A Randomized Controlled Study on the Efficacy of Different Approaches of Intramedullary Nailing with Blocking Screws for Proximal Tibial Fractures

SUMMARY: The objective of this study was to compare and analyze the clinical efficacy of different approaches of intramedullary nailing with blocking screws for proximal tibial fractures. One hundred cases of proximal tibial fractures treated in the orthopedic department from April 2021 to September 2023 were included in the study and divided into control and treatment groups using a random number table. A control group (n=50) treated with infrapatellar intramedullary nailing with blocking screws, and a treatment group (n=50) treated with suprapatellar intramedullary nailing with blocking screws. We observed the excellent and good rates in both groups, compared various perioperative indicators, changes in joint range of motion (ROM), Visual Analog Scale (VAS) pain scores, Lysholm knee joint function scores, changes in inflammatory factors, and various bone markers before and after treatment, and analyzed postoperative complications. There were no significant differences in baseline data such as age, sex, body mass index, fracture site, concomitant fibular fractures, time from fracture to surgery, injury mechanism, and AO/OTA fracture classification between the two groups (P>0.05). The excellent and good rate in the treatment group after treatment was 90.00 % (45/50), significantly higher than 72.00 % (36/50) in the control group (P0.05). However, the treatment group had shorter surgical times and fewer fluoroscopy times than the control group (P<0.05). After treatment, both groups showed increased ROM and Lysholm scores, as well as decreased VAS scores. Moreover, compared to the control group, the treatment group had higher ROM and Lysholm scores and lower VAS scores (P<0.05). Inflammatory factors including interleukin-1β (IL-1β), C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), osteocalcin (BGP), and calcitonin (CT) increased in both groups after treatment, while total n- terminal propeptide of type I procollagen (Total-PINP) and b-C-terminal telopeptide of type I collagen (β-CTX) decreased. Compared to the control group, the treatment group exhibited greater increases in inflammatory factors and lower levels of Total-PINP and β-CTX, but higher BGP and CT levels (P<0.05). The incidence of postoperative complications was 8.00 % (4/50) in the treatment group and 24.00 % (12/50) in the control group, with statistically significant differences (P=4.762, X2=0.029). In the treatment of proximal tibial fractures, intramedullary nailing with blocking screws using the suprapatellar approach achieves significant clinical efficacy. It reduces surgical time, minimizes radiation exposure to healthcare workers and patients, improves knee joint range of motion and function, decreases postoperative pain and complication rates, suppresses inflammatory reactions, and promotes the improvement of bone markers related to fracture healing.

El objetivo de este estudio fue comparar y analizar la eficacia clínica de diferentes abordajes de clavo intramedular con tornillos de bloqueo para las fracturas de tibia proximal. Se incluyeron en el estudio 100 casos de fracturas de tibia proximal tratados en el departamento de ortopedia desde abril de 2021 hasta septiembre de 2023 y se dividieron en grupos de control y de tratamiento mediante una tabla de números aleatorios. Un grupo control (n=50) tratado con clavo intramedular infrapatelar con tornillos de bloqueo, y un grupo tratamiento (n=50) tratado con clavo intramedular suprapatelar con tornillos de bloqueo. Observamos excelentes y buenas tasas en ambos grupos, comparamos varios indicadores perioperatorios, cambios en el rango de movimiento articular (ROM), puntuaciones de dolor en la escala visual analógica (EVA), puntuaciones de función Lysholm de la articulación de la rodilla , cambios en factores inflamatorios y varios marcadores óseos, antes y después del tratamiento, y se analizaron las complicaciones postoperatorias. No hubo diferencias significativas en los datos iniciales como edad, sexo, índice de masa corporal, sitio de fractura, fracturas de fíbula concomitantes, tiempo desde la fractura hasta la cirugía, mecanismo de lesión y clasificación de fractura AO/OTA entre los dos grupos (P>0,05). La tasa de excelente y buena en el grupo con tratamiento después del tratamiento fue del 90,00 % (45/50), significativamente mayor que el 72,00 % (36/50) en el grupo control (P0,05). Sin embargo, el grupo con tratamiento tuvo tiempos quirúrgicos más cortos y menos tiempos de fluoroscopía que el grupo control (P <0,05). Después del tratamiento, ambos grupos mostraron un aumento de las puntuaciones de ROM y Lysholm, así como una disminución de las puntuaciones de VAS. Además, en comparación con el grupo control, el grupo con tratamiento tuvo puntuaciones ROM y Lysholm más altas y puntuaciones EVA más bajas (P <0,05). Los factores inflamatorios que incluyen interleucina-1β (IL-1β), proteína C reactiva (CRP), factor de necrosis tumoral-α (TNF-α), osteocalcina (BGP) y calcitonina (CT) aumentaron en ambos grupos después del tratamiento, mientras que el total disminuyó el propéptido n-terminal del procolágeno tipo I (Total-PINP) y el telopéptido β-C-terminal del colágeno tipo I (β-CTX). En comparación con el grupo control, el grupo con tratamiento mostró mayores aumentos en los factores inflamatorios y niveles más bajos de Total-PINP y β-CTX, pero niveles más altos de BGP y CT (P <0,05). La incidencia de complicaciones postoperatorias fue del 8 % (4/50) en el grupo de tratamiento y del 24 % (12/50) en el grupo control, con diferencias estadísticamente significativas (P=4,762, X2=0,029). En el tratamiento de las fracturas de tibia proximal, el clavo intramedular con tornillos de bloqueo mediante el abordaje suprapatelar logra una eficacia clínica significativa. Reduce el tiempo quirúrgico, minimiza la exposición a la radiación de los trabajadores de la salud y los pacientes, mejora el rango de movimiento y la función de la articulación de la rodilla, disminuye el dolor postoperatorio y las tasas de complicaciones, suprime las reacciones inflamatorias y promueve la mejora de los marcadores óseos relacionados con la curación de las fracturas.

Manejo de fractura de platillo tibial medial utilizando placas rim anteromedial y posteromedial / Management of Medial Tibial Plateau Fracture using Antero- and Posteromedial Rim Plates

INTRODUCCION En los últimos años, se ha descrito el uso de placas horizontales para la fijación de fracturas que comprometen el reborde articular de los platillos tibiales, lo que se conoce como placa rim. La mayoría de las publicaciones al respecto describen su uso en columnas posteriores y posterolaterales de los platillos tibiales, y a la fecha hay escasos reportes del uso de este tipo de placa en la columna anteromedial y ninguno para la posteromedial. El objetivo de este artículo es presentar dos casos clínicos de fracturas conminutas del platillo tibial medial mostrando su tratamiento con el uso de placas rim. CASOS CLINICOS El primer caso presentaba compromiso anteromedial y posteromedial, y el segundo, compromiso posteromedial. En ambos casos, se logró la reducción mediante un abordaje posteromedial y su fijación con placa bloqueada de 2,7 mm como placa rim. En cada caso, se detalló la estrategia de reducción y el manejo postoperatorio. RESULTADOS Ambos pacientes consiguieron la consolidación ósea entre las semanas 14 y 18 tras la osteosíntesis definitiva, sin presentar pérdidas de reducción. Ambos lograron rango de movilidad articular completo (0°­125°), y retornaron a sus trabajos a los 4 y 6 meses respectivamente. CONCLUSIONES Estas placas ofrecen una buena opción de tratamiento para fracturas articulares conminutas del borde del platillo tibial, tanto en la columna anteromedial como en la posteromedial. A pesar de la ausencia de grandes series de pacientes con uso de placas rim mediales, el resultado de los casos presentados aquí nos permite plantear su utilidad al momento de enfrentarnos a fracturas del reborde articular

INTRODUCTION In recent years, the use of horizontal plates has been described to achieve fixation of fractures that compromise the articular ridge of the tibial plateau; these plates are known as "rim plates." Most publications report their use in the posterior and posterolateral columns of the tibial plateau, and to date there are few reports of its use for the fixation of the anteromedial column and none for the posteromedial column. The objective of the present article is to report two clinical cases of comminuted fractures of the medial tibial plateau, showing their treatment with the use of medial rim plates. CLINICAL CASES The first case presented with an anteromedial and posteromedial tibial plateau fracture, and the second, a posteromedial fracture. In both cases, reduction was achieved through a posteromedial approach, and the fixation was performed with a 2.7-mm locked rim plate. The reduction strategy and postoperative management were detailed in each case. RESULTS Both patients achieved bone consolidation during the 14th and 18th weeks after the definitive osteosynthesis, without presenting loss of reduction. Both patients achieved full range of joint motion (0°­125°) and returned to work after four and six months respectively. CONCLUSION These plates offer a good treatment option for comminuted fractures of the rim of the tibial plateau, for both the anteromedial and posteromedial columns. Despite the absence of large series of patients with the use of medial rim plates, the results of the two cases herein presented enables us to propose it as a useful tool when dealing with fractures of the medial rim of the tibial plateau

INTRODUCTION In recent years, the use of horizontal plates has been described to achieve fixation of fractures that compromise the articular ridge of the tibial plateau; these plates are known as "rim plates." Most publications report their use in the posterior and posterolateral columns of the tibial plateau, and to date there are few reports of its use for the fixation of the anteromedial column and none for the posteromedial column. The objective of the present article is to report two clinical cases of comminuted fractures of the medial tibial plateau, showing their treatment with the use of medial rim plates. CLINICAL CASES The first case presented with an anteromedial and posteromedial tibial plateau fracture, and the second, a posteromedial fracture. In both cases, reduction was achieved through a posteromedial approach, and the fixation was performed with a 2.7-mm locked rim plate. The reduction strategy and postoperative management were detailed in each case. RESULTS Both patients achieved bone consolidation during the 14th and 18th weeks after the definitive osteosynthesis, without presenting loss of reduction. Both patients achieved full range of joint motion (0°­125°) and returned to work after four and six months respectively. CONCLUSION These plates offer a good treatment option for comminuted fractures of the rim of the tibial plateau, for both the anteromedial and posteromedial columns. Despite the absence of large series of patients with the use of medial rim plates, the results of the two cases herein presented enables us to propose it as a useful tool when dealing with fractures of the medial rim of the tibial plateau

The polymicrobial infection affects the infection recurrence rate (not failure) in treating femoral and tibial bone defects with the Masquelet technique-a comparative retrospective analysis of 54 patients with mono- and polymicrobial infections.

INTRODUCTION: This study evaluated whether polymicrobial infection affects reoperation rates due to infection recurrence and treatment failure with the Masquelet technique in infected posttraumatic segmental bone defects of the femur and tibia. METHODS:  We retrospectively analyzed patients treated between 2012 and 2021 in two trauma referral centers. We evaluated demographic data, injury, treatment, infection recurrence, failures, and bone healing rates according to whether the infection was mono- or polymicrobial. After uni-bivariate analysis between patients with polymicrobial and monomicrobial infection, we identified the variables associated with infection recurrence and failure through multivariate analysis. RESULTS:  We analyzed 54 patients, 30 (55.55%) with tibial and 24 (44.44%) femoral segmental bone defects, with a mean follow-up of 41.7 ± 15.0 months. Forty-four (81.48%) presented monomicrobial, and 10 (18.51%) polymicrobial infections. Comparatively, the need for soft tissue reconstruction and the infection recurrence rate was significantly higher in patients with polymicrobial infections. There was no significant difference in the failure rate (20 vs. 6.81% p = 0.23). Multivariable logistic regression analysis identified the polymicrobial infection as the only independent variable associated with infection recurrence (Odds Ratio = 11.07; p = 0.0017). CONCLUSION:  Our analysis suggests that polymicrobial infection is associated with a higher risk of infection recurrence in treating the femur and tibia segmental bone defects with the Masquelet technique. This information can help surgeons to inform patients about this and give them a realistic expectation of the outcome and the possibility of reoperation.

Modified gastrocnemius splitting anatomic approach to the tibial plateau. Medium-term evaluation.

BACKGROUND: Posterior tibial plateau fractures, including avulsion fractures of the posterior cruciate ligament (PCL) insertion, represent a challenge for the orthopedic trauma surgeon. These injuries have gained a new perspective both diagnostically and therapeutically after the regular use of multiplanar computed tomography. In the herein study, we describe the outcome of patients sustaining a tibial plateau fracture with posterior articular involvement treated by open reduction and internal fixation (ORIF) using our modified gastrocnemius splitting anatomic approach. METHODS: This observational retrospective descriptive study was conducted at Complejo Medico de la Policia Federal Argentina Churruca-Visca. All patients were treated by ORIF by our team through our modified gastrocnemius splitting anatomic approach, and followed-up for a minimum of 12 months. RESULTS: A total of 18 patients sustaining plateau fracture were treated by this approach. Satisfactory tomographic reduction with articular gap and/or step-off <2 mm was achieved in 16. The mean time to the return to activities of daily living was 192.2 days. CONCLUSION: The modified gastrocnemius splitting anatomic approach represents a good alternative for the management of tibial plateau fractures involving the posterior quadrants.

Acute Fixation Protocol for High-Energy Tibial Pilon Fractures Decreases Time to Fixation and Lowers Operative Costs Without Affecting Wound Complications and Reoperations.

OBJECTIVES: To determine whether an acute fixation protocol for high-energy tibial pilon fractures increases the rate of wound complications. DESIGN: Retrospective comparative study. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: One hundred forty-seven patients with OTA/AO 43B and 43C high-energy tibial pilon fractures treated with open reduction and internal fixation (ORIF). INTERVENTION: Acute (<48 hours) versus delayed ORIF protocols. MAIN OUTCOME MEASUREMENT: Wound complications, reoperations, time to fixation, operative costs, and hospital length of stay (LOS). Patients were compared by protocol, regardless of ORIF timing, for an intention-to-treat analysis. RESULTS: Thirty-five and 112 high-energy pilon fractures were treated under the acute and delayed ORIF protocols, respectively. In the acute ORIF protocol group, 82.9% of patients received acute ORIF versus 15.2% of patients in the standard delayed protocol group. The 2 groups had no observed difference (OD) in the rate of wound complications (OD -5.7%, confidence interval (95% CI) -16.1% to 7.8%; P = 0.56) or reoperations (OD -3.9%, 95% CI, -14.1% to 9.4%; P = 0.76). The acute ORIF protocol group had a shorter LOS (OD -2.0, 95% CI, -4.0 to 0.0; P = 0.02) and lower operative costs (OD $-2709.27, 95% CI, -3582.02 to -1601.16; P < 0.01). On multivariate analysis, wound complications were associated with open fractures (odds ratio 3.36, 95% CI, 1.06-10.69; P = 0.04) and an American Society of Anesthesiologists score >2 (odds ratio 3.68, 95% CI, 1.07-12.67; P = 0.04). CONCLUSION: This study suggests that an acute fixation protocol for high-energy pilon fractures decreases time to definitive fixation, lowers operative costs, and shortens hospital LOS without affecting wound complications or reoperations. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fractura triplanar de tibia distal: Reporte de un caso y revisión de la literatura / Triplanar fracture of proximal tibia: A case report and literature review

Las fracturas triplanares de tibia distal, son fracturas complejas caracterizadas por afectación multiplanar, clasificándose como Salter Harris tipo IV, en el periodo de cierre fisiario. Son poco frecuentes, representando el 5-15% de las fracturas pediátricas. El mecanismo de lesión que ocurre con mayor frecuencia, consiste en supinación y rotación externa. La tomografía computarizada es actualmente el Gold Standard para el diagnóstico de este tipo de fractura, nos permite evaluar todos los planos, siendo la radiografía simple insuficiente para el diagnóstico ya que puede pasar desapercibida. Paciente de 14 años de edad con fractura triplanar en 2 partes de tibia distal, con resolución quirúrgica. Nuestro caso es un ejemplo de una fractura triplanar de tibia distal, la cual es de baja frecuencia, difícil diagnostico e interpretación. Presentamos imágenes preoperatorias, intraoperatorias y postoperatorias del manejo de esta lesión, obteniendo resultados satisfactorios clínicos, funcionales y en estudios de imágenes. Es indispensable lograr una reducción anatómica de la superficie articular para lograr una evolución satisfactoria. Se recomienda una tomografía computarizada para diagnosticar y manejar esta lesión de manera adecuada. El seguimiento postoperatorio es crucial para el manejo de este paciente, ya que se espera una discrepancia en la longitud de las extremidades y/o deformidad(AU)

Triplane fractures of the distal tibia are complex fractures characterized by multiplane effects. They are classified in the Salter-Harris system as type IV in the period of physeal closure. These fractures are rare and represent 5-15% of pediatric fractures. The most common mechanism of injury is supination and external rotation. Computed tomography is currently the Gold Standard for the diagnosis of this type of fracture since it allows us to evaluate all planes, while plain radiography is insufficient because the fracture can go unnoticed. The objective is to report the clinical case of a 14-year-old patient with triplanar fracture in 2 parts of the distal tibia with surgical resolution. This case is an example of a triplanar fracture of the distal tibia, which is of low frequency, and difficult to diagnose and interpret. Preoperative, intraoperative and postoperative images of the management of this lesion are presented, obtaining satisfactory clinical, functional and imaging study results. It is essential to achieve an anatomical reduction of the joint surface to achieve a satisfactory evolution. A CT scan is recommended to properly diagnose and manage this injury. Postoperative follow-up is crucial for the management of this patient, as a limb length discrepancy and/or deformity is expected(AU)

Does the distal nail position impact the rates of misalignment and bone union in distal tibial fractures?

PURPOSE: This retrospective study aimed to assess the impact of distal nail placement on misalignment and healing rates in distal tibial fractures. METHODS: We reviewed all patients with distal tibial fracture treated with intramedullary nailing between 2015 and 2021, and a minimum follow-up of 12 months. Distal nail positioning was determined according to the Triantafillou zones. We related these positioning zones to misalignments (alignment ≥ 3°) and too bony union disorders (delayed union, non-union). RESULTS: Out of the 62 patients included, 56 (90.3%) show bone union without additional procedure, 3 (4.8%) with dynamization, and 3 (4.8%) showed non-union. Twenty-one (33.8%) presented misalignment, with valgus in the coronal plane being the most frequent (76.19%). In patients with and without misalignment, the most frequent distal nail position was 2-2 in 47.6% and 80.5%, respectively (p = 0.01). In multivariate analysis, distal nail positioning in the 2-2 zone showed a significant protective effect against misalignment (OR 0.18; p = 0.018), while nail positioning in the 3-2 zone generated a significant risk of misalignment (OR 18.55; p = 0.009). CONCLUSION: In intramedullary nailing of distal tibial fractures, distal positioning of the nail slightly lateral to the center of the talus in the coronal plane and slightly posterior in the sagittal plane (zone 2-2) allows high alignment percentages to be obtained. Positioning medial to this point in the coronal plane (zone 3) is associated with more significant misalignment and should be avoided.

Outcomes of the Carlson Approach in the Treatment of Posterior Tibial Plateau Fractures / Resultados da abordagem de Carlson para o tratamento de fraturas no platô tibial posterior

Abstract Objectives To describe a series of cases of tibial fractures surgically treated using the posterior approach as described by Carlson, focusing on evaluating its functional results and complication rate. Methods Eleven patients with tibial plateau fractures, who underwent surgical treatment using the Carlson approach from July to December 2019, were followed-up. The minimum follow-up period was defined as 6 months. The American Knee Society Score (AKSS), American Knee Society Score/Function (AKSS/Function) and the Lysholm score were used to check treatment results at 6 months after the fracture. The patients underwent standard anteroposterior and lateral radiographs to assess fracture healing, and clinical healing was determined by the absence of pain during full weight-bearing. Results The mean follow-up period was 12 months (9-16 months). The primary mechanism of trauma was motorcycle accident, and the most prevalent side of fracture was the right side. Eight participants were male. The mean age of the patients was 28 years. All fractures healed, and none of the patients presented complications. The AKSS was excellent in 11 patients, with a mean AKSS/Function of 99.1±3, and Lysholm scores with a median of 95.0±5.6. Conclusions The Carlson approach for posterior fractures of the tibial plateau can be considered safe, presenting a low complication rate and satisfactory functional results.

Resumo Objetivos O objetivo deste trabalho é descrever uma série de casos de fraturas de tíbia submetidas ao tratamento cirúrgico pela via posterior de Carlson para avaliação de resultados funcionais e frequência de complicações. Métodos Onze pacientes com fraturas do platô tibial foram submetidos a tratamento cirúrgico pela via de Carlson de julho a dezembro de 2019 e acompanhados por um período mínimo de 6 meses. As pontuações American Knee Society Score (AKSS), American Knee Society Score/Function (AKSS/Função) e de Lysholm verificaram os resultados do tratamento 6 meses após a fratura. Os pacientes foram submetidos a radiografias comuns em incidência anteroposterior e de perfil para avaliação da consolidação da fratura e a cicatrização clínica foi determinada pela ausência de dor à descarga total de peso. Resultados O período médio de acompanhamento foi de 12 meses (9 a 16 meses). O principal mecanismo de trauma foi acidente motociclístico e a fratura foi mais prevalente no lado direito. Oito pacientes eram do sexo masculino. A média de idade dos pacientes foi de 28 anos. Todas as fraturas cicatrizaram e nenhum paciente apresentou complicações. A AKSS foi excelente em 11 pacientes, com AKSS/Função média de 99,1 ±3, e a mediana das pontuações de Lysholm foi de 95,0 ±5,6. Conclusões Nas fraturas posteriores do platô tibial, a abordagem de Carlson pode ser considerada segura, apresentando baixo índice de complicações e resultados funcionais satisfatórios.

An Acute Fixation Protocol for High-Energy Tibial Plateau Fractures Decreases Time to Fixation and Lowers Operative Costs Without Affecting Wound Complications and Reoperations.

OBJECTIVES: To investigate whether an acute fixation protocol for high-energy tibial plateau fractures increases the rate of wound complications. DESIGN: Retrospective comparative study. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: One hundred thirty-four patients with high-energy tibial plateau fractures (OTA/AO 41B/C [Schatzker VI/V/VI]) treated with open reduction and internal fixation (ORIF). INTERVENTION: Utilization of an acute ORIF (<48 hours) versus delayed ORIF protocol. MAIN OUTCOME MEASURE: Primary outcomes: wound complications (wound dehiscence/necrosis, superficial/deep infections) and reoperations. Secondary outcomes: total operative costs and hospital length of stay. RESULTS: Overall, 83.9% (26/31) of patients received definitive fixation within 48 hours under the acute ORIF protocol versus 18.4% (19/103) of patients treated under the standard delayed protocol with no observed differences in the rate of wound complications (proportional difference (PD) -4.6%, confidence interval (CI) -17.2% to 11.3%; P = 0.78) or reoperations (PD 2.0%, CI, 13.0% to 12.5%; P = 1.00). The acute ORIF protocol lowered operative costs (median difference (MD) $-2.563.00, CI, 3021.00 to -1661.00; P < 0.001) and hospital length of stay (MD 4.0 days, CI, 6.0-1.0; P = 0.001). On multivariate analysis, wound complications were associated with increasing age (odds ratio (OR) 1.05, CI, 1.01-1.10; P = 0.01) and tobacco use (OR 3.75, CI, 1.19-11.82; P = 0.02). CONCLUSION: An acute ORIF protocol for high-energy tibial plateau fractures decreased time to fixation and lowered operative costs without increasing the risk of wound complications or reoperations. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Photobiomodulation therapy combined with static magnetic field in tibial fracture healing of a dog: A case report.

A 10-week-old male, Xoloitzcuintle (Mexican hairless dog), weighing 8.9 kg was presented after its owner accidentally stepped on its paw. The dog presented with acute pain, inflammation and grade IV lameness in the right hind paw. A complete transverse fracture in the right proximal tibia was diagnosed from radiography. The dog underwent a minimally invasive plate osteosynthesis (MIPO) procedure. After surgery, photobiomodulation therapy combined with static magnetic field (PBMT-sMF) was applied twice daily for 21 days. A multi-wavelength PBMT-sMF device was applied at three sites using different frequencies: proximal and distal of the fracture zone (3000 Hz, 40.35 J per site, and 300 s per site) and in the fracture zone (250 Hz, 39.11 J and 300 s per site). Follow up radiographies were performed after surgery and treatment with PBMT-sMF. Eighteen days post-surgery the healing process of bone was advanced. Fifty-five days post-surgery the callus was enlarged. In addition, radiographic union and clinical union was evidenced by closure of the fracture gap. This case report has reported the use of PBMT-sMF in order to accelerate and improve bone healing following a MIPO procedure on a complete transverse fracture in the proximal tibia of a puppy.

Distal articular involvement in tibial shaft fractures: an evaluation of 125 consecutive cases.

PURPOSE: To report the incidence and morphology of ipsilateral distal articular involvement (DAI) in a consecutive series of tibial shaft fractures. METHOD: A retrospective review was performed on 115 patients who underwent intramedullary nailing for tibia shaft fractures. Ankle evaluations included preoperative radiographs and computed tomography (CT) scans in all patients. RESULTS: Thirty-two patients (27.8%) in our series presented with tibial shaft fractures associated with DAI. Tibial spiral fractures (42A1) were significantly related to DAI (RR: 1788). In 28 (87.5%; 28/32) articular fractures, posterior malleolus fractures (PMF) were present; 22 were isolated, and six (18.8%) occurred in combination with medial malleolus or anterolateral fractures. The remaining (12.5%; 4/32) were isolated medial malleolus fractures. Ten (31.2%; 10/32) articular fractures were occult on the radiographs and only detected on CT scan. CONCLUSION: DAI is common in tibial shaft fractures. CT evaluation is mandatory due to the high number of occult fractures. Although isolated PMF is the most frequent pattern of DAI involvement, 31.3% of the cases exhibited different patterns.

Comparison between functionality and quality of reduction between suprapatellar vs infrapatellar approaches in the treatment of diaphyseal and distal tibial fractures.

INTRODUCTION: Intramedullary nailing is the most frequent procedure used for the treatment of tibial fractures that do not involve the articular surfaces. The goal of this study is to analyse the clinical outcomes, time of surgery and use of fluoroscopy in patients with midshaft and distal tibial fractures treated with suprapatellar and infrapatellar nailing and compare the results between these different groups. METHODS: A retrospective study was conducted, and patients were selected between the period of March 2018 and October 2019. The following variables were studied: age, gender, AO classification, time of surgery (minutes), time of fluoroscopy (seconds), quality of reduction in postoperative controls and 1 year follow-up (using the angles MPTA, LDTA, PPTA, ADTA). Functional outcomes were studied at 1 month and 1 year follow-up. The visual analogue scale was used to study and compare the postoperative pain of the patients. The Lysholm Knee Score was used to evaluate the functional outcomes of the patients. RESULTS: A total of 80 patients meeting the inclusion criteria were included in this study. The suprapatellar approach was used in 44 patients and the infrapatellar in 36 patients. The time of surgery (p=0.008) and the mean time of use of fluoroscopy (p <0.001) difference were significant in favour of the suprapatellar approach. In the quality of reduction analysis, we have statistically significant results in the LDTA and ADTA angles. Also, in the evaluation of postoperative pain, significant difference was found in favour of the suprapatellar approach. CONCLUSION: In conclusion, our study compared the suprapatellar approach and the infrapatellar approach for the treatment of midshaft and distal tibia fractures with intramedullary nailing. The results showed lesser time of surgery and use of fluoroscopy, lower knee pain, and lower rate of malalignment with the suprapatellar approach than with the infrapatellar approach.

The relevance of the number of distal locking planes and nail to canal ratio in bone healing after intramedullary nailing in tibial shaft fractures.

INTRODUCTION: The objective of this retrospective study was to assess the effect of the nail to canal ratio and the number and configuration of distal locking screws in bone healing in tibial shaft fractures. METHODS: We analyzed 223 consecutive tibial shaft fractures treated with reamed intramedullary nailing between January 2014 and December 2020. We recorded and evaluated the nail to canal ratio (NCR) and the number and configuration of distal locking screws. Median NCR was 0.87 (IQR 0.82-0.94). Ten (4.48%) fractures were treated with one distal locking screw, 173 (77.57%) with two, and 40 (17.93%) with three. Uniplanar fixation was used in 63 (28.25%), biplanar in 150 (67.26%), and triplanar in 10 (4.48%) cases. Uni-, bi-, and multivariate analyses were performed to compare patients who achieved bone union with those who did not. RESULTS: Bone union was achieved in 195 (87.44%) patients. Uni- and bivariate analyses showed that bone union increased significantly with larger NCR (p = 0.0001) and a greater number of locking planes (p = 0.001) and distal screws (p = 0.046). NCR > 0.78 (OR 48.77 CI 95% 15.39-154.56; p = < 0.0001) and distal locking screw configuration (OR 2.91 CI 95% 1.12-9.91; p = 0.046) were identified as independent variables for union. CONCLUSION: Our findings suggest that in tibial shaft fractures treated with intramedullary nailing, NCR should be equal to or greater than 0.79. Additionally, distal locking screws should be used with a biplanar or triplanar configuration.

Fracturas del platillo tibial con hundimiento articular. Comparación entre reconstrucción con injertos óseos y sustitutos sintéticos. Revisión bibliográfica sistematizada / Depressed tibial-plateau fractures, a comparison between bone graft reconstruction and synthetic substitutes. Systematic bibliographic review / Fraturas do platô tibial com afundamento da articulação: comparação entre reconstrução com enxerto ósseo e substitutos sintéticos

Objetivo: comparar si existe diferencia en resultados clínicos, radiológicos y funcionales con el uso de diferentes tipos de injertos óseos o sustitutos sintéticos, así como tiempo quirúrgico y consolidación para el tratamiento de fracturas de platillo tibial con hundimiento articular en pacientes mayores de 18 años. Material y método: se realizó una búsqueda sistematizada en bases de datos de literatura médica, PubMed, Lilacs, Scielo, Cochrane y portal Timbó. Se utilizaron términos "tibial plateau fracture", "bone grafting", "bone substitutes". Se incluyeron estudios comparativos en seres humanos, pacientes mayores de 18 años, fracturas de platillo tibial que asociaron hundimiento articular, en los cuales se realizó aporte de injerto óseo o material sintético. Artículos en español, inglés, portugués. Publicaciones enero 1980 y diciembre 2021. Se obtuvieron 10 artículos. Resultados: los tipos de injertos y sustitutos óseos encontrados fueron 10. Las muestras en sumatoria total 524 pacientes. La edad promedio fue 49 años. El promedio de seguimiento fue de 12 meses. Se dividieron los estudios en tres grupos: comparación entre injerto autólogo (IOA) e injerto alogénico, IOA con sustitutos sintéticos, y los que comparan sustitutos sintéticos entre sí. El aloinjerto y los sustitutos sintéticos demostraron no ser inferiores en resultados clínicos, funcionales e imagenológicos, mejorando los tiempos intraoperatorios y disminuyendo complicaciones en el sitio donante con respecto al IOA. Conclusiones: el IOA continúa siendo el gold standard a pesar de sus posibles complicaciones vinculadas al sitio donante. El aloinjerto y los sustitutos sintéticos representan una opción válida para tratar estas lesiones.

Objective: to find out whether there are clinical, radiological and functional differences when using different types of bone grafts or synthetic substitutes, as well as surgical times and consolidation to treat depressed tibial-plateau fractures in patients older than 18 years old. Method: a systematized search was conducted in medical literature, PubMed, Lilacs, Scielo, Cochrane and Timbó portal databases using the following terms: "tibial plateau fracture", "bone grafting", "bone substitutes". The study included comparative studies in human patients older than 18 years old with depressed tibial-plateau fractures who were treated with bone grafts or synthetic materials. Publications in Spanish, English and Portuguese, between January, 1980 and December, 2021 were included in the search, what resulted in 10 articles found. Results: there were 10 kinds of bone grafts and bone substitutes found. Samples added up to 524 patients. Average age was 49 years old. Average follow up was 12 months. Studies were divided into 3 groups: comparison between autologous bone grafts and allogenic bone grafts, comparison between autologous grafts and synthetic substitutes and studies comparing synthetic substitutes with one another. Allogenic grafts and synthetic grafts proved at least equivalent in terms of clinical, functional and imaging studies results, improving intraoperative times and reducing complications in donor site when compared to autologous grafts. Conclusions: autologous grafts continue to be the gold standard despite possible complications associated to the donor site, and allogenic grafts and synthetic substitutes constitute a valid option to treat these lesions.

Objetivo: comparar os resultados clínicos, radiológicos e funcionais com o uso de diferentes tipos de enxertos ósseos ou substitutos sintéticos, bem como tempo cirúrgico e consolidação para o tratamento de fraturas do platô tibial com colapso articular em pacientes com mais de 18 anos. Material e método: foi realizada busca sistemática nas bases de dados da literatura médica, PubMed, Lilacs, SciELO, Cochrane e portal Timbó. Utilizaram-se os termos "tibial plateau fracture", "bone grafting", "bone substitutes". Foram incluídos estudos comparativos incluindo seres humanos maiores de 18 anos e fraturas do platô tibial associadas a colapso articular, nas quais foi realizado enxerto ósseo ou sintético, publicados entre janeiro de 1980 e dezembro de 2021 em espanhol, inglês e português. Foram obtidos 10 artigos. Resultados: foram identificados 10 tipos de enxertos e substitutos ósseos. 524 pacientes com idade média de 49 anos foram estudados. O seguimento médio foi de 12 meses. Os estudos foram divididos em 3 grupos: comparação entre enxerto autólogo (IOA) e enxerto alogênico, IOA com substitutos sintéticos e substitutos sintéticos entre si. O aloenxerto e os substitutos sintéticos mostraram-se não inferiores nos resultados clínicos, funcionais e de imagem, melhorando os tempos intraoperatórios e reduzindo as complicações da área doadora em relação à IOA. Conclusões: o IOA continua a ser o padrão ouro apesar de suas possíveis complicações relacionadas ao local doador; tanto o aloenxerto como os substitutos sintéticos representam uma opção válida para tratar essas lesões.

Tratamiento mínimamente invasivo/percutáneo de fracturas de pilón tibial con asistencia artroscópica en Hospital Regional de Talca / Minimally invasive/percutaneous treatment of tibial pilon fractures with arthroscopic assistance at the Regional Hospital

Tibial pilon fractures are a complex injury to treat due to the great involvement of soft and bone tissues. The classic surgical treatment is based on open reduction with internal fixation (ORIF), adding morbidity to the soft tissues, increasing the risk of complications. This has motivated the development of minimally invasive and/or percutaneous techniques to reduce complications, and with the advent of arthroscopy, achieve anatomical reductions. METHODS: A retrospective observational study of twelve patients with tibial pilon fractures who were treated in our center with minimally invasive and/ or percutaneous osteosynthesis with arthroscopic support was carried out between January 2019 and June 2021. Fractures were characterized using the AO/OTA classification for tibial pilon. Age, sex, fracture mechanism, exposure and initial management in the emergency department (cast immobilization or external fixation), definitive treatment, complications and clinical and functional evaluation twelve months after definitive osteosynthesis. For this last point, plantar flexion, dorsiflexion and the AOFAS and FAOS Score were measured. RESULTS: The operated patients were 12, 8 were men (67%) and 4 were women (33%). The average age was 49 (17-68) years. The definitive treatment was carried out after an average of 8 days (5-12 days). Surgical treatment schemes were as follows: percutaneous osteosynthesis with medial anatomical plate and arthroscopic support (OPAA), minimally invasive osteosynthesis with cannulated screws and arthroscopic support (OMIAA) and osteosynthesis with external circular guide and arthroscopic support (OTCAA). In the AOFAS Score, three patients had excellent results (≥ 90 points), 6 patients had good results (≥ 80 points) and 3 patients had acceptable results (≥ 70 points). In the FAOS Score, eight patients had over 80% (good results) and 4 patients had over 60% (accep - table results). DISCUSSION: Historically, tibial pilon fractures have been considered non-reconstructable and with poor long-term results. Initially this paradigm changed with the principles of Rüedi for the reconstruction of the tibial pilon and improve the results. ORIF has been widely used until today, it allows achieving an anatomical joint reduction, it allows to give stability and length to the fibula, graft contribution and sta - bilization with the medial plate. Today this concept is changing again, since the emphasis is on the care of the soft tissues to allow a better recovery of the patient and reduce the complications of the classic approach, it is in this context that the appearance of minimally invasive and/or percutaneous techniques with arthroscopic assistance has allowed us to have excellent functional and clinical results with less da - mage to the soft tissues. CONCLUSION: The proper management and care of the soft tissues in a high-energy fracture of the tibial pilon is essential to obtain favorable clinical results and thus achieve restoration of ankle function. Percutaneous and minimally invasive management has optimized management of the tibial pilon, redu - cing the rates of complications, amputation, and pri - mary arthrodesis.

Compresión-distracción en el tratamiento de pseudoartrosis de tibia distal utilizando el aparato de Ilizarov: reporte de casos / Compression-distraction in the treatment of distal tibial no union using the Ilizarov apparatus: case report / Compressão-distração no tratamento da pseudoartrose distal da tibia com Ilizarov: relato de caso

El método de Ilizarov, con sus diferentes variantes y mediante la utilización de su aparato, desarrollado en la década del 50, continúa vigente, sobre todo en el tratamiento de las complicaciones de fracturas, principalmente aquellas vinculadas a la infección y a las dificultades de la consolidación. Reportamos 2 pacientes adultos con diagnóstico de pseudoartrosis hipertrófica, rígida, con deformidad, sin infección activa y sin dismetría, tratados mediante el método de distracción y compresión realizado con el aparato de Ilizarov. En ambos casos se logró la alineación y consolidación del miembro con escasas complicaciones.

The Ilizarov method, with its different variants and using its apparatus, developed in the 1950s, is still valid, especially in the treatment of fracture complications, mainly those linked to infection and consolidation difficulties. We report 2 adult patients with a diagnosis of hypertrophic, rigid nonunion, with deformity, without active infection and without dysmetria, treated by the distraction and compression method performed with the Ilizarov device. In both cases, the alignment and consolidation of the limb was achieved with few complications.

O método de Ilizarov, com suas diferentes variantes e pelo uso de seu aparato, desenvolvido na década de 1950, ainda é válido, principalmente no tratamento de complicações de fraturas, principalmente aquelas ligadas à infecção e dificuldades de consolidação. Relatamos 2 pacientes adultos com diagnóstico de pseudoartrose hipertrófica, rígida, com deformidade, sem infecção ativa e sem dismetria, tratados pelo método de distração e compressão realizado com o dispositivo de Ilizarov. Em ambos os casos, o alinhamento e a consolidação do membro foram alcançados com poucas complicações.

Isolated open tibial shaft fracture: a seven-hospital, prospective observational study in two Latin America countries.

INTRODUCTION: open tibial fractures are challenging due to the frequent severe bone injury associated with poor soft tissue conditions. This is relevant in low- and middle-income countries, mainly related to delayed definitive fixation and lack of adequate training in soft tissue coverage procedures. Due to these factors, open tibial fracture is an important source of disability for Latin American countries. Herein we sought to provide an epidemiological overview of isolated open tibial shaft fracture across seven hospitals in southern cone of Latin America. The secondary goal was to assess the impact on quality of life based on return-to-work rate (RWR). METHODS: patients with an isolated open tibial shaft fracture treated in seven different hospitals from Brazil and Argentina from November 2017 to March 2020 were included in the study. Clinical and radiographic results were evaluated throughout the 120-day follow-up period. Final evaluation compared RWR with the SF-12 questionnaire, bone healing, and gait status. RESULTS: Seventy-two patients were treated, 57 followed for 120 days and 48 completed the SF-12 questionnaire. After 120 days, 70.6% had returned to work, 61.4% had experienced bone healing. Age, antibiotic therapy, type of definitive treatment, and infection significantly influenced the RWR. Gait status exhibited strong correlations with RWR and SF-12 physical component score. CONCLUSIONS: Isolated open tibial shaft fractures are potentially harmful to the patient's quality of life after 120 days of the initial management. RWR is significantly higher for younger patients, no history of infection, and those who could run in the gait status assessment.

Biomechanical comparison of a modified TPLO plate, a locking compression plate, and plate-rod constructs applied medially in a proximal gap model in canine synthetic tibias / [Comparação biomecânica entre placa de TPLO modificada, placa bloqueada e construção placa-pino intramedular aplicadas medialmente em modelo de fratura proximal em tíbias sintéticas caninas]

The aim of this study was to develop a modified tibial plateau leveling osteotomy (TPLO) plate and to compare its biomechanical properties with a locking compression plate (LCP) and plate-rod constructs for the stabilization of experimentally induced gap fractures in canine synthetic tibias. The tibial models were assigned to either repair with a modified TPLO plate (Group 1), locking compression plate construct (Group 2), or plate-rod construct (Group 3). The specimens were loaded to failure in axial compression, three-point mediolateral and craniocaudal bending. There was no statistical difference between the three groups regarding stiffness (N/mm) and deformation (mm) in axial compression. The modified TPLO plate achieved load to failure similar to the plate-rod construct in craniocaudal bending. There was no significant difference between groups on mediolateral bending tests regarding load to failure and deformation. Furthermore, there was no significant difference in stiffness between groups 1 and 2. In conclusion, the modified TPLO plate had similar mechanical properties to LCP and plate-rod construct in the axial compression and bending tests. Nonetheless, clinical studies with a large population of dogs are required to determine the value of this new implant in proximal tibial fracture repair.

Objetivou-se desenvolver uma placa de osteotomia niveladora do platô tibial (TPLO) modificada e compará-la biomecanicamente à placa de compressão bloqueada (LCP) e à construção placa-pino intramedular na estabilização da fratura cominutiva proximal em tíbias sintéticas caninas. Para tal, tíbias caninas sintéticas foram divididas em três grupos, sendo o grupo 1 formado pela placa de TPLO modificada, o grupo 2 por placas LCP e o grupo 3 pela construção placa-pino intramedular. Os espécimes foram submetidos à carga até a falha em compressão axial, flexão mediolateral e craniocaudal em três pontos. Não houve diferença estatística entre os três grupos quanto à rigidez (N/mm) e à deformação (mm) nos testes de compressão axial. A placa de TPLO modificada obteve carga até a falha semelhante à construção placa-pino intramedular em flexão craniocaudal. Não houve diferença significativa entre os grupos nos testes de flexão mediolateral em relação à carga até a falha e a deformação, e a variável rigidez não apresentou diferenças significativas entre os grupos 1 e 2. Em conclusão, a placa de TPLO modificada apresentou similaridade mecânica em comparação com a LCP e a construção placa-pino. No entanto, estudos clínicos são necessários para determinar o valor desse novo implante na fixação de fraturas tibiais proximais.

Early Knee Range of Motion Following Operative Treatment for Tibial Tubercle Avulsion Fractures Is Safe.

BACKGROUND: Tibial tubercle avulsion fractures (TTAF) often require surgical reduction and stabilization. Traditional teachings recommend postoperative knee immobilization for 4 to 6 weeks; however, the necessity of these restrictions is unclear and the actual practice varies. This study's purpose was to: (1) retrospectively review operatively managed TTAFs at a single center to examine the spectrum of postoperative rehabilitation guidelines, and (2) compare the outcomes of patients based on the timing of initiation of postoperative knee range of motion (ROM). METHODS: Operatively managed TTAFs treated at a single center from 2011-2020 were identified. Patients with polytrauma, associated lower extremity compartment syndrome, or treatment other than screw fixation were excluded. Patient demographics, mechanism of injury, Ogden Classification, associated injuries, operative technique, postoperative ROM progression, and time to release to unrestricted activities were collected. Patients were grouped based on the initiation of postoperative ROM as Early (<4 wk, EROM) or Late (≥4 wk, LROM). Bivariate analysis was used to compare characteristics between these 2 groups. RESULTS: Study criteria identified 134 patients, 93.3% (n=125) of whom were male. The mean age of the cohort was 14.77 years [95% confidence interval (CI: 14.5 to 15.0]. Forty-nine patients were designated EROM; 85 patients were categorized as LROM. The groups did not differ significantly with regards to age, race, injury characteristics, or surgical technique. Both groups progressed similarly with regards to postoperative range of motion. Ultimate activity clearance was achieved at ~20 weeks postoperatively without differences between groups ( P >0.05). Four instances of postoperative complication were identified, all of which occurred in the LROM group. CONCLUSION: A broad range of postoperative immobilization protocols exists following the screw fixation of TTAFs. Across otherwise similar cohorts of patients undergoing operative treatment, initiation of knee range of motion before 4 weeks was without complication and provided equivalent outcomes to traditional immobilization practices. Given the clear benefits to patients and caregivers provided by the permission of early knee motion and the avoidance of casting, providers should consider more progressive postoperative rehab protocols following operatively treated TTAFs. LEVEL OF EVIDENCE: Level III, Retrospective Cohort.

Posterolateral Fractures of the Tibial Plateau Revisited: A Simplified Treatment Algorithm.

High-energy fractures of the proximal tibia with extensive fragmentation of the posterolateral (PL) quadrant of the tibial plateau are challenging to manage. Herein, we present a review of the literature on the patterns and options of approach and fixation of the PL fragment of the tibial plateau to optimize the treatment of this specific injury pattern. We searched PubMed (1980-May 2020) to identify and summarize the most relevant articles evaluating both the morphology and treatment recommendations, including the choice of approach and fixation strategy, for the PL tibial plateau fracture. We found PL fragment can present in several patterns as a pure split, split depression, contained pure depression, and noncontained depression (rim crush), which are mostly determined by the position of the knee and the force magnitude applied during the course of the accident. Based on previous concepts described by Schatzker and Kfuri, we suggest a simplified treatment algorithm highlighting the two concepts (buttressing and containment) used for plating the PL tibial plateau fragments. Based on the available current evidence, we propose an algorithm for these two morphological types of PL tibial plateau fracture. Shear-type fractures need buttressing (the "rule of thumb"), whereas noncontained peripheral rim-type fractures need peripheral repair and containment. Contained pure depression fractures are not frequent and need percutaneous-assisted elevation and subchondral rafting, either controlled by fluoroscopy or arthroscopically. It is believed that such an approach would simplify their assessment and preoperative planning and would assist the clinicians to appreciate and manage more consistently these complex injuries.