Nailing distal tibial fractures: does entry technique affect distal alignment?

PURPOSE: In treating distal third tibial fractures, restoration of the axial alignment and therefore accurate reduction of the distal fragment minimise the risk of tibiotalar joint malalignment. The aim of this study is to investigate whether there was a difference in accuracy of reduction and axial alignment, when nailing distal third tibial fractures using either the suprapatellar or the infrapatellar tibial nailing entry technique. METHODS: This retrospective cohort study compared alignment of intramedullary nails performed for distal third tibial fractures between 2015 and 2018 through the suprapatellar and infrapatellar approach at a UK Level 1 trauma centre. It compared a consecutive series of 74 suprapatellar nails and 51 infrapatellar nails, with radiographic assessment of tibial alignment in the antero-posterior and sagittal planes. It included inter- and intra-observer analyses of radiographic measurements. RESULTS: In the coronal plane, mean malalignment in the suprapatellar technique group was 2.8 ± 0.7° and 4.7 ± 0.9° in the infrapatellar technique group (P < 0.01). In the sagittal plane, mean malalignment in the suprapatellar technique group was 4.0 ± 0.8° and 3.5 ± 0.9° in the infrapatellar technique group (P = 0.42). Intra- and inter-observer analysis showed strongly positive correlations between observers. CONCLUSIONS: We suggest that the suprapatellar technique may improve coronal plane alignment when intramedullary nailing distal tibial fractures. There was no significant difference in alignment in the sagittal plane. We conclude that the suprapatellar technique may be superior in preventing malalignment when treating distal third tibial fractures, potentially improving clinical outcome.

Three-dimensional reconstruction of the orbital retrobulbar vasculature.

PURPOSE: The retrobulbar orbital vasculature is known to be complex and variable between individuals. This study aimed to produce a method to map the retrobulbar vessels, to generate 3D reconstructions, to visualise and to improve our understanding of their complexity. METHODS: Five human orbits donated under the Human Tissue Act (2004) were fixed in formalin, decalcified in 10% formic acid, and dehydrated in acetone at -20°C. Specimens were impregnated with epoxy resin, cured, and cut into 0.3 mm sections. Sections were stained with Gomori's trichrome stain, imaged, and reconstructed using 3D reconstruction software (BioVis3D, version 3.1). RESULTS: The arterial system was reconstructed in all five specimens. The superior ophthalmic vein (SOV) and the central retinal vein (CRV) were reconstructed in four specimens. E12 sheet plastination showed excellent results for histological analysis at a macroscopic level; however, anatomical topology was not entirely preserved on a microscopic level. Gomori's trichrome stain gave excellent results in highlighting axial sections of the arterial walls and their tunics, including finer calibre vessels, thus allowing detailed reconstruction of the arterial vasculature. Miller's stain for elastin showed poor results in differentiating vessels from soft tissue; venous vasculature was poorly identified with both stains. CONCLUSIONS: This study provided a detailed anatomical model of the retrobulbar orbital vascular system, a method that can be used for further studies to form a database relating to the topography of the arterial system. These models may be employed for teaching, and possible surgery planning, for both trainees and ophthalmic surgeons.