Posterior tibial slope angle in contact versus non-contact anterior cruciate ligament injuries.

BACKGROUND: Increased Posterior Tibial Slope (PTS) angle has been reported to be a risk factor for primary anterior cruciate ligament (ACL) tears. However, it is unknown whether increased PTS has an associated increased risk for non-contact versus contact ACL injury. PURPOSE: The purpose of this study is to determine whether patients with non-contact ACL injury have a higher PTS angle than those with contact ACL injury. METHODS: A total of 1700 patients who underwent primary ACL reconstruction between January 2011 and June 2023 at a single academic institution were initially included. Electronic medical records were reviewed for demographic information as well as evidence that the patient sustained a contact or non-contact ACL injury. Patients in the contact cohort were propensity score matched to patients in the non-contact cohort by age, sex and BMI. Additionally, patients in the contact cohort were then propensity score matched to a control group of patients with intact ACLs also by age, sex and BMI. RESULTS: One hundred and two patients with contact injury were initially identified and 1598 patients with non-contact injuries were identified. Of the 102, 67 had knee X-rays that were suitable for measurement. These 67 contact injury patients were propensity score matched to 67 noncontact patient and 67 patients with intact ACLs based on age, sex and BMI. There were no significant differences between contact and non-contact cohorts in age (28.7±6.3 vs. 27.1±6.5, p = 0.147), sex (Female: 36.0% vs. 34.3%, p = 0.858), or BMI (26.7±5.6 vs 26.1±3.4, p = 0.475). There was no significant difference in PTS angle between contact versus non-contact ACL injury patients (11.6±3.0 vs.11.6±2.8, p = 0.894). There was a significant difference in PTS between the contact ACL injury and the intact cohort (11.6±3.0 vs. 10.0±3.9, p = 0.010) and the non-contact ACL injury and the intact cohort (11.6±2.8 vs. 10.0±3.9, p = 0.010). CONCLUSION: There was no significant difference in the degree of PTS between patients who sustained contact versus non-contact ACL injuries. Additionally, there was a significantly increased PTS in both the contact and non-contact ACL injury cohorts compared to patients with intact ACLs.

Bicondylar Tibial Plateau Fracture in Below-Knee Amputation: A Rare Injury Case Report.

Introduction: With current prostheses, below-knee amputees have sufficient mobility to perform activities with a risk of trauma and therefore fracture. However, bicondylar fractures of the tibial plateau are rare in this population and we found no recent literature or consensus regarding the management of these fractures. The aim of this study is to report a case with its surgical management, post-operative follow-up, and the specificities inherent in transtibial amputees. Case Report: This is a case of 33-year-old below-the-knee amputee male who sustained an ipsilateral tibial plateau fracture after an electric scooter accident. The patient underwent open reduction and internal fixation with posteromedial and anterolateral plate using dual incision. We followed the patient for 1 year with good clinical and functional outcomes. Conclusion: Bicondylar fractures of the proximal tibia in below-knee amputees are rare injuries with potentially severe consequences. Nevertheless, appropriate surgical management and multidisciplinary collaboration with physiotherapists and orthopedic technicians allow the patient to regain mobility and autonomy without compromising prosthesis fitting in the long term.

Exploring Knee Flexion Techniques in Tibial Nailing: A Comparative Study of Two Different Methods Knee Flexion Techniques in Tibial Nailing.

BACKGROUND: Tibial fractures, particularly diaphyseal fractures, are common and can result in prolonged non-weight-bearing periods, especially in older adults. Intramedullary nailing has become the standard treatment, offering early weight-bearing and improved functional outcomes. This study aims to compare the efficacy and safety of two knee flexion methods - Method A (using an adjustable triangular frame) and Method B (Seyhan method) - in tibial nailing procedures. MATERIAL AND METHODS: A prospective randomized controlled trial was conducted with 90 adult patients aged 18-70 requiring intramedullary nailing for isolated closed tibial fractures. Method A utilized an adjustable triangular frame, allowing various degrees of knee flexion. In Method B (Seyhan method), knee flexion was achieved by leg sloping on the operation table with a cushion pillow under the distal thigh. RESULTS: In terms of complication rates, a key finding was a significantly higher incidence of edema in Method B compared to Method A. The results indicated minor differences in satisfaction levels, with a slightly higher percentage of 'Well Satisfied' and a higher dissatisfaction rate in Method B. However, these variations in surgeon satisfaction did not reach statistical significance. CONCLUSIONS: 1. The Seyhan method and the adjustable triangular frame were compared in our study, with the latter showing advantages in terms of ease of use and reduced complications. 2. While complications like knee pain were observed in some cases, the triangular frame showed superior results in surgical efficiency and patient outcomes. 3. Further research is needed to confirm these findings and explore specific scenarios where each method may excel.

A novel 3D printed model for educating medical students on limb fractures: a randomized controlled preliminary study.

BACKGROUND: Medical education related to bone fracture must address numerous challenges including complex anatomical characteristics, diverse injury mechanisms, fracture typing, and treatment modalities. Our newly developed 3D printed model comprises components that may be combined or split to simulate various anatomical features, fracture types, and treatment modalities. This study aims to analyze the teaching utility of the new 3D-printed model compared with the traditional solid model. METHODS: This prospective study included 112 students randomly assigned to fracture-related education with a conventional model or the newly developed 3D-printed model. All students received 40 min of lecture, 20 min for femoral neck and 20 min for tibiofibular fractures, and a post-class quiz (10 min each) immediately followed. Scores on tests of fracture-related knowledge and user satisfaction were measured pre and post education for comparison. RESULTS: The 3D printing group had an advantage in retention of anatomic knowledge, fracture typing and choice of treatment for the femoral neck fracture (P < 0.05). For the tibiofibular fracture the 3D printing group had an advantage in retention of anatomic knowledge and fracture complications (P < 0.05).Scores on the questionnaire survey also showed increased satisfaction in the 3D-printed model group(P < 0.05). CONCLUSIONS: The proposed 3D-printed model can enhance the teaching effect significantly and has potential for widespread use in medical student education.

Anterior Slope-Modifying Osteotomies Alter the Length Change Behavior of the Superficial Medial Collateral Ligament: A Biomechanical Study.

BACKGROUND: Increased tibial slope has been shown to lead to higher rates of anterior cruciate ligament graft failure. A slope-decreasing osteotomy can reduce in situ anterior cruciate ligament force and may mitigate this risk. However, how this procedure may affect the length change behavior of the medial ligamentous structures is unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to examine the effect of anterior slope-modifying osteotomies on the medial ligamentous structures. It was hypothesized that (1) decreasing the tibial slope would lead to shortening of the superficial medial collateral ligament (sMCL), (2) while the fibers of the posterior oblique ligament (POL) would be unaffected. STUDY DESIGN: Descriptive laboratory study. METHODS: Eight fresh-frozen cadaveric knee specimens underwent anatomic dissection to precisely identify the medial ligamentous structures. The knees were mounted in a custom-made kinematics rig with the quadriceps muscle and iliotibial tract loaded. An anterior slope-modifying osteotomy was performed and fixed using an external fixator, which allowed modification of the wedge height between -15 and +10 mm in 5-mm increments. Threads were mounted between pins positioned at the anterior, middle, and posterior parts of the tibial and femoral attachments of the sMCL and POL. For different tibial slope modifications, length changes between the tibiofemoral pin combinations were recorded using a rotary encoder as the knee was flexed between 0° and 120°. RESULTS: All sMCL fiber regions shortened with slope reduction (P < .001) and lengthened with slope increase (P < .001), with the anterior sMCL fibers more affected than the posterior sMCL fibers. A 15-mm anterior closing-wedge high tibial osteotomy (ACWHTO) resulted in a 6.9% ± 3.0% decrease in the length of the anterior sMCL fibers compared with a 3.6% ± 2.3% decrease for the posterior sMCL fibers. A 10-mm anterior opening-wedge high tibial osteotomy (AOWHTO) increased anterior sMCL fiber length by 5.9% ± 2.3% and posterior sMCL fiber length by 1.6% ± 1.0%. The POL fibers were not significantly affected by a slope-modifying osteotomy. CONCLUSION: Tibial slope-modifying osteotomies changed the length change pattern of the sMCL such that an AOWHTO increased whereas an ACWHTO decreased the sMCL strain. This effect was most pronounced for the anterior fibers of the sMCL. The length change pattern of the POL remained unaffected by slope-modifying osteotomy. CLINICAL RELEVANCE: Surgeons should be aware that anterior tibial slope-modifying osteotomies affect the biomechanics of the sMCL. After an extensive ACWHTO, patients may develop a medial or anteromedial instability, while an AOWHTO may overconstrain the medial compartment.

How does cruciate ligament rupture treatment affect range of motion in dogs?

This study aimed at evaluating the changes in passive range of motion (ROM) of the stifle joint associated with cranial cruciate ligament (CCL) rupture in dogs and assessing whether the surgical treatment carried out on the affected joints affected additional changes. A retrospective cohort study design was used. The clinical records of dogs treated with tibial tuberosity advancement (TTA), tibial plateau leveling osteotomy (TPLO) and tight rope (TR) were reviewed as were the extension angle (EA), flexion angle (FA) and lameness. The data recorded at T0, before surgery, were compared with the data at 1 month and 6 months post-surgery. The data were classified as normal or abnormal. The main results obtained one month after surgery indicated that dogs treated with TTA showed a significant worsening of flexion (the FA was abnormal in 69.6% of dogs at T0 and 80.4% at T1 with p = 0.0208). Dogs treated with TPLO achieved asignificant improvement in extension (the EA was normal in 16.7% of dogs at T0 and in 33.3% at T1 with p < 0.0001), and in flexion (the FA was normal in 23.8% of dogs at T0 and 43.5% at T6 with p = 0.0434). The dogs treated with TR showed a significant worsening of extension (the EA was abnormal in 68.8% of dogs at T0 and in 81.3% at T1 with p = 0.0024). Six months post-surgery, the ROM value was not normal in 100% of the stifle joints; however, the lameness significantly improved with each procedure. This study confirmed the influence of surgical procedures on changes in ROM and provided useful indications for planning therapy to improve and speed up the postoperative rehabilitation process in dogs.

Influence of Tibial Component Design Features and Interference Fit on Implant-Bone Micromotion in Total Ankle Replacement: A Finite Element Study.

BACKGROUND: Implant survivorship in uncemented total ankle replacement (TAR) is dependent on achieving initial stability. This is because early micromotion between the implant and bone can disrupt the process of osseointegration, leading to poor long-term outcomes. Tibial implant fixation features are designed to resist micromotion, aided by bony sidewall retention and interference fit. The goal of this study was to investigate design-specific factors influencing implant-bone micromotion in TAR tibial components with interference fit. METHODS: Three implant designs with fixation features representative of current TAR tibial components (ARC, SPIKES, KEEL) were virtually inserted into models of the distal tibias of 2 patients with end-stage ankle arthritis. Tibia models were generated from deidentified patient computed tomography scans, with material properties for modeling bone behavior and compaction during press-fit. Finite element analysis (FEA) was used to simulate 2 fixation configurations: (1) no sidewalls or interference fit, and (2) sidewalls with interference fit. Load profiles representing the stance phase of gait were applied to the models, and implant-bone micromotions were computed from FEA output. RESULTS: Sidewalls and interference fit substantially influenced implant-bone micromotions across all designs studied. When sidewalls and interference fit were modeled, average micromotions were less than 11 µm, consistent across the stance phase of gait. Without sidewalls or interference fit, micromotions were largest near either heel strike or toe-off. In the absence of sidewalls and interference fit, the amount of micromotion generally aligned inversely with the size of implant fixation features; the ARC design had the largest micromotion (~540 µm average), whereas the KEEL design had the smallest micromotion (~15 µm). CONCLUSION: This study presents new insights into the effect of TAR fixation features on implant-bone micromotion. With sidewalls and interference fit, micromotion is predicted to be minimal for implants, whereas with no sidewalls and no interference fit, micromotion depended primarily on the implant design. CLINICAL RELEVANCE: This study presents new insights into the effect of TAR primary fixation features on implant-bone micromotion. Although design features heavily influenced implant stability in the model, their influence was greatly diminished when interference fit was introduced. The results of this study show the relative importance of design features and interference fit in the predicted initial stability of uncemented TAR, potentially a key factor in implant survivorship.

Tibialis anterior and extensor hallucis longus tendon ruptures complicating a closed tibial fracture: A case report.

INTRODUCTION AND IMPORTANCE: Acute rupture of the tibialis anterior tendon and other tendons is an extremely rare injury. It is usually associated with minor trauma in older patients with medical comorbidity. Surgeons must be alert for rupture of these tendons which can complicate a closed tibial fracture. CASE PRESENTATION: A 19-year-old man was transferred to the emergency department with a segmental fracture at the lower third of his tibia. The patient could not actively dorsiflex his right ankle and first toe but was able to dorsiflex other toes actively. The tibialis anterior and extensor hallucis longus tendon were discovered torn at the same point, supposedly by a bone spike. The fracture was reduced and fixed and the tendons were repaired. CLINICAL DISCUSSION: A traumatic rupture of the tibialis anterior and extensor hallucis longus tendons occurs rarely in conjunction with or as a consequence of a bony fracture in closed trauma, with only a few cases documented in the literature. They typically occur as a result of direct blunt or penetrating injury. In three papers, the tibial fracture caused a direct rupture in the tendon. We believe that the tendons rubbing against the fractured edges of the segmental bone of the tibia led to the tendons tearing gradually. CONCLUSION: Further investigation is needed for an evaluation of ankle and first toe dorsiflexion to check for a palpable gap in the soft tissues of a lower third tibial fracture. The tibialis anterior and other tendons can be located between the segment of the tibial fracture and ruptured.

Huge Intraneural Ganglion Cyst of Tibial Nerve in a 78-Year-Old Male Patient With Gonarthrosis: A Case Report and Review of the Literature.

Intraneural ganglion cysts (IGCs) are mucinous cysts located within peripheral nerves, often associated with an articular nerve branch and the adjacent synovial joint capsule. These cysts, while rare, can occur in various nerves, with the tibial nerve being an infrequent site. Tibial nerve IGCs are rare pathologies. We present a case of a tibial nerve IGC in a 78-year-old male patient with pre-existing grade III gonarthrosis. Furthermore, we performed a brief review of the existing literature for tibial nerve IGCs. To our knowledge, we present the second case of an IGC in a patient with known pre-existing gonarthrosis. This case raises the potential association between IGCs and degenerative knee pathologies and underscores the crucial role of early and accurate diagnosis. Differential diagnosis of nerve sheath tumors and extra-articular calf neuropathy is essential not only for definitive treatment but also to rule out more serious alternative diagnoses. While ultrasound-guided aspiration of cystic fluid with steroid injection and conservative management are also treatment methods defined in the literature, we believe that exploratory surgery is the critical point of treatment. Early and accurate diagnosis is paramount, as delayed diagnosis and treatment may cause persistent functional and sensory deficits.

Reconstruction of traumatic tibial nerve defect with two parallel conduit strands: a case report.

We herein report a case of traumatic tibial nerve defect involving the ankle joint. A 16-mm-long defect was observed in a 5-mm-diameter tibial nerve. Two 3-mm-inner-diameter PGA-collagen tubes were transferred to the bifurcated tibial nerve. Satisfactory recovery was achieved at 3 year and 9 months postoperatively.

Clinical Outcomes and Long-term Survivorship After Osteochondral Autologous Transfer Combined With Valgus High Tibial Osteotomy: An Analysis After 19 Years With 56 Patients.

BACKGROUND: Osteochondral defects of the medial femoral condyle combined with varus malalignment in young and active patients are a debilitating condition, which can result in early osteoarthritis. Osteochondral autologous transfer (OAT) combined with valgus high tibial osteotomy (HTO) might therefore be a comprehensive solution to maintain long-term knee function. PURPOSE/HYPOTHESIS: The purpose of this study was to report clinical results and survivorship after combined OAT and valgus HTO for symptomatic osteochondral defects of the medial femoral condyle in the setting of varus malalignment at a long-term follow-up. It was hypothesized that undergoing combined OAT and valgus HTO would produce favorable clinical results along with a low rate of conversion to arthroplasty. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All patients treated between 1998 and 2008 with combined valgus HTO and OAT for deep osteochondral defects of the medial femoral condyle and concomitant varus malalignment >2° without meniscal repair/transplantation, osteoarthritis, or ligamentous instability/reconstruction were included. The survival rates of this combined procedure were evaluated. Failure was defined as conversion to knee joint arthroplasty during the follow-up period. Patient-reported outcomes were collected pre- and postoperatively, including the Lysholm score, visual analog scale score, Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale score, and subjective level of satisfaction (scale 0-10). RESULTS: Of 74 patients who were included for 10-year follow-up, 3 had died. A total of 15 patients were lost to follow-up, so 56 patients could be reevaluated, for a follow-up rate of nearly 80%. The mean age at surgery was 38.8 ± 9.9 years (range, 19.9-62.4 years), and the mean follow-up time was 18.9 ± 3.0 years (median, 18.8 years; range, 14.1-24.8 years). The survival rates were 87% at 10 years, 86% at 15 years, and 77% at 19 years after surgery. At final follow-up, the Lysholm score showed a mean increase of 39 points (95% CI, 25.4-50.0 points; P < .001) from 40 points to 79 points, representing a significant improvement. Overall, 96% of patients surpassed the minimal clinically important difference (MCID) for the Lysholm score. The visual analog scale score decreased by a mean of 4.8 points (range, 5-10 points) from 7.5 points to 2.7 points (P < .001), and 80% of patients surpassed the MCID. The mean Tegner Activity Scale score was 4.5 ± 1.6, and the mean KOOS subscale scores at final follow-up were as follows: Pain: 81 ± 21 (range, 19-100), Symptoms: 80 ± 22 (range, 21-100), Activities of Daily Living: 85 ± 21 (range, 18-100), Sports: 68 ± 32 (range, 0-100), and Quality of Life: 67 ± 28 (range, 0-100). Overall, 78% of the patients were satisfied with the results of the operation. CONCLUSION: The combination of OAT and valgus HTO presents a viable treatment option for patients affected by osteochondral defects of the medial femoral condyle and concurrent varus malalignment. A sustained and substantial improvement in clinical outcomes, significantly reduced pain severity, and a high rate of long-term survivorship can be anticipated in the long-term follow-up.

Peak tibial accelerations in different foot strike patterns during level running: an independent investigation in different cohorts.

Peak tibial accelerations are used to monitor impact severity during distance running and as input for bio-feedback. Here, peak tibial accelerations were compared between rearfoot and forefoot strikes. Two different studies were undertaken by independent research centres. Tibial acceleration and optical motion capture were collected in 14 rearfoot strikers who changed to a forefoot strike in the first centre. In the second centre, tibial acceleration of 14 other rearfoot strikers and nine forefoot strikers were collected and processed. In over-ground level running at a submaximal speed, the resultant peak tibial acceleration was greater in the instructed forefoot strike condition (ΔX = 7.6 ± 1.3 g, mean ± standard error difference) and in the habitual forefoot strikers (ΔX- = 3.7 ± 1.1 g) than in the rearfoot strikers. The shank kinematics revealed a greater decrease in antero-posterior velocity following touchdown in the forefoot strike condition. The forefoot strikes experienced greater posterior tibial acceleration, which resulted in an increased resultant peak tibial acceleration that also occurred earlier than in the rearfoot strikes. No significant difference in axial peak tibial acceleration was found between these foot strike patterns. In conclusion, the foot strike pattern differently affects peak tibial accelerations in level running, which can have implications for monitoring and biofeedback applications.

Application of a customized 3D-printed osteotomy guide plate for tibial transverse transport.

Enhance the efficiency of tibial transverse transport by employing customized 3D-printed osteotomy guide plates and striving to improve precision through CT evaluation for enhanced guide design. 17 diabetic foot patients were treated with the plate for tibial transverse transport. Preoperatively, we collected DICOM data from the affected tibia's CT and designed the geometric parameters of the tibial cortical bone window. A customized 3D-printed osteotomy guide plate was then fabricated using 3D printing technology. Postoperative X-ray and CT evaluations, conducted at two and five weeks post-surgery, assessed five crucial geometric parameters of the bone window. Measurements included the distance from the upper edge of the tibial cortical bone window to the tibial plateau, the distance from the anterior edge of the tibial cortical bone window to the bone ridge, the height of the tibial cortical bone window, the center-to-center distance between the 4.0 mm diameter Schanz pin and the osteotomy Kirschner pin, and the center-to-center distance of the 4.0 mm diameter Schanz pin. These measured parameters were subsequently compared to the preoperative design parameters. The Clinical trial registration number is ChiCTR2400087174. CT measurements showed no significant differences (P > 0.05) from preoperative design parameters across the five evaluated aspects. The average osteotomy duration was 35 ± 15 min with no bone window fractures. The bone window aligned effectively with the tibial shaft, achieving complete incorporation after distraction. A 4 to 8-month postoperative follow-up confirmed full healing of the tibial surgical wound and diabetic foot wounds. Utilizing customized 3D-printed osteotomy guide plates in tibial transverse bone transport surgery enables accurate translation of preoperative virtual designs into real-time procedures, enhancing surgical efficiency and quality.

Consent in Limb Lengthening Surgery: Predicting the True Incidence of Material Risk.

Aim: The consent process involves supported decision-making between the surgeon and the patient. Both potential benefits and material risks of the procedure require explanation, with adequate time for reflection. The complexity of limb reconstruction surgery includes the potential for multiple types of complications. In an attempt to delineate the material risks in lower limb lengthening, a literature review was undertaken to ascertain the published rates of complications. Materials and methods: A review of articles from 2003 to 2023 via PubMed and Google Scholar, including keywords 'lengthening', 'tibia', 'lengthening nail' and 'external fixator' was undertaken. Studies with a minimum of 20 patients, undergoing lengthening of the femur, tibia, or both by an external fixator and/or an intramedullary lengthening nail were included for analysis. Complications were reported according to Paley's problems, obstacles, and complications. Results: Twenty-two papers met the inclusion criteria. The commonest complications listed following lengthening using an external fixator were pin site infections (52% in the femur and 18.8% in the tibia), delayed consolidation (8.3%), bone re-fracture (13%), and joint stiffness (18.8%). Following femoral lengthening using the intramedullary lengthening nails reported complication rates were lower, including implant issues (8%) and delayed consolidation (6%). Conclusion: Patients require a full understanding of both benefits and potential harms when undergoing any surgical intervention. Our study has identified the published rates of complications following lower limb lengthening. These figures can be used to guide the consultation and enable surgeons to audit their own surgical results against the published literature. How to cite this article: Makvana S, Robertson A, Britten S, et al. Consent in Limb Lengthening Surgery: Predicting the True Incidence of Material Risk. Strategies Trauma Limb Reconstr 2024;19(2):61-66.

Medial Closing Wedge High Tibial Osteotomy Accurately Corrects Genu Valgum without Iatrogenic Deformity or Complications: A Consecutive Series of Thirty-one Procedures.

Introduction: Angular deformities of the tibia and femur lead to mechanical axis deviation (MAD) of the lower limb and malorientation of the joints adjacent to the deformity. The current study analyses the outcomes of using a medial closing wedge high tibial osteotomy (MCWHTO) for the management of genu valgum with high medial proximal tibial angle (MPTA), and combined MCWHTO with lateral opening-wedge distal femoral osteotomy (LOWDFO) in the setting of concomitant genu varum with low lateral distal femoral angle (LDFA). Methods: There were 18 high tibial osteotomy (HTO)-only and 13 combined HTO + distal femoral osteotomy (DFO) procedures performed. The primary radiographic outcome variables included postoperative MPTA and MAD (in mm). The accuracy of MAD correction was expressed as a percentage. The postoperative posterior proximal tibial angle (PPTA) and limb length discrepancy (LLD) were also measured as secondary radiographic outcome variables. The clinical outcome variables included intraoperative surgical complications (e.g., hinge fracture), all-causes for revision, union rate, time to union, and postoperative knee range of motion. Functional outcomes used included the LDSRS, PROMIS, and EuroQOL scores. Results: The mean preoperative MPTA was 92.9° (SD = 1.81, range: 88-96). After surgical correction, the mean MPTA was 86.0° (SD = 1.80, range: 83-90) (p < 0.0001). The mean preoperative MAD was 32.5 mm (SD = 20.16, range: 10-77) lateral to the centre of the knee joint. The mean postoperative MAD was 2.44 mm medial to the centre of the joint (SD = 7.13, range: 13 medial - 15 lateral) (p < 0.0001). The mean change in MAD achieved through surgical correction was 38.16 mm (SD = 17.94, range: 13-77). The accuracy of MAD correction was 96.1% (SD = 0.06%, range: 81.25-100%). The time to unassisted WB was a mean of 75 days (SD = 44.5, range: 44-242).There was a single stable hinge fracture and one case of chronic regional pain syndrome diagnosed. There were no cases of non-union and no indications for revision surgery in any case. Conclusion: Medial closing wedge high tibial osteotomy is an effective surgical procedure for the management of genu valgum deformity. The MPTA, LDFA, and MAD can be accurately corrected without significantly altering PPTA or limb length. It may be combined with open lateral distal femoral osteotomy for cases with femoral and tibial contributions to deformity without significantly impacting clinical outcomes. Functional outcomes, specifically relating to self-image are significantly improved after the MCWHTO has been performed. How to cite this article: Sheridan GA, Page BJ, Greenstein MD, et al. Medial Closing Wedge High Tibial Osteotomy Accurately Corrects Genu Valgum without Iatrogenic Deformity or Complications: A Consecutive Series of Thirty-one Procedures. Strategies Trauma Limb Reconstr 2024;19(2):82-86.

Comparison of Duplex Ultrasound and Digital Subtraction Angiography for Assessing Tibial Vessel Disease.

Background Duplex ultrasonography (DUS) is readily available and often used as the first diagnostic test for patients with peripheral artery diseases (PADs). PAD is a disease that affects the general population but more commonly affects diabetics. To date, the role of DUS in the assessment of tibial vessel disease is inconclusive at best. The goal of our study is to assess the validity of DUS in characterizing the presence and severity of tibial diseases via comparison with digital subtraction angiography (DSA) findings. Methods This is a single-center retrospective cohort study analyzing three arterial segments (anterior tibial, posterior tibial, and fibular arteries) in patients who received a duplex study followed by DSA within a 30-day period. All arterial segments were graded from normal (Grade 0) to occluded (Grade 4), based on duplex interpretation and directly compared to direct visualization findings from DSA. Using statistical methods, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of DUS were determined. Results A total of 171 tibial vessel segments from 57 enrolled subjects with critical limb ischemia symptoms were analyzed in this study. The agreement between both modalities was poor (Kappa=0.19, p < 0.05), with DUS demonstrating a significant underestimation of vessel pathologies. This is also reflected by the overall sub-optimal sensitivity (23%), specificity (84%), PPV (69%), and NPV (41%) in DUS when compared to DSA results as the gold standard. Conclusion Significant disagreements were noted in this study between DUS and DSA findings, primarily significant underestimation of tibial vessel disease by the DUS when compared with the DSA. Caution is advised in the clinical application of DUS in patients with chronic limb-threatening ischemia (CLTI) symptoms and multi-segment tibial vessels due to its demonstrated limitations in this study.

Occurrence of Patellofemoral Joint Osteoarthritis in Long-Term Postoperative Cases of Open-Wedge High Tibial Osteotomy: Differences in Symptoms Based on Patient-Standing Type Evaluation with and Without Patellofemoral Joint Osteoarthritis.

Purpose: To examine the frequency of patellofemoral joint (PFJ) osteoarthritis (OA) and its symptoms in the long-term course of open-wedge high tibial osteotomy (OWHTO). Methods: We analyzed 113 joints of 91 patients. OA and osteonecrosis (ON) developed in 91 and 22 joints, after an average postoperative period of 127.5 ± 19.5 months. For X-ray evaluation, the standing femorotibial angle (FTA), % mechanical axis (%MA), Caton-Deschamps index (CDI), patellar tilt angle (TA), lateral patellar shift (LPS), and PFJ space width (medial [MJS] and lateral [LJS]) were analyzed. PFJ-associated symptoms were evaluated using the hospital for special surgery patellar score (HSS-PS) and knee injury and osteoarthritis outcome score patellofemoral subscale (KOOS-PF). Statistical analysis was performed with paired and unpaired t tests, and a risk rate of less than 1% was significantly judged. Results: Preoperative FTA and CDI decreased from 180.8° to 170.0° and 0.88 to 0.70 at the final follow-up. Preoperative %MA lateralized from 20.8 to 66.0 at the final follow-up. TA and LPS values decreased significantly compared with before surgery until plate removal. The MJS and LJS significantly decreased, and OA with a joint space < 3 mm occurred in 14 cases. However, HSS-PS and KOOS-PF scores were not significantly different between the groups with and without OA. Conclusion: PFJ OA occurred in 12.4% cases in the long-term postoperative course of OWHTO; however, no symptomatic difference was found in the group with or without OA. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-024-01250-z.

Anterior or Posterior Tibial Tendon Transfer to the Peroneus Tertius for Equinovarus Deformity.

BACKGROUND: Equinovarus deformity correction was performed by soft tissue release and bone deformity correction, and tendon transfer to maintain deformity correction. Because of the high complication rate of tendon fixation methods, partial or total anterior tibial tendon or posterior tibial tendon transfer to the peroneus tertius tendon was reported. The purpose of this study was (i) to review the results of this tendon transfer technique after release and correction of talipes equinovarus, and (ii) to analyze the complication of this technique. METHODS: Between February 2017 and May 2022, 176 patients (210 feet) with equinus and/or varus foot and ankle deformities underwent anterior or posterior tibial tendon transfer to the peroneus tertius in our institute. Preoperative and postoperative foot and ankle range of motion (passive and active) were checked. The postoperative radiographic assessment included antero-posterior (AP), lateral, and hindfoot alignment radiographs. Preoperative and postoperative lateral tibio-talar, talo-calcaneal, talo-first metatarsal, tibial-sole angles, hindfoot alignment, and anterior subluxation of the talus were checked. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and visual analog scale (VAS) were used to assess pain. Paired Student's t-test was used to compare the clinical scores and radiographic angles before the operation and at the last follow-up. RESULTS: The mean age of the patients was 23.27 ± 13.44 years (range, 3-69 years). The mean follow-up time was 25.56 ± 16.37 months (range, 12-68 months). There were significant differences between the preoperative and postoperative measurements of the lateral tibio-talar angle, lateral talo-calcaneal angle, lateral talo-first metatarsal angle, lateral tibial-sole angle, and hindfoot alignment (p < 0.001). There was significant difference between the preoperative and postoperative AOFAS and VAS scores (p < 0.001). The early complications included infection in one patient, skin necrosis in two patients, and plantar numbness in three patients. The late complications included pin infection in three patients, tibio-talar joint compression in four patients, forefoot pain in two patients, toe flexion in two patients, and plantar numbness in one patient. There were three cases of complications (1.43%) related to the transferred tendons. CONCLUSION: Tibialis anterior or posterior tendon transfer to the peroneus tertius is a safe and effective method for equinovarus deformity correction. It yielded excellent outcomes that produced high patient satisfaction and few complications.

How Does the Stress in the Fixation Device Change during Different Stages of Bone Healing in the Treatment of Fractures? A Finite Element Study of External Fixation for Tibial Fractures.

BACKGROUND: Although the specific relationship between the stress changes in the external fixator during tibial fracture treatment and the bone healing process remains unclear, it is believed that stress variations in the external fixator scaffold can, to a certain extent, reflect the progress of tibial healing. OBJECTIVE: This study aims to propose a non-invasive method for assessing the degree of fracture healing by monitoring the changes in stress transmission, the locations of stress-sensitive points, and displacement in the external fixator-tibia system during the healing process of tibial fractures. METHODS: In this study, finite element models of tibial fractures at various healing stages were developed. Physiological conditions, including axial, torsional, and bending loads on the tibia, were simulated to evaluate stress and strain within the external scaffold-tibia system under normal physiological loading conditions. RESULTS: The results indicate variations in the stress distribution between the external fixator and the tibia during different stages of healing. In the early phase of fracture healing, the external fixator plays a crucial role as the primary load-bearing unit under all three loading conditions. As the fracture healing progresses, the stress on the tibia gradually increases, concentrating on the medial part of the tibia under axial and torsional loading, and at the upper and lower ends, as well as the central part of the anterior and posterior tibia during bending loading. The stress at the callus gradually increases, while micro-movements decrease. The stress within the external bracket gradually decreases, with a tendency for the connecting rod to transfer stress towards the screws. Throughout the fracture healing process, the location of maximum stress in the external fixator remains unchanged. Under axial and torsional loading, the maximum stress is located at the intersection of the lowest screw and the bone cortex, while under bending loading, it is at the intersection of the second screw and the connecting rod. CONCLUSION: During the bone healing process, stress is transferred between the external fixation frame and the bone. As bone healing advances, the stress on the connecting rods and screws of the external fixation frame decreases, and the amplitude of stress changes diminishes. When complete and robust fusion is achieved, stress variations stabilize, and the location of maximum stress on the external fixation frame remains unchanged. The intersections of the lowest screw and the bone cortex, as well as the second screw and the connecting rod, can serve as sensitive points for monitoring the degree of bone healing.

Exploring the Changes in IL-6 and Related Cytokines in Angiogenesis after Tibial Transverse Transplantation in Diabetic Foot Ulcers.

OBJECTIVE: The transverse tibial transfer technique is employed primarily to treat diabetic foot ulcers (DFUs), aiming to enhance leg circulation and promote new blood vessel growth. This technique is also beneficial for various conditions associated with poor blood flow in the lower extremities. However, there is no clear molecular mechanism to explain the relationship between the transverse tibial transfer technique and angiogenesis in patients with diabetic foot. This study aims to preliminarily explore the change of IL-6 and related cytokines in promoting angiogenesis during transverse tibial transplantation, providing a direction for future research. METHODS: We retrospectively assessed a study from April 2022 to November 2023 on 76 patients with severe DFUs at Wagner stages 3-4. Flow cytometry was used to detect the levels of 12 cytokines in serum before the operation and 3, 7, 14, 21, and 35 days after the operation. Ankle-brachial index (ABI), transcutaneous oxygen tension (TcPO2), and glycosylated hemoglobin (Hba1c) were recorded at admission and discharge. We examined the variations in cytokine levels, wound healing duration, amputation rates, infection incidence, and other key outcomes. RESULTS: In our investigation, a total of 76 individuals participated, comprising 49 males and 27 females. These subjects had an average age of 64.7 years, with a standard deviation of 13 years. The mean ulcer healing time was 74 ± 31 days, amputation occurred in 3 patients, pin tract infection occurred in one patient (1.3%), and incision infection occurred in one patient (1.3%). By day 35 following the surgery, both the ABI and TcPO2 values showed a significant increase from their preoperative levels. HbA1c significantly improved compared with presurgery (p < 0.001), IL-6 levels were significantly increased compared with presurgery (p < 0.05), and then decreased. CONCLUSION: The transverse tibial transfer (TTT) technique is safe and efficient for managing DFUs. The wound healing time in patients who smoke or consume alcohol is statistically significant compared with that of nonsmoking and nondrinking patients. IL-6 exhibited substantial changes at various postoperative time points. Future research could investigate the role of IL-6 in tibial transverse translation.