Application of double plate fixation combined with Masquelet technique for large segmental bone defects of distal tibia: a retrospective study and literature review.

BACKGROUND: There is no effective consensus on the choice of internal fixation method for the Masquelet technique in the treatment of large segmental bone defects of the distal tibia. Thus, the study aimed to investigate the outcomes of the Masquelet technique combined with double plate fixation in the treatment of large segmental bone defects. METHODS: This was a retrospective study involving 21 patients with large segmental bone defects of the distal tibia who were treated between June 2017 and June 2020. The length of bone defect ranged from 6.0 cm to 11 cm (mean, 8.19 cm). In the first stage of treatment, following complete debridement, a cement spacer was placed to induce membrane formation. In the second stage, double plate fixation and autologous cancellous bone grafting were employed for bone reconstruction. Each patient's full weight-bearing time, bone healing time, and Iowa ankle score were recorded, and the occurrence of any complications was noted. RESULTS: All patients were followed up for 16 to 26 months (mean, 19.48 months). The group mean full weight-bearing time and bone healing time after bone grafting were 2.41 (± 0.37) months and 6.29 (± 0.66) months, respectively. During the treatment, one patient had a wound infection on the medial side of the leg, so the medial plate was removed. The wound completely healed after debridement without any recurrence. After extraction of iliac bone for grafting, one patient had a severe iliac bone defect, which was managed by filling the gap with a cement spacer. Most patients reported mild pain in the left bone extraction area after surgery. The postoperative Iowa ankle score range was 84-94 (P < 0.05). In this cohort, 15 cases were rated as "excellent", and 6 cases as "good" on the Iowa ankle scoring system. CONCLUSION: The Masquelet technique combined with double plate fixation is a safe and effective method for the treatment of large segmental bone defects of the distal tibia.

Effects of dietary supplementation of vitamin A on the tibia quality of goslings.

Objective: This study was conducted to evaluate the effect of dietary supplementation of VA on the tibial growth, calcium (Ca) and phosphorus (P) metabolism, VA and vitamin D (VD) deposition, and associated gene expression in goslings. Methods: A total of 180 healthy, 1-day-old male goslings were randomly divided into 3 treatment groups (0, 9,000, and 15,000 IU VA/kg), with 6 replicates containing 10 goslings each. They were weighed and sampled on days 14, 28, 42, 56, and 70. Results: No addition of VA reduced VA content in the serum and liver of goslings, and supplementation of 15,000 IU/kg VA increased VA content from day 14 (p<0.05). The trend of VA concentration in the serum and liver was in line with the relative mRNA expression of retinoic acid receptor ß in the jejunal mucosa. In both no addition of VA and supplementation of 15,000 IU/kg VA reduced 25-hydroxycholecalciferol (25-OH-VD3) content in the serum and VD content in the liver (p<0.05). From day 28, no addition of VA or supplementation of 15,000 IU/kg VA had a negative effect on tibia length, strength, and Ca, P, and ash content in goslings (p<0.05). Tibia P content was lower in the supplementation of 15,000 IU/kg VA group than in the no addition of VA group (p<0.05). No addition of VA or supplementation of 15,000 IU/kg VA had the most effect on early serum parathyroid hormone (PTH) levels in goslings (p<0.05). The effect of no addition of VA on the bone gla protein (BGP) content of goslings started from day 14 (p<0.05). The relative mRNA expression of BGLAP and bone morphogenetic protein 4 (BMP4) in the liver and jejunal mucosa was decreased by either no addition of VA or supplementation of 15,000 IU/kg VA (p<0.05). Conclusion: Both no addition of VA and supplementation of 15,000 IU/kg VA affected the mineralization process of the bone, and ultimately reduced tibial quality.

Unusual Presentation of a Giant Cell Tumor of the Bone: A Case Report.

Bone giant cell tumors (GCTs) are rare, non-cancerous tumors that mostly affect the meta-epiphyseal region of long bones in the legs and arms. We are reporting a case of GCT of bone of a 14-year-old male; it usually occurs in the age group of 20-40 years. The presence of multinucleated giant cells and stromal cells in the proximal diaphysis of the left tibia serves as a distinguishing characteristic. The majority of GCTs are benign; they have the potential to induce bone loss and can be locally aggressive. Treatment options often include surgery, and in some cases, medications like denosumab may be used to help shrink the tumor or manage recurrent cases.

Non-vascularized Fibular Autograft and Locking Plate: A Solution to the Resistant Nonunion of a Tibial Metaphyseal Fracture.

The union of tibial fractures often raises concerns. In one such case, a 62-year-old female patient presented in our Emergency Room (ER) with a comminuted tibial metaphyseal fracture resulting from a traffic accident. The patient underwent three surgical procedures in the following two years. The first intervention was open reduction internal fixation (ORIF) with a plate and screws. The second intervention, which took place three months after the first surgery, addressed the union delay through implant removal and closed reduction and internal fixation (CRIF) with an antegrade intramedullary tibial nail. The third intervention addressed the implant failure and oligotrophic nonunion through the removal of the broken tibial nail and ORIF using a proximal tibia locking plate and screws, augmented with fibular shaft and reamed iliac crest autografts. We conducted frequent follow-ups with the patient and performed multiple X-rays to confirm and monitor the fracture union. At the last follow-up, two years after the last surgical intervention, imagistic investigations showed that the patient presented with fracture union, she could support her full body weight on the operated leg, and was able to walk and carry out normal daily activities. As such, we concluded that the surgical method chosen (ORIF with proximal tibia locking plate and screws, augmented with a fibula shaft strut and reamed iliac crest autograft) was a viable option to treat an aseptic oligotrophic nonunion in a high-energy comminuted tibia fracture.

The Epidemiology of Lower Limb Fractures: A Major United Kingdom (UK) Trauma Centre Study.

INTRODUCTION: Understanding the epidemiology and incidence of fractures can help inform policymakers and clinicians about the needs of the population and highlight trends over time, allowing for tailoring of healthcare delivery to the population. This study reports on the lower limb fractures treated at a major trauma centre over a seven-year period. METHODS: We collected data on fracture locations, age, gender, BMI, hospital admission length, and treatment options of all lower limb fractures treated at a level I trauma centre from January 2015 to December 2021. We included data on the femur, tibia, and fibula, which were each split up into distinct regions. Fractures were subdivided by location and graphed, separated by gender, over age group. Finally, each location area's frequency was graphed over the entire study period. RESULTS: A total of 8,511 patients sustained 8,613 fractures, given an overall incidence of 215.9 fractures per 100,000 patients per year. The mean age was 62.3 years, and 56.3% of patients were female. Fractures of the peri trochanteric region of the femur had the highest mean average age (79.9 years), which was closely followed by fractures of the head and neck of the femur (78.2 years). Fractures of the head and neck of the femur and the peri trochanteric region of the femur also had the highest proportion of females suffering from these fractures (67 and 66% female, respectively). Femur shaft fractures had the lowest average age (36.5 years) and the lowest proportion of female patients (29%). On graphing by location, separated by gender, over age group, overall fractures showed a bi-peak distribution of younger males and older, post-menopausal females having their respective peaks. Three further distinct distributions were observed in individual location fractures. CONCLUSION: Identifying the relative incidence and demographic associations with lower limb fractures helps highlight a changing population's needs. There is an absence of such study in literature in the United Kingdom (UK) since 2006. Our study's insights and results aid clinicians and policymakers in the creation of guidelines and the distribution of resources based on the most recent information and elucidate changing healthcare service needs for the population.

Improving Healing: The Putative Effects of Low-Level Laser Therapy for Ulcer in Parkinson's Disease.

The progressive nature of Parkinson's disease and its associated motor and non-motor symptoms can lead to various complications when patients experience immobilization, exacerbating existing motor impairments and potentially giving rise to secondary health issues. The variability, progression, and management of tremors in PD can be challenging. Due to low bone mass density, patients with Parkinson's disease are susceptible to vitamin D deficiency. The lack of movement can worsen muscle rigidity and stiffness, leading to contractures and a decreased range of motion in joints. Additionally, immobility may contribute to cardiovascular deconditioning, orthostatic hypotension, and an increased risk of pressure ulcers due to prolonged pressure on specific areas of the body. In this case report, we hereby report a case of Parkinson's disease further complicated by sinus discharge from the ulcer. This case report describes the putative effects of low-level laser therapy on discharging sinus from the wound secondary to a diabetic ulcer in idiopathic Parkinson's disease. Achieving an ideal level of functional independence and preventing problems associated with extended immobility are essential goals of structured physical therapy postoperative care. This may assist the patient in returning to their pre-injury position more quickly. Our patient underwent several interventions for wound healing, including proprioception training, tremor management, improving dynamic trunk balance, and pain control measures. Clinical outcome measures like the Barthel Index, lower extremity functional scale, and Visual-Analog Scale were used to assess the progress of the patient. Managing these interconnected conditions requires a multi-disciplinary approach.

Lower Limb Malrotation following Minimally Invasive Plating in Distal Tibia Fractures.

Introduction: Minimally invasive percutaneousosteosynthesis (MIPO) plating techniques havedemonstrated good outcomes in the treatment of distal tibia fractures. Early arthritis and functional impairment mayoccur if length and rotation are not restored. This study aims to determine the incidence and severity of tibia malrotation following MIPO plating of isolated unilateral distal tibia fractures, defined as torsional difference of greater than 10° as compared to the contralateral limb and whether the degree of malrotation affects functional outcomes scores. Materials and methods: This was a level 2 prospective cohort study. All patients with fractures of the distal tibia who underwent surgical fixation with the exclusion ofpatients with polytrauma, neurovascular injuries or pre-existing disabilities were recruited. Patients underwent MIPO plating followed by a post-operative ComputedTomography (CT) scan of bilateral lower limbs. AOFAS ankle-hindfoot score was recorded at six months and one year follow-up. Results: A total of 24 patients (28 to 83 years old) were recruited. Nineteen patients obtained CT scans. Nine of the 19 patients (47.3%) had tibia malrotation. The mean tibia malrotation angle was 10.3° (0° - 45°). The average AOFAS scores was 82.4 and 84.3 at 6 months and 1 year follow-up. Degree of CT malrotation was not significantly associated with AOFAS scores at 6 month (spearman rho -0.386) and 1 year (spearman rho -0.343). Conclusions: Tibia malrotation following MIPO plating of distal tibia fractures is common, with an incidence of 47.3% and an average malrotation angle of 10.3°. The degree of malrotation does not appear to have significant mid-term functional impact on the patient.

Morphology and transverse alignment of the patella have no effect on knee gait characteristics in healthy Chinese adults over the age of 40 years.

Background: The influence of patella morphology and horizontal alignment on knee joint kinematics and kinetics remains uncertain. This study aimed to assess patella morphology and transverse alignment in relation to knee kinetics and kinematics in individuals without knee conditions. A secondary objective was to investigate the impact of femur and tibia alignment and shape on knee gait within this population. Patients and methods: We conducted a prospective collection of data, including full-leg anteroposterior and skyline X-ray views and three-dimensional gait data, from a cohort comprising 54 healthy individuals aged 40 years and older. Our study involved correlation and logistic regression analyses to examine the influence of patella, femur, and tibia morphology and alignment on knee gait. Results: The patellar tilt angle or the patella index did not show any significant relationships with different aspects of gait in the knee joint, such as velocity, angle, or moment (p > 0.05, respectively). Using multivariate logistic regression analysis, we found that the tibiofemoral angle and the Q angle both had a significant effect on the adduction angle (OR = 1.330, 95%CI 1.033-1.711, p = 0.027; OR = 0.475, 95%CI 0.285-0.792, p = 0.04; respectively). The primary variable influencing the knee adduction moment was the tibiofemoral angle (OR = 1.526, 95% CI 1.125-2.069, p = 0.007). Conclusion: In healthy Chinese individuals aged over 40, patella morphology and transverse alignment do not impact knee gait. However, the femoral-tibial angle has a big impact on the knee adduction moment.

Preventing of nonunion in congenital pseudarthrosis of the tibia cases of Crawford Type I and II through the use of allograft bypass and a brace: Midterm findings.

Background: Congenital pseudarthrosis of the tibia is a limb deformity, which can be distressing for the affected patients and the pediatric orthopedic surgeons involved. We hypothesized that the modified McFarland procedure would avoid fractures and even have a corrective effect on the affected tibia in congenital pseudarthrosis of the tibia patients. Toward this end, we evaluated the midterm results of treating congenital pseudarthrosis of the tibia patients of Crawford Type I and II with allograft bypass combined with long-term bracing. Methods: This study retrospectively evaluated 7 patients with congenital pseudarthrosis of the tibia who were treated with allograft bypass combined with long-term bracing between 2009 and 2018. The median follow-up was 7.0 years (range 3.8-10.0 years). The medical records and radiographs were reviewed for demographic data, clinical characteristics, outcomes, and complications. Results: At the time of the last follow-up, all allografts revealed complete consolidation in the patients' tibiae at both ends. All patients presented no functional restriction of the lower limbs and no amputation or non-union has occurred. Most of the obvious deformities of the tibia diaphysis or ankle joint were corrected. Two complications occurred that required successful revision surgery. Conclusion: In this series of seven congenital pseudarthrosis of the tibia patients, the allograft bypass technique showed satisfactory midterm results and validated our hypothesis. For congenital pseudarthrosis of the tibia patients of Crawford Type I and II, this procedure combined with long-term bracing, which involves the affected leg only, can delay or possibly prevent fractures, decrease tibial malalignment, and preserve leg length. Level of evidence: level IV.

Laying hen responses to multi-strain Bacillus-based probiotic supplementation from 25 to 37 weeks of age.

Objective: Investigate the efficacy of Bacillus-based probiotics supplemented at two different levels to modulate the productive performance, egg quality, tibia traits, and specific cecal bacteria counts of Hy-Line Brown layers from 25 to 37 weeks of age. Methods: A total of 216 twenty-five-week-old hens were randomly distributed into 3 experimental diets with 12 replicates of 6 birds per cage. Diets included basal diet supplemented with 0 (CON), 3 × 108 (PRO1), or 3 × 109 (PRO2) CFU of the test probiotic containing Bacillus subtilis PB6, Bacillus subtilis FXA, and Bacillus licheniformis G3 per kilogram of feed. Results: Improved egg weights and mass at 29 weeks; and feed intake at 31 weeks (p < 0.10) were noticed with the probiotic-supplemented PRO1 and PRO2 diets. Considering egg quality, the shell thickness, Haugh units, and yolk color were improved; but yolk cholesterol was lowered (p < 0.05) with PRO1 and PRO2 diets at 29 weeks. At both 33 and 37 weeks, the egg-breaking strength, shell color and thickness, albumen height, Haugh units, and yolk color were improved; but yolk cholesterol was similarly lowered (p < 0.05) with the PRO1 and PRO2 diets. Improved tibia Ca, ash, weights, and density; and raised cecal counts of Bifidobacteria and Lactobacilli (p < 0.05) were noticed with PRO1 and PRO2 diets. Improved tibia P but reduced Clostridia counts (p < 0.10) were also observed with the PRO1 and PRO2 diets. Conclusion: Probiotic supplementation of Bacillus subtilis PB6, Bacillus subtilis FXA, and Bacillus licheniformis G3 at 3 ×108 CFU/kg of feed is adequate to significantly improve egg quality, lower yolk cholesterol, enhance several tibia traits, and raise the populations of beneficial cecal bacteria. Modest improvements in several productive parameters and tibia P but reduced Clostridia were also observed; and could warrant further investigation of probiotic effects beyond the current test period.

Circular frame versus reamed intramedullary tibial nail in the treatment of grade III open tibial diaphyseal fractures.

BACKGROUND: Grade III open tibial diaphyseal fractures are challenging to treat and controversy exists on whether to treat them with an intramedullary nail (IMN) or a circular frame (CF). This study aims to compare outcomes for intramedullary nail and circular frame in the treatment of open tibial diaphyseal fractures. METHODOLOGY: Retrospective study at a major trauma center of all patients admitted with a grade III open tibial diaphyseal fracture between January 2016 and January 2022. The primary outcome measures were major complications: non-union, malunion, refracture, DBI and amputation. Secondary outcome measures were time to union and reoperation rates. RESULTS: Fifty-five patients were included in the study, 32 patients in CF group and 23 patients in IMN group. There were no significant differences in the baseline demographics of patients in both groups. Major complications were recorded in 13 limbs (54%) in IMN group and in 18 limbs (56%) in CF group which were not statistically significant (p = 0.797). Deep bone infection rates were noted in 4 (12.5%) in the CF group, compared to 1 (4%) in IMN group; however, the result was not statistically significant (p = 0.240). Amputation rates as a result of infected non-unions were seen in 1 limb (4%) in IMN group and 2 limbs (6%) in CF group (p = 0.99). Median time to union was significantly shorter in IMN group at 30 weeks compared to 30 weeks for CF group (p = 0.04). CONCLUSION: IMN should be the treatment of choice in the treatment of grade III open tibial diaphyseal fracture, but CF should be considered for delayed treatment and in patients with bone loss.

Diagnosis and Management of Monostotic Fibrous Dysplasia of the Tibia in an Adolescent Patient: A Case Report.

A rare benign bone condition called monostotic fibrous dysplasia (MFD) is characterized by the growth of fibrous tissue in place of a normal bone. It may lead to deformity in the affected bone, pain, and a pathologic fracture due to bone weakness. Hereunder, a case report of MFD in a 17-year-old male adolescent presenting to the hospital with localized bone pain and swelling in his right tibia is presented. After clinical examination and radiographic imaging, a provisional diagnosis of benign osteolytic lesion was considered. A magnetic resonance imaging (MRI) scan of the leg suggested the possibility of fibrous dysplasia or adamantinoma. The patient was managed with an intralesional curettage of the dysplastic bone and packing the cavity with blocks of a synthetic bone. The excised material was sent for histopathology, which established the diagnosis of fibrous dysplasia.

Efficacy of damage control orthopedics strategy in the management of lower limb trauma.

Background: Little is known about the efficacy of damage control (DC) surgery in the management of lower limb trauma. Here we compared the clinical parameters and complication rates of such patients received either DC or emergency comprehensive (EC) surgery treatment. Methods: This study is a retrospective study on patients with lower limb trauma that received surgical treatment. Data of 120 patients were divided into DC and EC surgery groups. Clinical parameters obtained at hospital admission and complications during follow-up were analyzed. Injury Severity Score (ISS), Gustilo classification and Mangled Extremity Severity Score (MESS) were used to assess trauma severity, open fractures and viability of injured limb, respectively. Results: Age, sex, ISS, fracture type, injury site, MESS, operation time, blood loss, pulmonary and cranial injuries were compared. We found that patients in the DC group had more severe injury as reflected by the higher injury severity score (ISS) (28.1 ± 10.9 vs 21.3 ± 7.4, P < 0.001). ISS was also identified as a significant influencer for the treatment selection (P < 0.001). In addition, patients treated with DC surgery demonstrated less complications (7 cases vs 27 cases), which was supported by the propensity score logistic regression analysis (Odd ratio 4.667). Conclusions: DC surgery is more often selected to treat patients with more severe lower limb injuries, which leads to lower complication rates.

Homogenized finite element analysis of distal tibia sections: Achievements and limitations.

High-resolution peripheral quantitative computed tomography (HR-pQCT) based micro-finite element (µFE) analysis allows accurate prediction of stiffness and ultimate load of standardised (∼1 cm) distal radius and tibia sections. An alternative homogenized finite element method (hFE) was recently validated to compute the ultimate load of larger (∼2 cm) distal radius sections that include Colles' fracture sites. Since the mechanical integrity of the weight-bearing distal tibia is gaining clinical interest, it has been shown that the same properties can be used to predict the strength of both distal segments of the radius and the tibia. Despite the capacity of hFE to predict structural properties of distal segments of the radius and the tibia, the limitations of such homogenization scheme remain unclear. Therefore, the objective of this study is to build a complete mechanical data set of the compressive behavior of distal segments of the tibia and to compare quantitatively the structural properties with the hFE predictions. As a further aim, it is intended to verify whether hFE is also able to capture the post-yield strain localisation or fracture zones in such a bone section, despite the absence of strain softening in the constitutive model. Twenty-five fresh-frozen distal parts of tibias of human donors were used in this study. Sections were cut corresponding to an in-house triple-stack protocol HR-pQCT scan, lapped, and scanned using micro computed tomography (µCT). The sections were tested in compression until failure, unloaded and scanned again in µCT. Volumetric bone mineral density (vBMD) and bone mineral content (BMC) were correlated to compression test results. hFE analysis was performed in order to compare computational predictions (stiffness, yield load and plastic deformation field pattern) with the compressive experiment. Namely, strain localization was assessed based on digital volume correlation (DVC) results and qualitatively compared to hFE predictions by comparing mid-slices patterns. Bone mineral content (BMC) showed a good correlation with stiffness (R2 = 0.92) and yield (R2 = 0.88). Structural parameters also showed good agreement between the experiment and hFE for both stiffness (R2 = 0.96, slope = 1.05 with 95 % CI [0.97, 1.14]) and yield (R2 = 0.95, slope = 1.04 [0.94, 1.13]). The qualitative comparison between hFE and DVC strain localization patterns allowed the classification of the samples into 3 categories: bad (15 sections), semi (8), and good agreement (2). The good correlations between BMC or hFE and experiment for structural parameters were similar to those obtained previously for the distal part of the radius. The failure zones determined by hFE corresponded to registration only in 8 % of the cases. We attribute these discrepancies to local elastic/plastic buckling effects that are not captured by the continuum-based FE approach exempt from strain softening. A way to improve strain localization hFE prediction would be to use longer distal segments with intact cortical shells, as done for the radius. To conclude, the used hFE scheme captures the elastic and yield response of the tibia sections reliably but not the subsequent failure process.

Lengthening in congenital posteromedial bowing of tibia: a follow-up series at skeletal maturity.

PURPOSE: Congenital posteromedial bowing (CPMB) of tibia is a rare, usually self-resolving condition that is present at birth. The data on the long-term outcome of lengthening, choice of fixator, outcome in early and late age groups, and complications is sparse, hence the need for this study. METHODS: This retrospective study included 93 patients with 94 affected legs from 1991 to 2023. The patients were categorized into early (under 10 years) and late (10 years or above) intervention groups. Eighteen patients with nineteen lengthening episodes who attained skeletal maturity made the basis of this study and will be discussed in detail. RESULTS: The outcome for the lengthening group at maturity was satisfactory, with 5.53 cm of average length gained per lengthening episode, a mean LLD of 0.31 cm at final follow-up, a mean age of 23.63 years (range 14-38 years), and an average follow-up of 12.51 years (range 3-28 years) post-lengthening, but the procedure was associated with difficulties like ankle stiffness, tibial valgus, pin tract infections, and fractures through regenerate. CONCLUSION: This study represents a large single-centre series on CPMB. We recommend that surgery for lengthening should be done at an older age, close to skeletal maturity, wherever possible to reduce the risk of repeat lengthening procedures. Based on our experience, we recommend the use of a circular fixator. Uniplanar distractors should have an adequate number and spread of Schanz screws in each segment to reduce the risk of valgus malalignment of distracting segments of bone.

Are extra locking bolts or fibular plating more important in extreme nailing of distal tibia fractures? A cadaveric biomechanical analysis.

OBJECTIVES: In far-distal extra-articular tibia fracture "extreme" nailing, debate surrounds the relative biomechanical performance of plating the fibula compared with extra distal interlocks. This study aimed to evaluate several constructs for extreme nailing including one interlock (one medial-lateral interlock), one interlock + plate (one medial-lateral interlock with lateral fibula compression plating), and two interlocks (one medial-lateral interlock and one anterior-posterior interlock). METHODS: Fifteen pairs of fresh cadaver legs were instrumented with a tibial nail to the physeal scar. A 1 cm segment of bone was resected from the distal tibia 3.5 cm from the joint and an oblique osteotomy was made in the distal fibula. We loaded specimens with three different distal fixation constructs (one interlock, one interlock + plate, and two interlocks) through 10,000 cycles form 100N-700 N of axial loading. Load to failure (Newtons), angulation and displacement were also measured. RESULTS: Mean load to failure was 2092 N (one interlock), 1917 N (one interlock + plate), and 2545 N (two interlocks). Linear mixed effects modeling demonstrated that two interlocks had a load to failure 578 N higher than one interlock alone (95 % CI, 74N-1082 N; P = 0.02), but demonstrated no significant difference between one interlock and one interlock + plate. No statistically significant difference in rates or timing of displacement >2 mm or angulation >10° were demonstrated. CONCLUSIONS: When nailing far-distal extra-articular tibia and fibula fractures, adding a second interlock provides more stability than adding a fibular plate. Distal fibula plating may have minimal biomechanical effect in extreme nailing.

Fixation of Proximal Tibial Fractures with Intramedullary Nail and Immediate Weightbearing: A Beneficial Alternative.

Newer intramedullary (IM) nails have become another option in the fixation of proximal tibia fractures. There is limited data on the successful use of these implants in intra-articular and extra-articular fractures of the proximal tibia, and no studies assessing the ability of these implants to maintain alignment with early weight bearing. Our objective was to determine whether immediate weight bearing after IM fixation, with or without supplemental plate or screw fixation, of proximal third tibial fractures (OTA/AO 41A-C) results in a change in alignment prior to union. 35 patients with 39 proximal tibia fractures from 2015 to 2020, all treated with IM nailing with or without supplemental plate or screw fixation, all made weight-bearing as tolerated following surgery, were included. The main outcomes were change in medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA) from initial post-operative films to final follow up. 12 fractures were OTA/AO 41 type A, 14 were type B, and 13 were type C. Mean initial MPTA was 87.0 +/-2.53 degrees, while mean initial PPTA was 79.6 +/- 3.50 degrees. The mean change in MPTA was 0.048 +/- 2.8 degrees (P=0.92), and mean change in PPTA was 0.264 +/- 3.67 degrees. 92.3% of fractures had normal final coronal plane alignment, with MPTA between 85.0 and 90.0 degrees. 89.7% of fractures had normal final sagittal plane alignment, with PPTA between 77.0 and 84.0 degrees. No patients required reoperation for malalignment. In OTA/AO type 41 fractures, immediate weight bearing after IM nail fixation, with or without supplemental plate or screw fixation when indicated, leads to minimal change in final coronal or sagittal alignment, and was well tolerated in most patients. [authors blinded for review].

Femoral Coronal Malalignment is Associated With Failure in Mobile-Bearing Medial Unicompartmental Knee Arthroplasty.

INTRODUCTION: Femur-first technique (FF) for mobile-bearing medial unicompartmental knee arthroplasty (UKA) has been described as an alternative to tibia first-technique (TF). The aim of this study was to compare the radiographic results in UKAs using FF or TF techniques and their influence on failure rates. MATERIALS AND METHODS: We retrospectively reviewed 288 UKAs with a minimum 2-year follow-up. There were 147 knees in the TF and 141 knees in the FF cohorts. Alignment parameters and overhang were assessed as outliers and far outliers. The mean follow-up was six years (range, 2 to 16), the mean age was 63 years (range, 27 to 92), and 45% of patients were women. Univariate and multivariate statistical analyses were carried out with Cox regression models. RESULTS: There were 13 and 6 revisions in the TF and FF cohorts, respectively. The FF had lower rates of femoral coronal alignment (FCA) or femoral sagittal alignment (FSA) outliers compared to the TF (5.7 versus 19%, P = 0.011). Tibial coronal alignment (TCA) and tibial sagittal alignment (TSA) did not significantly differ between the techniques (22.7% in FF versus 29.9% in TF, P = 0.119). Overhang outliers did not differ significantly between the groups. Younger age was associated with a higher revision rate (P = 0.006), while FF versus TF, sex, BMI, and postoperative mechanical axis did not show significant associations. In multivariate analysis, FCA outliers and younger age were significantly associated with revision. CONCLUSION: The FF technique in mobile-bearing UKA resulted in fewer FCA outliers compared to TF. Despite improved knee alignment with the FF technique, FCA outliers and younger age were associated with a higher revision rate, independent of technique.

Treatment of Schatzker Type VI Tibia Fractures Using Circular External Fixation: State of the Art, Surgical Technique and Results.

BACKGROUND: Schatzker type VI tibia fractures are usually associated with infection and surgical wound-related problems. Circular external fixation (CEF) has been shown to minimize such complications. METHODS: We pose a retrospective study of patients with Schatzker type VI fractures treated with CEF. RESULTS: Twenty-two (22) patients were included (11M/11F) with a mean age of 60.1 ± 14.9 years. According to the AO/OTA classification, two fractures (9.1%) were A2, three (13.6%) were A3, and seventeen (77.3%) were C3. Three (13.6%) of them were open. The tissue damage observed in the nineteen (86.4%) closed fractures was classified according to Tscherne (four grade I, twelve grade II, and three grade III). The mean ex-fix time was 24.1 ± 5.1 weeks. None of the patients experienced deep infections, nonunion, or malunion. The mean ROM was 111.4 ± 17.8 degrees. Although stability was achieved in all cases, 50% of them suffered osteoarthritic degeneration. Four knees required TKR at a mean of 8.77 ± 5.58 years from trauma. The mean HHS knee score was 84.2 ± 10.3 points (excellent in fifteen (68.2%) cases, good in four (18.2%), and acceptable in three (13.6%)). The mean Rasmussen radiological score was 13.3 ± 3.5 (excellent in three (13.6%) cases, good in fifteen (68.2%), and acceptable in four (18.2%)). The mean SF-12 score was 35.1 ± 10.4 points on the physical scale and 53.0 ± 10.6 points on the mental scale. CONCLUSIONS: CEF has shown itself to be a valid treatment for patients with Schatzker type VI fractures, particularly for those where the fracture is comminuted, severely displaced, open, or associated with severe soft tissue damage.

Comparative experimental study of the biomechanical properties of retrograde tibial nailing and distal tibia plate in distal tibia fracture.

Objective: A biomechanical comparative analysis was conducted to evaluate the retrograde tibial nailing (RTN) and distal tibia plate techniques for the treatment of distal tibia fractures. Methods: Fourteen fresh adult tibia specimens were selected, consisting of seven males and seven females aged 34-55 years. The specimens were randomly divided into two groups (Group A and Group B) using a numerical table method, with seven specimens in each group. Group A underwent internal fixation of distal tibial fractures using RTN, while Group B received internal fixation using a plate. The axial compression properties of the specimens were tested in the neutral positions under pressures of 100, 200, 300, 400, and 500 N. Additionally, the torsional resistance of the two groups was assessed by subjecting the specimens to torques of 1.0, 2.0, 3.0, 4.0, and 5.0 N m. Results: At pressures of 400 and 500 N, the axial compression displacement in Group A (1.11 ± 0.06, 1.24 ± 0.05) mm was significantly smaller than that in Group B (1.21 ± 0.08, 1.37 ± 0.11) mm (p = 0.023, 0.019). Moreover, at a pressure of 500 N, the axial compression stiffness in Group A (389.24 ± 17.79) N/mm was significantly higher than that of the control group (362.37 ± 14.44) N/mm (p = 0.010). When subjected to torques of 4 and 5 N m, the torsion angle in Group A (2.97° ± 0.23°, 3.41° ± 0.17°) was significantly smaller compared to Group B (3.31° ± 0.28°, 3.76° ± 0.20°) (p = 0.035, 0.004). Furthermore, at a torque of 5 N m, the torsional stiffness in Group A (1.48 ± 0.07) N m/° was significantly higher than that in Group B (1.36 ± 0.06) N·m/° (p = 0.003). Conclusion: The results obtained from the study demonstrate that the biomechanical performance of RTN outperforms that of the distal tibial plate, providing valuable biomechanical data to support the clinical implementation of RTN.