap. MATERIALS AND METHODS: A bilateral dissection of seven cadavers was performed to harvest 14 flaps. Superficial circumflex iliac artery parameters, number, length and diameters of perforators were measured. Correspondent perforasomes were highlighted through semi-selective injections. RESULTS: The major perforator of the superficial branch had a mean caliber of 2.0 mm, and a mean length of 1.8 mm. The major perforator of the deep branch had a mean caliber of 2.1 mm and a mean length of 1.43 mm. The mean area of the superficial pattern perforasome was 178.6 cm2 and the mean measured surface of the deep pattern perforasome was 156.2 cm2. The descending branches of the deep branch anastomosing with the ascending branch of the lateral circumflex femoral artery were found in three cases. CONCLUSION: Several anatomical variations were observed in this anatomical study, but major perforators supplying large perforasomes were always found.

Anatomy of the cutaneous lymphatic system of the trunk: a clinico-anatomical study of 90 cutaneous melanomas.

PURPOSE: The cutaneous lymphatic system of the trunk is a complex network, the anatomical knowledge of which remains unclear. The lymphatic system plays a major role in the dissemination of lymphophilic cancers like melanomas. The aim of this study was to improve our knowledge, optimize the care of patients with cutaneous tumors of the trunk, and to use our clinical experience of the topography of pathologic lymph nodes related to cutaneous melanomas and depicted by lymphoscintigraphy. MATERIALS AND METHODS: This prospective study included 90 consecutive patients who had primary resection of cutaneous melanoma of the trunk between June 2011 and January 2015. All patients had lymphatic mapping by lymphoscintigraphy, followed by sentinel lymph node procedure. We compared data of lymphatic imaging (lymphoscintigraphy and SPECT-CT) and surgery. We divided the trunk into 36 regions based on cutaneous anatomical landmarks to determine the topography of the lymphatic system for each tumor. RESULTS: Our study showed cutaneous lymphatic drainage of melanomas of the trunk in 16 different areas. This drainage could be single or multiple. We observed that drainage could be controlateral in medial regions of the trunk, and lymphatic pathway could be retrograde. This drainage could be bilateral for medial regions and mainly into axillary areas for regions above L1 level. Posterior regions of the trunk had more diversity of drainage areas than anterior regions. CONCLUSIONS: Cutaneous lymphatic drainage of the trunk was not limited to axillary and inguinal areas, showed interindividual variability, and was single or multiple, unilateral or bilateral, and unpredictable.

[Original three-dimensional reconstruction of a case of metopism associated with a unilateral complete absence of the left frontal sinus: Clinical interest and review of the literature]. / Représentation tridimensionnelle originale d'un cas de métopisme associé à une agénésie unilatérale complète du sinus frontal gauche : intérêt clinique et revue de la littérature.

Metopism (complete persistence of the metopic suture in adults) is a rare but not exceptional variation of the calvaria. Hypoplasia or aplasia of the frontal sinus may be associated without evident correlation. Nevertheless, a misdiagnosis of these variations may have clinical consequences, especially in a traumatic context. The aim of this paper was to report a case of metopism associated with a unilateral aplasia of the left frontal sinus, originally illustrated with 3D image fusion volume rendering reconstructions.

Validity of rotational laxity coupled with anterior translation of the knee: A cadaveric study comparing radiostereometry and the Rotab®.

BACKGROUND: In current practice, anterior cruciate ligament (ACL) tears can be diagnosed using several devices to measure anterior tibial translation and rotational knee laxity, but these measures are never collected together. The Rotab®, which yields simultaneous measurements of anterior tibial translation and passive lower limb rotation under stress, would therefore be advantageous in current practice, but its reliability has never been tested. AIM OF STUDY: To evaluate the accuracy and reliability of the Rotab® compared to the reference system, radiostereometric analysis (RSA). METHODS: This anatomical study was conducted on 14 lower limbs collected from fresh cadavers. Simultaneous measurements of anterior tibial translation and rotation were obtained with both systems, with antero-posterior (AP) forces of 134N and 250N using the Rotab®. Measurements were made on intact ACL and then repeated after ACL section. Variables were analyzed in univariate analysis by ANOVA, and the intraclass correlation coefficient (ICC) between the systems was determined by the Bland and Altman method. RESULTS: The difference between the two methods for evaluating anterior tibial translation was 0.05±0.98mm at 134N and 0.29±1.04mm at 250N. The correlation between the tests was high (r134=r250=0.97, p=0.8). The difference between the two methods for rotational laxity was 0.69±2.7° at 134N and 0.5±0.6° at 250N. The Rotab® showed a significant difference only at 250N for rotational laxity after the ACL tear. CONCLUSION: The Rotab® is a reliable device to measure rotational laxity coupled with anterior translation of the knee.

Do temperature variations at the bearing surface during gait affect polyethylene wear in Charnley low-friction arthroplasty of the hip? Simulator study comparing UHMWPE and highly cross-linked polyethylene.

INTRODUCTION: There are significant individual variations in the polyethylene (PE) wear of Charnley total hip arthroplasty (THA) in published studies. This could be in part related to variations in hip joint kinematics with abnormal heating at the metal/PE interface. The objectives of our hip simulator experiment were: (1) to measure PE wear as a function of hip kinematics and temperature variations at the interface; (2) to compare ultra-high molecular weight polyethylene (UHMWPE) to latest generation highly cross-linked PE (XLPE). HYPOTHESIS: Our hypothesis was that PE wear is correlated with temperature increases at the interface and thereby hip joint kinematics. MATERIAL AND METHODS: A simulator study was performed with four UHMWPE cups (Initiale™, Amplitude, Valence, France) and two XLPE cups (X3, Stryker, Kalamazoo, Michigan, USA) subjected to 5 million cycles each. The temperature at the femoral head/cup interface was measured every 500 cycles and implant dimensions were measured every 1 million cycles. RESULTS: The average temperature was 42°C for 1Hz and 50°C for 1.5Hz, no matter the type of PE tested. There was a large difference between UHMWPE and XLPE in their roughness, but no temperature variations or wear effects. Femoral head penetration after the first 1 million cycles was 0.18mm for the XLPE and 0.075mm UHMWPE on average. Between 1 and 5 million cycles, the penetration was less than 0.1mm per million cycles, with XLPE being similar to UHMPWE. DISCUSSION: Our study found a significant temperature increase at the bearing interface as a function of frequency. But there was no correlation between temperature variations and PE degradation. However, shear stresses were under-estimated because our simulator could not reproduce abduction and adduction movements. Our hypothesis was not confirmed because PE deformation was not correlated to temperature variations. XLPE was not better than UHMWPE in the particular conditions of this study. Simulator studies are limited because of the lack of standards on cycling and the simulator bath. LEVEL OF EVIDENCE: III-prospective case-control study in vitro.

Reliability of radiographic measurements for acromioclavicular joint separations.

INTRODUCTION: The treatment of acromioclavicular (AC) joint separations is controversial, particularly for Rockwood type III injuries. Rockwood type IV injuries, which correspond to horizontal instability, are very likely under-diagnosed. The objective of this study was to evaluate the inter- and intra-observer reproducibility of the Rockwood classification through an evaluation of standard radiographs, as described in the original article. MATERIAL AND METHODS: This was a prospective radiographic study using protocol-based data from the 2014 symposium of the French Society of Arthroscopy (SFA). Fifteen anonymized radiological records were analysed by six independent examiners on two occasions, 1 week apart. The records consisted of a comparative A/P view of the two acromioclavicular joints (Zanca view), an axillary lateral view and dynamic lateral views (Tauber protocol) to uncover dynamic horizontal instability. A detailed analysis protocol was implemented that included absolute and relative measurements on each view; the relative measurements were used to account for radiographic magnification. RESULTS: The inter- and intra-observer reproducibility on the A/P radiographs was good to excellent. The reproducibility was fair to good on the lateral views, but the measurements varied greatly from one subject to another, and significant errors were found with certain records. The reproducibility of the dynamic views proposed by Tauber was poor to fair. DISCUSSION: Radiographic analysis of AC joint separations is reproducible in the vertical plane, which makes it possible to diagnose Rockwood type II, III and V injuries. On the other hand, static and dynamic analyses in the horizontal plane do not have good reproducibility and do not contribute to make an accurate diagnosis of Rockwood type IV injuries. LEVEL OF EVIDENCE: Level I, Diagnostic study.

Complication rates and types of failure after arthroscopic acute acromioclavicular dislocation fixation. Prospective multicenter study of 116 cases.

AIMS: To report and analyze both the surgical and radiographic complications associated with anatomic coracoclavicular (CC) ligament procedures and to evaluate the effect of these complications on patient outcomes. PATIENTS AND METHODS: From July 2012 to July 2013, 116 primary anatomic CC ligament procedures (all arthroscopic endobutton fixations) were performed in 14 different centers. Demographic, surgical, subjective, and radiographic data were prospectively analyzed in 14 centers with a minimum follow-up of 12 months. RESULTS: This series included 96 men and 20 women, mean age 37 years old, with a mean delay to surgery of 10 days. No intraoperative complications were reported. There were 11 complications due to hardware failure resulting in a loss of reduction, 1 coracoid fracture, 7 cases of adhesive capsulitis, 2 local infections, 5 cases of hardware pain. There were significant differences in outcomes between patients who did and did not develop complications: mean CS=71 vs. 93, (P<0.0001). All the parameters of the CS were statistically affected (P<0.0001). Forty-eight patients had persistent dislocation>150% on an AP X-ray which affected the pain and activity CS (P=0.023 and P=0.044). No preoperative predictive factors were identified. These patients could not return to the same level of sports activities due to persistent pain. DISCUSSION: Anatomic procedures to treat AC joint dislocation using CC ligament reconstruction resulted in an overall complication rate of 22.4% and influenced the return to sports. Good to excellent outcomes were reported in patients without complications. CLINICAL SERIES: Level of evidence 4.

Is coracoclavicular stabilisation alone sufficient for the endoscopic treatment of severe acromioclavicular joint dislocation (Rockwood types III, IV, and V)?

BACKGROUND: The primary objective was to evaluate correlations linking anatomical to functional outcomes after endoscopically assisted repair of acute acromioclavicular joint dislocation (ACJD). HYPOTHESIS: Combined acromioclavicular and coracoclavicular stabilisation improves radiological outcomes compared to coracoclavicular stabilisation alone. MATERIAL AND METHODS: A prospective multicentre study was performed. Clinical outcome measures were pain intensity on a visual analogue scale (VAS), subjective functional impairment (QuickDASH score), and Constant's score. Anatomical outcomes were assessed on standard radiographs (anteroposterior view of the acromioclavicular girdle and bilateral axillary views) obtained preoperatively and postoperatively and on postoperative dynamic radiographs taken as described by Tauber et al. RESULTS: Of 116 patients with acute ACJD included in the study, 48% had type III, 30% type IV, and 22% type V ACJD according to the Rockwood classification. Coracoclavicular stabilisation was achieved using a double endobutton in 93% of patients, and concomitant acromioclavicular stabilisation was performed in 50% of patients. The objective functional outcome was good, with an unweighted Constant's score ≥ 85/100 and a subjective QuickDASH functional disability score ≤ 10 in 75% of patients. The radiographic analysis showed significant improvements from the preoperative to the 1-year postoperative values in the vertical plane (decrease in the coracoclavicular ratio from 214 to 128%, p=10(-6)) and in the horizontal plane (decrease in posterior displacement from 4 to 0mm, p=5×10(-5)). The anatomical outcome correlated significantly with the functional outcome (absolute R value=0.19 and p=0.045). We found no statistically significant differences across the various types of constructs used. Intra-operative control of the acromioclavicular joint did not improve the result. Implantation of a biological graft significantly improved both the anatomical outcome in the vertical plane (p=0.04) and acromioclavicular stabilisation in the horizontal plane (p=0.02). The coracoclavicular ratio on the anteroposterior radiograph was adversely affected by a longer time from injury to surgery (p=0.02) and by a higher body mass index (BMI) (p=0.006). High BMI also had a negative effect on the difference in the distance separating the anterior edge of the acromion from the anterior edge of the clavicle between the injured and uninjured sides, as assessed on the axillary views (p=0.009). CONCLUSION: This study demonstrates that acute ACJD requires stabilisation in both planes, i.e., at the coracoclavicular junction and at the acromioclavicular joint. Coracoclavicular stabilisation alone is not sufficient, regardless of the type of implant used. Implantation of a biological graft should be considered when the time from injury to surgery is longer than 10days. The weight of the upper limb should be taken into account, with 6weeks of immobilisation to unload the construct in patients who have high BMI values. LEVEL OF EVIDENCE: II, prospective non-randomised comparative study.

Prognostic factors to succeed in surgical treatment of chronic acromioclavicular dislocations.

INTRODUCTION: Treatment of chronic acromioclavicular joint dislocation (ACJD) remains a poorly known and controversial subject. Given the many surgical options, it is not always easy to determine which steps are indispensable. METHODS: This article reports a multicenter prospective study. The clinical and radiological follow-up involved a comparative analysis of the preoperative and postoperative data at 1 year, including pain (visual analogue scale), subjective functional incapacity (QuickDASH), and the objective Constant score, as well as a comparative analysis of vertical and horizontal movements measured on simple x-rays. RESULTS: Based on a series of 140 operated ACJDs, we included 24 chronic ACJDs. The mean time to surgery was 46 weeks (range, 1 month to 4 years). The patients' mean age was 41 years, with a majority of males (75%), 72% of whom participated in recreational sports. Professionally, 40% of the subjects had jobs involving manual labor. We noted 40% grade III, 24% grade IV, and 36% grade V injury according to the Rockwood classification. In 92% of cases, coracoclavicular stabilization was provided by a double button implant, reinforced with a biological graft in 88% of the cases. In 29%, millimeters to centimeters of the distal clavicle were resected and acromioclavicular stabilization was associated in 54%. We observed complications in 33% of the cases. At 1 year postoperative, 21 patients underwent clinical and radiological follow-up (87.5%). Only 35% of the patients were satisfied or very satisfied, whereas 100% of them would recommend the operation. Full-time work was resumed in 91% of the cases and all sports could be resumed in 86%. The pre- and postoperative values at 1 year changed as follows: the mean Constant score improved from 61 to 87 (p=0.00002); the subjective QuickDASH score decreased from 41 to 9 (p=0.00002); and radiologically significant reduction of the initial displacement was observed in the vertical plane (p<10(-3)) and the horizontal plane (p=0.022). CONCLUSION: In this study, the favorable prognostic factors found were: time to surgery less than 3 months (p=0.02), associated acromioclavicular stabilization, and postoperative immobilization with a sling extended to 6 weeks. However, resection of the distal clavicle did not influence the final result. LEVEL OF PROOF: Level II prospective non-randomized comparative study.

Opening the medial tibiofemoral compartment by pie-crusting the superficial medial collateral ligament at its tibial insertion: a cadaver study.

BACKGROUND: Arthroscopic treatment of tears in the middle and posterior parts of the medial meniscus can be difficult when the medial tibiofemoral compartment is tight. Passage of the instruments may damage the cartilage. The primary objective of this cadaver study was to perform an arthroscopic evaluation of medial tibiofemoral compartment opening after pie-crusting release (PCR) of the superficial medial collateral ligament (sMCL) at its distal insertion on the tibia. The secondary objective was to describe the anatomic relationships at the site of PCR (saphenous nerve, medial saphenous vein). MATERIAL AND METHOD: We studied 10 cadaver knees with no history of invasive procedures. The femur was held in a vise with the knee flexed at 45°, and the medial aspect of the knee was dissected. PCR of the sMCL was performed under arthroscopic vision, in the anteroposterior direction, at the distal tibial insertion of the sMCL, along the lower edge of the tibial insertion of the semi-tendinosus tendon. Continuous 300-N valgus stress was applied to the ankle. Opening of the medial tibiofemoral compartment was measured arthroscopically using graduated palpation hooks after sequential PCR of the sMCL. RESULTS: The compartment opened by 1mm after release of the anterior third, 2.3mm after release of the anterior two-thirds, and 3.9mm after subtotal release. A femoral fracture occurred in 1 case, after completion of all measurements. Both the saphenous nerve and the medial saphenous vein were located at a distance from the PCR site in all 10 knees. DISCUSSION: PCR of the sMCL is chiefly described as a ligament-balancing method during total knee arthroplasty. This procedure is usually performed at the joint line, where it opens the compartment by 4-6mm at the most, with some degree of unpredictability. PCR of the sMCL at its distal tibial insertion provides gradual opening of the compartment, to a maximum value similar to that obtained with PCR at the joint space. The lower edge of the semi-tendinosus tendon is a valuable landmark for PCR of the distal sMCL.

Minimally invasive posterior approach in the popliteal fossa for semitendinosus and gracilis tendon harvesting: an anatomic study.

INTRODUCTION: Harvesting the semitendinosus (ST) and gracilis (GR) tendons at the anteromedial side of the knee may be hampered by a conjoint tendon insertion on the tibial metaphysis and an accessory bundle between the ST and the medial gastrocnemius. Locating and sparing the terminal branches of the saphenous nerve are difficult on an anteromedial approach. The principal objective of the present anatomic study was to assess the feasibility of ST and GR harvesting from a minimally invasive posterior approach in the popliteal fossa. The secondary objective was to analyze the risk of saphenous nerve branch lesion during harvesting. METHOD: Ten cadaver knees, free of scarring, were used. The whole body was positioned supine. The tendons were located in the popliteal fossa with the knee in 30° flexion. A mini-incision was performed in the fossa. The ST and GR tendons were located, and retrograde followed by anterograde stripping was performed. Tendon lengths and diameters were measured. The knees were then dissected to check for saphenous nerve branch lesions (anterior, infrapatellar and posterior branches). RESULTS: The GR and ST tendons were respectively located at 14.4 and 24 mm from the medial edge of the knee. In 90% of cases, there was an accessory ST bundle toward the medial gastrocnemius muscle, 26 mm below the posterior edge. Tendons could be harvested without deviation of the stripper. Knee dissection did not find any saphenous nerve branches, these being protected by the sartorius fascia. DISCUSSION: Posterior ST and GR tendon harvesting in the popliteal fossa is reliable and reproducible. It allows easy sectioning of the accessory ST bundle, without deviation during retrograde stripping. Unlike anterior harvesting, which leads to a rate of saphenous branch lesion of 50-78%, posterior harvesting protects the nerve branches by keeping away from the sartorius. LEVEL OF EVIDENCE: Level 4.

Secondary nailing after external fixation for tibial shaft fracture: risk factors for union and infection. A 55 case series.

INTRODUCTION: Secondary intramedullary nailing (SIN) following external fixation (EF) of tibial shaft fracture is controversial, notably due to the infection risk, which is not precisely known. The present study therefore analysed a continuous series of tibial shaft SIN, to determine (1) infection and union rates, and (2) whether 1-stage SIN associated to EF ablation increased the risk of infection. HYPOTHESIS: Factors exist for union and onset of infection following tibial shaft SIN. MATERIALS AND METHODS: A retrospective series of SIN performed between 1998 and 2012 in over 16-year-old patients with non-pathologic tibial shaft fracture was analysed. EF pin site infection was an exclusion criterion. Fractures were graded according to AO and Gustilo classifications. Study parameters were: time to SIN, 1- versus 2-stage procedure, bacteriologic results on reaming product, post-nailing onset of infection, and time to union. RESULTS: Fifty-five patients (55 fractures) were included. There were 16 closed and 39 open fractures: 7 Gustilo type I, 26 type II and 6 type IIIA; 33 AO type A, 14 type B and 8 type C. Mean time to SIN was 9 ± 9.6 weeks (range, 4 days to 12 months). There were 23 1-stage procedures, and 32 two-stage procedures with a mean 12-day interval (range, 4-30 days). Twelve reaming samples were biologically positive without secondary infection. There were 4 septic complications (3 abscesses, 1 osteomyelitis), and 1 aseptic non-union required re-nailing. The union rate was 96%. The sole factor of poor prognosis was severity of fracture opening. One-stage SIN did not increase infection risk. DISCUSSION: The present results were better than reported in the literature, where the rates of Gustilo IIIA and IIIB fracture and pin site infection are, however, higher. Tibial shaft SIN is a reliable procedure, with infection risk correlating with Gustilo type and time to surgery. Surgery should be early, before onset of EF pin site infection. A 1-stage attitude appears feasible in early SIN. LEVEL OF EVIDENCE: Level IV. Retrospective study type.