Elastic stable intramedullary nail combined with Kirschner wire (E-K) technique for treating pediatric distal tibial diaphyseal metaphyseal junction (DTDMJ) fractures.

Objective: Elastic stable intramedullary nail (ESIN) is a commonly used method for treating diaphyseal fractures of the tibia, but its application in Distal Tibial Diaphyseal Metaphyseal Junction (DTDMJ) fractures has been a subject of controversy. This study aims to evaluate the clinical efficacy of the Elastic stable intramedullary nail-Kirschner wire (E-K) technique in treating pediatric DTDMJ fractures, providing better clinical decision-making for clinicians in diagnosing and treating such fractures. Methods: We conducted a retrospective analysis of patients aged 3-9 years who received treatment at our hospital from January 2019-January 2021 for distal tibial diaphyseal metaphyseal junction (DTDMJ) fractures. Based on their surgical procedures, they were categorized into the Elastic Stable Intramedullary Nail-Kirschner wire group (E-K) and the ESIN group. Demographic data, surgical duration, clinical outcomes, complications, and imaging data were recorded. Results: The study included a total of 57 patients, with 24 cases in the E-K group and 33 cases in the ESIN group. There were 30 males and 27 females. The average age was (6.25 ± 1.59) years in the E-K group and (6.27 ± 1.48) years in the ESIN group. There were no significant differences between the two groups in terms of gender, age, weight, time from injury to surgery, follow-up time, side of injury, associated injuries, nail site infection, deep infection, and nail removal time (P > 0.05). Neither group experienced nonunion or refracture. The E-K group exhibited significantly lower coronal and sagittal plane angular values at the final follow-up compared to the ESIN group (P < 0.001). In the E-K group, the final follow-up coronal plane angle was 2.67 (1.09)°, while in the ESIN group, it was 6.55 (2.05)°. The final follow-up sagittal plane angle was 3.12 (1.54)° in the E-K group and 7.58 (1.48)° in the ESIN group. Both groups showed good alignment in the initial postoperative x-rays, with no statistically significant differences. However, during clinical healing, the ESIN group exhibited significant displacement, whereas the E-K group had minimal displacement, demonstrating a significant statistical difference (P < 0.001). There was a statistically significant difference in the AOFAS joint function assessment between the two groups (P = 0.027). Conclusion: The E-K technique is a viable option for treating DTDMJ fractures in pediatric patients, with well-established clinical efficacy. Its advantages include a straightforward surgical procedure, safety, and a low incidence of severe complications.

Infrapatellar branch of the saphenous nerve lesion following tibial nailing: it is possible to avoid it?

BACKGROUND: Iatrogenic injury to the infrapatellar branches of saphenous nerve is a common complication following tibial nailing. This lesion seems to be directly related to the surgical approach adopted for nail insertion. The aim of the present study was to systematically review the current literature in order to assess the eventual superiority of one surgical approach for tibial nailing over the others in limiting the neurological impairment related to infrapatellar branch injury. MATERIALS AND METHODS: The available literature was systematically screened searching papers dealing with iatrogenic injury to the infrapatellar branch of saphenous nerve after intramedullary tibial nailing. The terms "Saphenous" and "Infrapatellar branch" were used in combination with "intramedullary nailing" and "tibial fractures", supplying no limits regarding the publication year. Only publications in English were considered. Case reports, technical notes, instructional course, literature reviews, biomechanical and/ or in vitro studies were all excluded. Coleman methodological score was performed in all the retained articles. RESULTS: Four articles matched the inclusion criteria. There were one original article and three retrospective study. Hypoesthesia and a larger extension of the area of sensory-loss were more frequently observed after vertical incision approach in three out of four articles. A trend towards a lower rate of iatrogenic nerve damage using a transverse incision was found in the remaining one, without any statistical significance. CONCLUSIONS: In order to avoid infrapatellar nerve lesion, horizontal or oblique incisions or percutaneous approaches should be favored, although in some cases a longitudinal incision is required. Limited-extension incisions could minimize the risk and the incidence of this complication.

Tibial Eminence Avulsion in a Tibial Plateau Fracture - Our Approach: A Clinical Case.

A middle-aged female patient with a tibial plateau fracture combined with an avulsion of the tibial eminence was treated with a combination of medial plate fixation for the plateau and an arthroscopic aided nonabsorbable suture of the eminence. Our technique for tibial eminence avulsion fractures has no interference with tibial plateau osteosynthesis materials and has proven, once again, to have good results in the treatment of combined and complex injuries of the knee.

Nationwide study on open tibial fractures in the Netherlands: Incidence, demographics and level of hospital care.

OBJECTIVES: Open tibial fractures are relatively common injuries following traffic accidents. The vulnerability of the soft tissues surrounding the tibia increases the susceptibility to complications, including infection and nonunion. To minimize complications, a multidisciplinary, timely approach is crucial. To date, the Dutch incidence and level of hospital treatment remain unknown due to a lack of condition-specific nationwide registries. This study aimed to estimate the incidence and management of open tibial fractures in the Netherlands, providing essential information for public health policymaking and guideline development. METHODS: The 2018 and 2019 Dutch National Hospital Care Basic Registration data, provided by the Dutch Hospital Data Foundation, were utilized to identify all patients admitted to Dutch hospitals with tibial fractures. Incidence rates, patient demographics, primary diagnoses, fracture classification, level of hospital, and length of hospital stays were analyzed using descriptive statistics. RESULTS: 1,079 ICD-10 codes for closed and open tibial fractures were identified in patients that were admitted to a Dutch hospital. Thirty-four percent were classified as open tibial fractures, accounting for an estimated incidence rate of 1.1 per 100,000 person-years (95 % CI 0.97-1.12). When categorized by age, the calculated incidence rate was higher in males for all age categories up until the age of 70. Notably, the overall highest incidence rate was found for females aged 90 and above (6.6 per 100,000 person-years). Open tibial fractures were predominantly treated in general or top clinical hospitals (comprising 69 % of open all tibia fractures). Notably, the minority (31 %) presented at university medical centers, all Level-1 trauma centers, equipped with orthoplastic teams. CONCLUSION: This is the first study to report the nationwide incidence rate of open tibial fractures in the Netherlands; 34 % of tibial fractures were registered as open. Notably, a limited proportion of open tibial fractures underwent treatment within Level-1 trauma centers. Consequently, in the majority of cases, the implementation of an orthoplastic team approach was unattainable. This study underscores the need for more comprehensive data collection to assess and improve the current treatment landscape.

Poller Screws and Post-Operative Pain Relief in Tibial Fractures.

Introduction Poller screws optimise fracture alignment in those fractures managed with intramedullary (IM) nails. They enhance stability, control nail insertion, and prevent translation. Indications encompass acute fractures, delayed unions/non-unions, and deformity. Classified into four generations, they've shown positive outcomes: improved alignment, reduced complications, and shorter healing. However, their pain management impact is understudied. This retrospective cohort study aimed to compare opioid medication needs in tibial fractures managed with IM nails with and without poller screws. Methods Between January 2015 and December 2022, a retrospective analysis was conducted on tibial fractures treated at a major trauma centre. Patients primarily treated with IM nails were included. Patient and operation notes as well as radiographs, were reviewed to identify poller screw utilisation. Opioid medication data was collected and converted to "coverage" (days) and "strength" (morphine milligrams equivalent or MME). Two-tailed independent samples T-tests were performed to determine differences between patients treated with (n=205) and without poller screws (n=540). Results Patients with poller screws had fewer days with opioid prescriptions in the second post-operative month (6.8 vs. 8.9 days, p=0.038) and significantly lower opioid strength requirements across the first post-operative year (688.4 vs. 1295.4 MME, p=0.001), except the first month. Conclusion There is limited research on the connection between poller screws and pain. This study discusses their potential to reduce post-operative pain in tibial fractures. The results highlight the importance of using poller screws alongside IM. This combination appears to be effective in improving post-operative pain management and enhancing overall patient outcomes.

Refracture-related bone transport of tibia: technical notes and preliminary clinical results in nineteen cases.

PURPOSE: Refracture is one of the main complications of bone transport, which brings additional physical and mental burden to surgeries and patients. We aimed to raise a new classification system of refracture-related bone transport based on the Simpson classification and to present our experience on treatment. METHODS: This retrospective analysis included 19 patients with refracture-related bone transport (average age of 37.7 years; 18 men). We developed a modified Simpson classification system to assist decision-making (conservative versus surgical). The ASAMI criteria were used to assess the outcomes at last follow-up. RESULTS: The mean follow-up was 12.3 ± 3.2 months. Complete union was achieved in all patients, with no reinfection. Based on the modified Simpson classification, refracture was Ia type (within regeneration area) in three cases, Ib (collapsed fracture at the regeneration area) in one case, Ic (stress fracture) in three cases, II (at the junction between the regenerate and original bone) in one case, III (at the docking site) in nine cases, and V (at distant site) in two cases. Refracture was managed conservatively in six cases and surgically in 13 cases. Average time to bone union was 2.8 ± 1.2 months in the conservative group versus 4.4 ± 1.4 months in the surgery group. Assessment at the final follow-up using the ASAMI criteria revealed excellent bone result in all patients, excellent functional results in six patients (31.6%), and good functional results in 13 patients. CONCLUSIONS: The modified Simpson classification could include refracture at the docking site and stress fracture in the regeneration zone and provide some guidance in determining the appropriate treatment strategy.

Illicit drug abuse and complexity of tibial shaft fracture based on AO/OTA classification: Is there any connection?

Purpose: Illicit drug abuse is a global epidemic afflicting millions worldwide. Several studies have investigated the contribution of this dependence as a risk factor for fracture, but its impacts on fracture severity have been rarely studied. The present study primarily aims to determine the relationship between illicit drug abuse and the severity of tibial shaft fractures. Methods: This retrospective study consecutively included patients aged ≥18 years with tibial shaft fracture who attended Sina Tertiary Hospital, Tehran, Iran, between 2016 and 2021. The fracture patterns were assessed according to the Arbeitsgemeinschaft für Osteosynthesefragen Foundation/Orthopaedic Trauma Association classification. Participants were divided into three individual specialists into groups: simple (A), wedge (B) and multifragmentary (C) fractures. The association of illicit drug abuse and other recorded variables, including age, sex, body mass index (BMI), comorbidities, physical activity, smoking habits and mechanism of injury, was also examined and assessed in multivariate logistic regression. Results: Of 219 patients, 26 were drug abusers, and 193 had no history of use. A total of 20 out of 26 drug abusers experienced a complex fracture, yielding a rate of 76.9%, while this rate for nonusers was 50.3% (97 out of 193), indicating a statistically significant difference between the two subgroups (p = 0.011). The smoking history also influenced the fracture pattern (p = 0.027) based on univariate analysis; however, using adjusted multivariate analysis yielded only illicit drug abuse (odds ratio = 3.495; confidence interval = 1.144-10.680) as a risk factor for more complex fractures. Conclusion: The evidence from this study suggests that complexity and fracture patterns can depend on illicit drug abuse history. Level of Evidence: Level III.

[Analysis of the risk factors for delayed union of extra-articular fractures of the middle and lower third of the tibia treated by locking plate].

OBJECTIVE: To investigate the risk factors for delayed union of extra-articular fractures of the middle and lower third of the tibia treated by locking plate. METHODS: Total of 135 patients of extra-articular fractures of the middle and lower third of the tibia from January 2013 to December 2018 were retrospectively analyzed, including 85 males and 50 females, ranged from 19 to 80 years old. All cases were treated with locking plates. The patients were divided into union group and delayed union group according to the condition of fracture union. The risk factors of delayed healing were determined by univariate analysis of 14 factors that might affect fracture healing first, then the factors with significance were analyzed by binary Logistic regression. RESULTS: There were 13 patients of delayed union, and the rate of delayed union was 9.63%. Univariate analysis showed that delayed union was associated with age, smoking, reduction method, anemia and time of preoperative preparation. Regression analysis showed that age[OR=0.849, 95%CI（0.755, 0.954）, P=0.006], smoking[OR=0.020, 95%CI（0.002, 0.193）, P=0.001], reduction method[OR=23.924, 95%CI（2.210, 258.943）, P=0.009], anemia[OR=0.016, 95%CI（0.001, 0.289）, P=0.005] were the contributory factors for delayed union. CONCLUSION: Young age, smoking, closed reduction and anemia are the risk factors for delayed union of extra-articular fractures of the middle and lower third of the tibia treated by locking plate.

External Fixation as a Primary and Definitive Treatment for Complex Tibial Diaphyseal Fractures: An Underutilized and Efficacious Approach.

Background: External fixation is one of the most often utilized treatment options for complicated tibial diaphyseal fractures (TDF). The purpose of this study was to assess the efficacy of unilateral external fixators as primary and definitive therapy for complex TDF in a resource-limited setting. Materials and Methods: A retrospective study between June 2016 and March 2021 included 110 subjects with TDF who were treated with an external fixator as definitive fixation in hospitals affiliated with Ibb University. The patient's demographic characteristics, complications, and outcomes were gathered and analyzed. Factors associated with pin site infection were also investigated. Results: The mean age was 42.1 ± 10.1 years, with 92.7% being male. Rural residents accounted for 22.7%. Smoking and diabetes mellitus were present in 27.3% and 30.0%, respectively. General complications occurred in 12.0%, with pulmonary embolism being the most common at 4.5%. Orthopedic complications included pin-track infections in 27.3% (30) and osteomyelitis in 1.8% (2). Pin site infections required medical treatment in 21 cases and external fixator changes in five. Two cases each needed several debridements for osteomyelitis and soft tissue. Full union occurred in 79.1% (87) over 23.1 ± 3.2 weeks and final alignment in 97.3% (107) over 34.8 ± 4.8 weeks. Malunions occurred in 1.8% (2), and one case had hypertrophic nonunion. Factors like rural residency, smoking, diabetes, open fractures, worst fracture grade (Gustilo and Anderson type C), and general complications occurrence significantly correlated with pin site infection (all p-values < 0.05). Conclusion: A unilateral external fixator as a primary and definitive treatment is a viable, simple, and effective option for TDF with a high success rate even in a resource-limited setting. In this study, residents in rural areas, smoking, diabetes, open fracture, worst fracture grade, and general complication occurrence were associated with pin site infection occurrence.

Hexaxial external fixator versus intramedullary nail in treating segmental tibial fractures: a retrospective study.

BACKGROUND: It's difficult to treat segmental tibial fractures (STFs), which are intricate injuries associated with significant soft tissue damage. The aim of this study was to compare the clinical effect of hexaxial external fixator (HEF) and intramedullary nail (IMN) in treatment of STFs. METHODS: A total of 42 patients with STFs were finally recruited between January 2018 and June 2022. There were 25 males and 17 females with age range of 20 to 60 years. All fractures were classified as type 42C2 using the Arbeitsgemeinschaftfür Osteosythese/Orthopaedic Trauma Association (AO/OTA) classification. 22 patients were treated with HEF and 20 patients were treated with IMN. The condition of vascular and neural injuries, time of full weight bearing, bone union time and infection rate were documented and analyzed between the two groups. The mechanical medial proximal tibial angle (mMPTA), mechanical posterior proximal tibial angle (mPPTA), mechanical lateral distal tibial angle (mLDTA), mechanical anterior distal tibial angle (mADTA), hospital for special surgery (HSS) knee joint score, American Orthopaedic Foot and Ankle Society (AOFAS) ankle joint score, range of motion (ROM) of flexion of keen joint and ROM of plantar flexion and dorsal flexion of ankle joint were compared between the two groups at the last clinical visit. RESULTS: There were no vascular and neural injuries or other severe complications in both groups. All 22 patients in HEF group underwent closed reduction but 3 patients in IMN group were treated by open reduction. The time of full weight bearing was (11.3 ± 3.2) days in HEF group and (67.8 ± 5.8) days in IMN group(P < 0.05), with bone union time for (6.9 ± 0.8) months and (7.7 ± 1.4) months, respectively(P < 0.05). There was no deep infection in both groups. In the HEF group and IMN group, mMPTA was (86.9 ± 1.5)° and (89.7 ± 1.8)°(P < 0.05), mPPTA was (80.8 ± 1.9)° and (78.6 ± 2.0)°(P < 0.05), mLDTA was (88.5 ± 1.7)° and (90.3 ± 1.7)°(P < 0.05), while mADTA was (80.8 ± 1.5)° and (78.4 ± 1.3)°(P < 0.05). No significant differences were found between the two groups at the last clinical visit concerning HSS knee joint score and AOFAS ankle joint score, ROM of flexion of keen joint and ROM of plantar flexion of ankle joint (P > 0.05). The ROM of dorsal flexion of ankle joint in IMN group was (30.4 ± 3.5)°, better than (21.6 ± 2.8)° in HEF group (P < 0.05). CONCLUSION: In terms of final clinical outcomes, the use of either HEF or IMN for STFs can achieve good therapeutic effects. While HEF is superior to IMN in terms of completely closed reduction, early full weight bearing, early bone union and alignment. Nevertheless, HEF has a greater impact on the ROM of dorsal flexion of the ankle joint, and much more care and adjustment are needed for the patients than IMN.

Estimating the economic impact of complications after open tibial fracture: A secondary analysis of the pilot Gentamicin Open Tibia trial (pGO-Tibia).

Objectives: To estimate the indirect economic impact of tibial fractures and their associated adverse events (AEs) in Tanzania. Design: A secondary analysis of the pilot Gentamicin Open (pGO)-Tibia randomized control trial estimating the indirect economic impact of suffering an AE, defined as a fracture-related infection (FRI) and/or nonunion, after an open tibial fracture in Tanzania. Setting: The pGO-Tibia trial was conducted from November 2019 to August 2021 at the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania. Patients/Participants: One hundred adults with open tibial shaft fractures participated in this study. Intervention: Work hours were compared between AE groups. Cost data were analyzed using a weighted-average hourly wage and converted into purchasing power parity-adjusted USD. Main Outcome Measurements: Indirect economic impact was analyzed from the perspective of return to work (RTW), lost productivity, and other indirect economic and household costs. RTW was analyzed using a survival analysis. Results: Half of patients returned to work at 1-year follow-up, with those experiencing an AE having a significantly lower rate of RTW. Lost productivity was nearly double for those experiencing an AE. There was a significant difference in the mean outside health care costs between groups. The total mean indirect cost was $2385 with an AE, representing 92% of mean annual income and an increase of $1195 compared with no AE. There were significantly more patients with an AE who endorsed difficulty affording household expenses postinjury and who borrowed money to pay for their medical expenses. Conclusions: This study identified serious economic burden after tibial fractures, with significant differences in total indirect cost between those with and without an AE. Level of Evidence: II.

Gait and strength assessment following surgical repair by intramedullary nailing of isolated tibial shaft fracture.

The objective of the study was to evaluate the long-term strength and gait outcomes after intramedullary nailing of isolated tibial diaphyseal fractures. This retrospective cohort study was conducted at an academic Level I trauma center. Fifteen participants with isolated tibial diaphyseal fractures (OTA/AO 42) at least 2 years postoperative from intramedullary nailing (IMN) provided informed consent. The average age was 40 ± 14 (range, 24-69); there were nine men and six women. Knee flexion-extension strength data were collected. Temporal-spatial, kinematic, and kinetic gait parameters were measured and compared to historic control data. Participants completed the SF-36 and shortened musculoskeletal function assessment questionnaires. The mean length of follow-up between surgery and gait analysis was 6 ± 2 years. The fractured limb demonstrated deficits in quadriceps strength between 9.8% and 23.4% compared to the unaffected limb. Temporal-spatial parameters revealed slower walking speed, shorter stride length, decreased cadence, and shorter single-limb support time in the fractured limb. Altered kinematic and kinetic findings included a knee extension shift during stance, with an increased knee flexor moment demand and decreased total knee power during loading and midstance. These findings represent deficits in concentric and eccentric knee extensor activity. Additionally, the fractured limb demonstrated decreased ankle dorsiflexion during stance and diminished ankle push-off power. Long-term outcomes after IMN of tibial diaphyseal fractures demonstrate decreased quadriceps strength and altered gait parameters that may have implications to the high incidence of knee and ankle pain in the fractured limb.

Monolateral external fixation versus internal fixation of Gustilo IIIB open tibial fractures: a multicenter comparative study.

PURPOSE: Gustilo IIIB open tibial fractures are associated with significant risks of complications particularly nonunion and fracture-related infections (FRI) due to the severity of the injuries. The commonly adopted viewpoint is that a Gustilo IIIB open tibial fracture is a relative contraindication for internal fixation. However, this study aims to assess the veracity of this viewpoint. The objective of this study was to evaluate the impact of the definitive fixation technique on fracture nonunion and FRI rates in Gustilo IIIB open tibial fractures. In this study, we compared the rates of nonunion and FRI rates in grade IIIB open tibial fractures managed definitively with either mono-lateral external fixation or internal fixation. METHODS: The study was a multicenter retrospective comparative study undertaken in seven Nigerian tertiary hospitals. Following ethical approval, medical records of patients diagnosed with Gustilo IIIB open tibial fractures (between 2019 and 2021) were retrieved, patients who had a minimum of nine months of follow-up period and were found eligible had their relevant data entered into an online data collection form. Data obtained was analysed with SPSS version 23, and chi-square test was used to determine the statistical significance of differences observed between the two groups with regard to nonunion and FRI rates. P values less than 0.05 were considered statistically significant. RESULTS: Out of a total of 47 eligible patients, 25 patients were managed definitively with mono-lateral external fixation whilst 22 patients were managed with internal fixation. Five of the 25 patients (20%) managed with external fixation had nonunion whilst two cases of nonunion were recorded amongst the 22 patients (9.1%) treated with internal fixation. The difference between the two techniques with regard to nonunion rates was not statistically significant (P = 0.295). 12 out of 25 patients (48%) in the external fixation group had FRIs whilst 6 out of 22 patients (27.3%) in the internal fixation group had FRIs. The rates of FRIs of the two groups were not significantly different (P = 0.145). CONCLUSION: Our findings suggest that mono-lateral external fixation and internal fixation do not differ significantly with respect to rates of nonunion and fracture-related infections in Gustilo IIIB open tibial fractures.

Do working length and proximal screw density influence the velocity of callus formation in distal tibia fractures treated with a medial bridge plate?

INTRODUCTION: Aim of our study was to evaluate the influence of working length and screw density on callus formation in distal tibial fractures fixed with a medial bridge plate. MATERIALS AND METHODS: 42 distal tibia fractures treated with a bridge plate were analyzed. Minimum follow-up was 12 months. mRUST score (modified Radiographic Union Scale for Tibial fractures) was used to assess callus formation. Working length and screw density were  measured from post-operative radiographs. RESULTS: 39 (92.9%) fractures healed uneventfully. 32 (76.19%) patients showed signs of early callus formation 3 months post-surgery. In these patients a lower screw density was used compared to patients who didn't show early callus (33.4 vs. 26.6; p = 0.04). No differences was noticed in working length. CONCLUSION: Bridge plate osteosynthesis is a good treatment option in distal tibia fractures. In our series increasing the working length was not associated with a faster callus formation in distal tibia fractures. Conversely, a lower screw density proximally to the fracture site was associated to a faster callus growth.

Predicting Union, Osteomyelitis, and Amputation Outcomes of Gustilo IIIC Open Tibial Fractures: A Retrospective Study.

OBJECTIVE: Open tibial fractures are frequently encountered in high-energy traumas and can result in significant complications such as nonunion, osteomyelitis, and even amputation. Among open tibial fractures, Gustilo type IIIC cases are particularly challenging due to the concomitant occurrence of neurovascular injuries and soft tissue defects. This study aimed to assess factors that affect union time and complications in Gustilo IIIC tibial fractures. METHODS: Patients who presented at our center with IIIC open tibial fractures from January 2000 to October 2020 were eligible for this retrospective analysis. Patient demographics, fracture characteristics, and the timing, number, and type of surgical intervention were documented. Outcomes of interest included union time, occurrence of osteomyelitis, and amputation. We performed univariate analyses including chi-squared test, Fischer's exact test, analysis of variance, and Kruskal-Wallis test based on the normality of the data and multivariate analyses including Cox proportional hazards model and logistic regression analyses. RESULTS: Fifty-eight patients were enrolled and grouped by fracture healing time; eight had timely union (13.8%); 27 had late union (46.6%); eight had delayed union (13.8%); three had nonunion (5.2%); and 12 underwent amputation (20.7%). Nine fractures (15.5%) were complicated by osteomyelitis. Union time was prolonged in cases of triple arterial injury, distal third fractures, multiple trauma with injury severity score (ISS) ≥ 16 points, and increased bone defect length. Additionally, a bone gap >50 mm, diabetes mellitus, low body mass index, and triple arterial injury in the lower leg were significant risk factors for amputation. A time from injury to definitive soft tissue coverage of more than 22 days was the major risk factor for osteomyelitis. A scoring system to predict union time was devised and the predicted probability of union within 2 years was stratified based on this score. CONCLUSION: IIIC tibial fractures involving the distal third of the tibia, fractures with bone defects, triple arterial injury, and multiple trauma with ISS ≥16 points demonstrated delayed union, and an effective prediction system for union time was introduced in this study. Early soft tissue coverage can reduce the risk of osteomyelitis. Finally, diabetes and severe bone and soft tissue defects pose a higher risk of amputation.

Assessing the effectiveness of intramedullary nailing for tibial shaft fractures in a low-income setting: a prospective study in Yemen.

BACKGROUND: Tibial shaft fractures are common injuries that can be treated with various methods, including interlocked intramedullary nail (IMN). However, there is limited data on the clinical outcomes of IMN for tibial shaft fractures in Yemen. OBJECTIVE: To evaluate the clinical outcomes of primary IMN for tibial shaft fractures in Yemen. METHODS: This was a prospective study of 134 patients who underwent primary IMN for tibial shaft fractures et al.-Thawra Modern General Hospital in Sana'a, Yemen, between June 2016 and June 2020. The patients were between 18 and 70 years old, and the fractures were classified according to the AO classification system. The fractures were treated with IMN using a standard technique. The patients were followed up for a minimum of 2 years. The outcome measures included union time, complications, and functional scores. RESULTS: The mean union time was 17 weeks. The overall complication rate was 18.7%. The most common complications were infection (8.2%), delayed union (6.7%), and nonunion (3.7%). The mean functional scores at the final follow-up were 91.4 for the Knee Society Score and 90.2 for the American Orthopaedic Foot and Ankle Society Score. CONCLUSION: Primary IMN is an effective and reliable method for treating tibial shaft fractures in Yemen, with acceptable union time, complication rate, and functional outcomes.

Comparison of Anatomic Locking Titanium Plate and Intramedullary Nail in the Treatment of Distal Tibial Fractures / 中山大学学报(医学科学版)

ObjectivesTo compare the clinical efficacy and complications of anatomic locking titanium plate （hereinafter referred to as “titanium plate screw”） and intramedullary nail in the treatment of distal tibial fractures.Methods From September 2019 to September 2021， 32 patients diagnosed with AO-A fracture of distal tibia at Sun Yat-sen Memorial Hospital of Sun Yat-sen University were included in this study. Of these， 15 cases were treated with titanium plate screws and 17 cases were treated with intramedullary nails. General surgical indexes， fracture healing time and postoperative operation were compared between the two groups.ResultsAll patients were followed up for 10 to 20 months， with an average of 12 months. The operative time and intraoperative fluoroscopy times of intramedullary nail group were longer than those of titanium plate screw group， but the preoperative waiting time and hospitalization days was less or were fewer than those of titanium plate screw group， the difference was statistically significant （P < 0.05）. There was no significant difference in fracture healing time between the two groups （P> 0.05）. At 6 weeks after operation， VAS scores in both groups were lower than those before operation， with statistically significant difference （P<0.05）. There was no significant difference in VAS scores between the intramedullary nail group and the titanium plate screw group （P> 0.05）. AOFAS scores 6 months after surgery， ankle joint motion and complication rate 1 year after surgery in intramedullary screw group were better than those in titanium plate screw group， and the differences were statistically significant （P< 0.05）. There was no significant difference in AOFAS scores between the two groups at 1 year after operation （P> 0.05）.ConclusionTitanium plate screw and intramedullary nail are both effective methods for the treatment of distal tibial AO-A fracture， and there is no significant difference in long-term clinical efficacy. Intramedullary nail has fewer soft tissue complications， less impact on ankle motion， faster recovery and higher safety， while titanium plate screw has a higher probability of postoperative soft tissue infection. We suggest that in clinical work， preoperative evaluation of patients should be done well. Under the premise of grasping the indications， intramedullary nail has fewer complications and certain advantages.

Olink proteomics analysis uncovers the landscape of inflammation-related proteins in patients with acute compartment syndrome.

Purpose: Our primary purpose was to explore the landscape of inflammation-related proteins, and our second goal was to investigate these proteins as potential biomarkers of acute compartment syndrome (ACS), which is a serious complication of tibial fractures. Methods: We collected sera from 15 healthy subjects (control group, CG) and 30 patients with tibial fractures on admission day, comprising 15 patients with ACS (ACS group, AG) and 15 patients without ACS (fracture group, FG). Ten samples in each group were analyzed by the inflammation panel of Olink Proteomics Analysis, and all samples were verified by an ELISA. Receiver-operating characteristic (ROC) curve analysis was performed to identify the diagnostic ability and cutoff values of potential biomarkers. Results: Our findings showed that the levels of IL6, CSF-1, and HGF in the FG were significantly higher than those in the CG. Similar results were found between the AG and CG, and their cutoff values for predicting ACS compared with the CG were 9.225 pg/ml, 81.04 pg/ml, and 0.3301 ng/ml, respectively. Furthermore, their combination had the highest diagnostic accuracy. Notably, compared with FG, we only found a higher expression of CCL23 in the AG. Additionally, we identified 35.75 pg/ml as the cutoff value of CCL23 for predicting ACS in patients with tibial fractures. Conclusion: We identified CCL23 as a potential biomarker of ACS in comparison with tibial fracture patients and the significance of the combined diagnosis of IL6, CSF-1, and HGF for predicting ACS compared with healthy individuals. Furthermore, we also found their cutoff values, providing clinicians with a new method for rapidly diagnosing ACS. However, we need larger samples to verify our results.

Risk of Neurovascular Injury during Screw Fixation of Tibial Tubercle Fractures in Pediatric and Adolescent Patients.

Objective To review knee magnetic resonance imaging (MRI) scans for the analysis of the location of neurovascular structures (NVSs), and to define the risk of bicortical fixation. Methods Distances between the posterior cortex and the popliteal NVSs were measured on the MRI scans of 45 adolescents (50 knees) at 3 levels (C1: center of the proximal tibial epiphysis; C2: 10 mm distal to the physis; and C3: 20 mm distal to the physis). The NVSs located between 5 mm and 10 mm from the incision were considered in a zone of moderate risk for damage, while those less than 5 mm from the incision were considered in a zone of high risk for damage, and those more than 10 mm from the incision were considered to be in a zone of low risk for damage. The independent Student t -test was used for the comparison of the NVS distance 0with gender, skeletal maturity, and the tibial tubercle-trochlear groove (TT-TG) distance. Values of p < 0.05 were regarded as statistically significant. Results The path of the C1 screw posed an increased risk of damage to the popliteal artery and vein compared with other screw paths ( p < 0.001). The popliteal artery has a high risk of damage at the level of C1 (4.2 ± 2.2mm), and a moderate risk at C2 (9.6 ± 2.4mm), and the popliteal vein has a moderate risk at C1 (6.0 ± 2.7 mm), and a low risk at C2 and C3 (10.8 ± 3.1mm, and 12.05 ± 3.1mm respectively). The C3 position presented the lowest risk of damage to these structures ( p < 0.001). The distance between the posterior tibial cortex and the posterior tibial nerve was < 15 mm at the 3 levels analyzed (C1: 11.0 ± 3.7 mm; C2: 13.1 ± 3.8 mm; and C3: 13 ± 3.9 mm). Conclusions The present study clarifies that the popliteal vessels are at risk of injury during tibial tubercle screw fixation, particularly when drilling the proximal tibial epiphysis. Monocortical drilling and screw fixation are recommended for the surgical treatment of tibial tubercle fractures. Level of Evidence III Diagnostic study.

Comparing Minimally Invasive Percutaneous Plate Osteosynthesis With Interlocking Intramedullary Nail Fixation for the Management of Adult Extra-Articular Distal Tibial Fractures: A Comprehensive Systematic Review and Meta-Analysis.

Intramedullary nailing (IMN) and minimally invasive percutaneous plate osteosynthesis (MIPPO) fixation are both viable approaches for managing distal tibia fractures. IM nailing offers advantages in terms of shorter operation time, faster union, and reduced infection rates, yet it may lead to alignment issues and residual knee pain. Conversely, MIPPO fixation provides better alignment and minimizes knee discomfort but comes with a higher risk of soft-tissue complications and hardware irritation. Notably, this review reveals that MIPPO is associated with a greater risk of both superficial (15% vs. 7% for IMN) and deep infections (14% vs. 6.3% for IMN). This study aims to comprehensively assess the optimal surgical approaches for distal tibia fractures by comparing clinical and functional outcomes between MIPPO and interlocking IMN techniques in treating extra-articular distal tibial fractures. Key outcome parameters include operation duration, union time, non-union occurrence, malunion cases, infection rates, secondary surgical interventions, and functional results, as indicated by quality of life and ankle scores. Regarding union complications, it is notable that IMN demonstrates a higher incidence of malunion, affecting 14.7% of patients compared to 8.8% in the MIPPO fixation group. Interestingly, both treatment methods exhibit a similar incidence of non-union, occurring in 3.5% of patients in both groups. Furthermore, when assessing the union time, IMN fixation notably achieves significantly shorter union times, especially evident in AO 43A fracture types and closed fractures. The mean time for union is 18 weeks with IMN compared to 20 weeks with MIPPO fixation. In our analysis of nine studies involving 813 patients, the reported operation times revealed an overall weighted mean operation time of 74.1 minutes (ranging from 56.4 to 124 minutes) for IMN and 85.4 minutes (ranging from 51.4 to 124 minutes) for MIPPO fixation. Notably, the operation time for IMN was significantly shorter compared to MIPPO, showing a weighted mean difference (WMD) of -11.24 minutes, with a 95% confidence interval (CI) ranging from -15.44 to -7.05 (P<0.05). This difference exhibited significant moderate heterogeneity (I2 = 68%). In light of this comprehensive study, both MIPPO and IMN emerge as equally effective therapeutic options for addressing functional outcomes in distal tibial extra-articular fractures. While IMN offers several advantages, including lower infection rates, reduced implant irritation, shorter operation time, and earlier weight-bearing and union, it is associated with a heightened risk of malunion and anterior knee pain. Consequently, the choice of implant should be tailored on a case-by-case basis. Patients at elevated infection risk, stemming from factors, such as advanced age, comorbidities, smoking, or severe soft tissue injuries, are better suited for nail treatment. Conversely, MIPPO fixation may present a more advantageous choice for young, active, and healthy patients, given its ability to mitigate the risk of knee pain and malunion.