Clasificación de Leonetti y Tigani para fracturas del pilón tibial: validación con residentes de Traumatología y Ortopedia, y fellows en tobillo y pie / Validation of the classification of Leonetti and Tigani in tibial pilon fractures through resident doctors in Traumatology and Orthopedics and foot and ankle fellows

Objetivo: Validar la clasificación de Leonetti y Tigani con evaluadores de diferentes niveles de experiencia. materiales y métodos: Se evaluó a 54 pacientes (54 fracturas del pilón tibial) en forma retrospectiva. Se tomaron radiografías de tibia distal, de frente y perfil, y una tomografía computarizada con cortes axiales, sagitales, coronales y reconstrucción 3D. Se incluyeron todos los subtipos de la clasificación de Leonetti y Tigani. Los evaluadores tenían diferentes niveles de entrenamientos: dos eran fellows en pie y tobillo, y dos, residentes del último año de formación. Para determinar la concordancia interobservador, cada caso fue clasificado en tipo I, II, III o IV, según Leonetti y Tigani. Para evaluar la concordancia intraobservador el mismo evaluador analizó los casos a las 6 semanas. Se utilizó el coeficiente kappa para determinar el grado de concordancia entre evaluadores y ese valor fue expresado con un intervalo de confianza del 95%. Resultados: La concordancia intraobservador fue moderada y muy buena para cada fellow, y buena y muy buena para los residentes, entre la primera y segunda evaluación. La concordancia interobservador arrojó un coeficiente kappa global de 0,7156 (IC95% 0,60-0,83), un valor bueno cuando se consideraron todas las fracturas por todos los evaluadores. Conclusiones: El sistema de clasificación de fracturas del pilón tibial alcanza concordancias superiores a las de estudios previos de otras clasificaciones. Dichas concordancias se lograron con médicos con diferentes niveles de experiencia y conocimiento. Nuestros hallazgos contribuyen a la validación externa e independiente de este nuevo sistema de clasificación. Nivel de Evidencia: IV

Objective: To validate the classification of Leonetti and Tigani with evaluators of different levels of expertise. Materials and methods: 54 patients with 54 tibial pilon fractures were evaluated retrospectively. Patients were studied using AP and lateral radiography of the distal tibia, as well as CT scans (axial, coronal, and sagittal images with reconstruction). All subtypes of the Leonetti classification were included. The evaluators presented different levels of training: two Foot and Ankle fellows and two residents in their last year of training. To determine the interobserver agreement, each case was classified into types I, II, III and IV according to Leonetti. To determine the intraobserver agreement, the cases were analyzed by the same evaluator after 6 weeks. The kappa coefficient (k) was used to determine the degree of agreement between the evaluators, that value was expressed with a 95% confidence interval. Results: The intraobserver agreement between the first and second evaluation for fellows was moderate and very good. For the residents, it was good and very good. The interobserver agreement for the classification of tibial pilon fractures presented an overall kappa of 0.7156 (95%CI: 0.60 to 0.83), which is a good value when all fractures are considered by all evaluators. Conclusion:This tibial pilon fracture classification system surpasses previous studies of other classifications in terms of agreement. These agreements were reached with physicians with varying levels of expertise. Our findings contribute to the external and independent validation of this new classification system. Level of Evidence: IV

Epidemiological characterization of tibial plateau fractures.

BACKGROUND: Tibial plateau fractures are traumatic injuries with severities ranging from nondisplaced to complicated fractures. This study describes the epidemiological characteristics of patients with tibial plateau fractures treated in five trauma clinics. METHODS: This retrospective, cross-sectional study included 1165 patients with tibial plateau fractures treated between December 2015 and May 2017. Subjects were selected from the medical records of five institutions based on the inclusion and exclusion criteria. Age, sex, laterality, fracture type, trauma mechanism, vehicle type, classification, and associated injuries were assessed via univariate and bivariate analyses. RESULTS: In total, 23.3% of patients with tibial fractures treated during the study period had tibial plateau fractures. Of those affected, 73% were men and 50% were younger than 40 years. Furthermore, 95.7% of fractures were caused by traffic accidents, 82.6% of which involved motorcycles. Fractures were closed in 93.1% of cases, and 78% of subjects had associated injuries. The most common fractures, according to Schatzker classification, were type VI (23%) and V (19.1%) fractures. CONCLUSIONS: Tibial plateau fractures are frequent injuries in our setting and mostly occur in men in their 30 s and 40 s. These fractures are typically caused by motorcycle traffic accidents. LEVEL OF EVIDENCE: IV.

Rol de la artroscopía en fracturas de platillo tibial: revisión bibliográfica / Role of arthroscopy in tibial plateau fractures: bibliographic review / Papel da artroscopia nas fraturas do planalto tibial: revisão bibliográfica

Objetivo: El objetivo del presente estudio es explorar y describir resultados y experiencias en el tratamiento de las fracturas de platillo tibial Schatzker1 I-IV con asistencia artroscópica para obtener reducción como parte de la técnica de fijación interna (ARIF). Metodología: Se realizó una búsqueda sistematizada en diferentes motores de búsqueda como Pubmed y Lilacs. Se buscó con la misma metodología por 2 revisores independientes utilizando términos MESH "Tibial Fracture", "Arthroscopic". Se incluyeron artículos publicados en los últimos 5 años (2014 a Setiembre 2020), que muestren resultados clínicos de los procedimientos, en inglés o español, en humanos y mayores de 18 años. Resultados: Siguiendo los criterios de inclusión se identificaron 114 títulos, y finalmente 9 artículos fueron incluidos en nuestra revisión sistematizada. De los 9 artículos revisados 5 corresponden a series de casos con un nivel de evidencia IV, 3 corresponden a estudios comparativos retrospectivos entre técnicas de reducción abierta y fijación interna (ORIF) y ARIF con nivel de evidencia III y un estudio corresponde a un nivel de evidencia I. Un total de 217 pacientes fueron intervenidos mediante ARIF en nuestra revisión, el tiempo promedio de seguimiento fue de 24.9 meses (12-90 m), en cuanto al tipo de fractura las más frecuentes fueron las fracturas de platillo tibial Schatzker II y III, la lesión asociada más frecuente fue la lesión meniscal seguida de la rotura del ligamento cruzado anterior. En cuanto al porcentaje total de resultados obtenidos independientemente de cada score utilizado, el 98% aproximadamente obtuvo resultados buenos o excelentes. El porcentaje de complicaciones operadas con asistencia artroscópica resultó ser aproximadamente del 6.5%, siendo la complicación más frecuente la trombosis venosa profunda con 6 casos. Conclusiones: De nuestra revisión podemos concluir que la asistencia artroscópica es útil en el tratamiento de las fracturas de platillo tibial Schatzker I-IV, siendo una técnica que provee resultados funcionales satisfactorios, sin incrementar el número de complicaciones y permite tratar lesiones asociadas en el mismo acto.

Objective: The objective of this study is to explore the experience and the results of Schatzker1 I-IV tibial plateau fractures internal fixation technique (ARIF) with arthroscopic assistance Methodology: A systematic review was carried out in different search engines such as Pubmed and Lilacs. The same methodology was applied by two independent reviewers using MESH terms "Tibial Fracture", "Arthroscopic". Articles published in the last 5 years (2014 to September 2020) were included, showing clinical results of the procedures, in English or Spanish, in humans and over 18 years of age. Results: Following the inclusion criteria, 114 titles were identified, and finally 9 articles were included in our systematic review. Of the 9 articles reviewed, 5 were case series (level of evidence IV), 3 retrospective comparative studies between open reduction and internal fixation techniques (ORIF) and ARIF with level of evidence III and one study was level of evidence I. A total of 217 patients underwent ARIF surgery in our review, the average follow-up time was 24.9 months (12-90 m), in terms of the type of fracture, the most frequent were Schatzker II tibial plateau fractures and III, the most frequent associated injury was meniscal injury followed by anterior cruciate ligament tear. Regarding the total percentage of results obtained independently of each score used, approximately 98% obtained good or excellent results. The percentage of complications with arthroscopic assistance turned out to be approximately 6.5%, the most frequent complication being deep vein thrombosis with 6 cases. Conclusions: From our review we can conclude that arthroscopic assistance is useful in the treatment of Schatzker I-IV tibial plateau fractures, since it provides satisfactory functional results, without increasing the number of complications and allows treating associated injuries simultaneously.

Objetivo: o objetivo deste estudo é explorar e descrever os resultados e experiências no tratamento das fraturas do planalto tibial de Schatzker1 I-IV com auxílio artroscópico para obter redução como parte da técnica de fixação interna (ARIF). Metodologia: : Foi realizada uma busca sistemática em diferentes motores de busca, como Pubmed e Lilacs. Foi pesquisado com a mesma metodologia por 2 revisores independentes usando os termos do MESH "Tibial Fracture", "Arthroscopic". Foram incluídos artigos publicados nos últimos 5 anos (2014 a setembro de 2020), mostrando resultados clínicos dos procedimentos, em inglês ou espanhol, em humanos e maiores de 18 anos. Resultados: Seguindo os critérios de inclusão, 114 títulos foram identificados e, finalmente, 9 artigos foram incluídos em nossa revisão sistemática. Dos 9 artigos revisados, 5 correspondem a séries de casos com nível de evidência IV, 3 correspondem a estudos comparativos retrospectivos entre técnicas de redução aberta e fixação interna (ORIF) e ARIF com nível de evidência III e um estudo corresponde a nível de evidência . evidências I. Um total de 217 pacientes foram submetidos a ARIF em nossa revisão, o tempo médio de acompanhamento foi de 24,9 meses (12-90 m), em termos do tipo de fratura, as mais frequentes foram as fraturas do planalto tibial de Schatzker II e III , a lesão associada mais frequente foi a lesão meniscal seguida de ruptura do ligamento cruzado anterior. Em relação ao percentual total de resultados obtidos independentemente de cada escore utilizado, aproximadamente 98% obtiveram resultados bons ou excelentes. O percentual de complicações operadas com assistência artroscópica revelou-se em torno de 6,5%, sendo a complicação mais frequente a trombose venosa profunda com 6 casos. Conclusões: Da nossa revisão podemos concluir que a assistência artroscópica é útil no tratamento das fraturas do planalto tibial de Schatzker I-IV, sendo uma técnica que fornece resultados funcionais satisfatórios, sem aumentar o número de complicações e permite tratar lesões associadas no mesmo ato.

A New Three-Dimensional Classification of Proximal Tibiofibular Fractures: A Multicenter Study.

OBJECTIVES: To propose an updated definition of proximal tibia and fibula fracture (PTFF) and establish a three-dimensional (3D) structure-based classification of PTFF. METHODS: In total, 1358 adult patients (837 males and 521 females; 43.61 ± 15.13 years， 1364 affected knees) who were diagnosed with PTFF at the departments of orthopaedic surgery of four hospitals from January 2010 to December 2019 were enrolled. The new classification of PTFF, termed Wu classification, included three parts: classification of columns in the horizontal plane, regions in the frontal plane, and segments in the sagittal plane. All PTFFs were classified according to Schatzker, Luo, and Wu classification systems. Additionally, the incidence and characteristics of PTFFs were analyzed. RESULTS: The major internal structural fractures of PTFF were tibial plateau fracture (TPF) only (725, 53.15%), TPF and proximal fibular fracture (274, 20.09%), and isolated avulsion fracture of the posterior cruciate ligament (PCL) (189, 13.86%). Approximately a quarter of PTFF cases could not be classified using Schatzker or Luo classifications, but all PTFF cases could be classified using Wu classification. The most frequent PTFFs included all four columns in region IV, segment 2 (235, 17.23%); the posterolateral and posteromedial columns in region II, segment 2 (191, 14.00%); and the lateral and posterolateral columns in region IV, segment 2 (136, 9.97%). Isolated avulsion fracture of the anterior cruciate ligament (ACL) was categorized as three injury types, most of which involved the lateral and medial columns in region II, segment 1 (40/63, 64%). More than 97% of cases of isolated fractures of the PCL involved the posterolateral and posteromedial columns in region II, segment 2. The most frequent combined avulsion fracture of the ACL and PCL included all four columns in region II, segment 2 (18/24, 75%). All of the isolated avulsion fractures of the ACL were located in segment 1, and all those of the PCL in segment 2. The most common type of isolated proximal fibular fracture involved the posterolateral column in region III, segment 2 (23/26, 88%). The most frequent combined TPF and proximal fibular fracture involved all four columns in region IV, segment 2 (107/274, 39.05%). CONCLUSIONS: All cases of PTFF could be classified by the new 3D Wu classification which should be beneficial for clinical diagnosis, guidance of treatment, statistical analysis, academic communication, and prognosis, and the most frequent PTFF involved all four columns in region IV, segment 2.

Classification and Treatment Strategies of Concomitant Fibular Column Injuries in Tibial Plateau Fractures.

BACKGROUND: About 1/3 of tibial plateau fractures are associated with proximal fibula fractures, but most proximal fibula fractures are often ignored. The aim of this study was to precisely explain the classification and treatment strategies of six injury types of the fibular column associated with tibial plateau fractures. METHODS: Patients with ipsilateral proximal fibula and tibial plateau fractures treated in our hospital were retrospectively reviewed from Aug 2007 to Mar 2020. Two experienced surgeons and two radiologists divided fibular column injury into 6 injury types according to the AO classification and four-column nine-segment classification. The treatment scheme (surgically treated or conservatively treated) was also recorded. RESULTS: In total, 355 proximal fibula fractures were included. Type 2 fibular head fracture was the most common type of injury in 122, and the segregate of superior tibiofibular syndesmosis was the rarest type in 3. In avulsion injury proximal of fibular pattern, the proportion of patients who need surgical intervention is the highest. CONCLUSIONS: Six injury types in the four-column nine-segment classification covered all types of bony and soft tissue injuries of the fibular column and concisely explained the injury mechanism. The classification is helpful for the precise judgement and decision-making of the concomitant fibular column injuries in tibial plateau fractures.

The Tibial Plateau Map: Fracture Line Morphology of Intra-Articular Proximal Tibial Fractures.

The purpose of this study was to characterize the patterns of a large series of tibial plateau fractures with the use of fracture mapping, with regard to different fracture types using the OTA/AO and Schatzker classification. Patients with intra-articular fractures of the tibial plateau were evaluated, using the OTA/AO and Schatzker classification on CT scans. For fracture mapping, the axial slice that completely displayed the tibial joint plane was first identified, then matched to a template congruently, and the fracture lines were identified and reproduced. In addition to epidemiological data (age and gender), the trauma mechanism (high-energy, low-energy, and pathological fracture) was recorded. In total, 271 patients with 278 intra-articular fractures of the tibial head were analyzed, including seven patients with both sides affected. The mean age was 49.1 years (men 46.3 years, women 53.5 years). The majority of fractures was caused by high-energy trauma. No significant difference could be shown with respect to trauma mechanism and resulting fracture type in terms of OTA/AO (p = 0.352) or Schatzker classification (p = 0.884). A significant difference could be found with respect to gender and resulting fracture type in terms of OTA/AO (p = 0.031). 170 (61.2%) were OTA/AO type B fractures, and 108 (38.8%) were type C fractures. Using the Schatzker classification, we found 53 type I (19.1%), 60 type II (21.6%), 27 type III (9.7%), 32 type IV (11.5%), 16 type V (5.8%), and 90 type VI (32.4%) fractures. The main affection was found in the lateral and intermedial column of the tibial plateaus, concerning both OTA/AO and Schatzker classification. The variability of intra-articular tibial head fractures is very high. In consequence, an individual analysis of fracture patterns and therapy planning by using CT scans is crucial.

Evaluation of the Interobserver Agreement of the Fraser and Blake & McBryde Classifications for Floating Knee / Avaliação da concordância interobservador das classificações de Fraser e Blake & McBryde para joelho flutuante

Abstract Objective To evaluate the interobserver agreement of two classifications for floating knee: Fraser and Blake & McBryde. Method Thirty-two observers, subdivided according to the degree of titration (26 resident physicians and 6 orthopedic physicians specialized in orthopedic trauma), classified 15 fractures of the ipsilateral femur and tibia. Interobserver agreement was evaluated by using the Kappa coefficient. Result When evaluating the agreement between the 9 R1, a Kappa index of 0.58 was obtained for the Fraser classification and of 0.46 for the Blake & McBryde classification. Among the 7 R2, a rate of 0.59 was obtained for the Fraser rating and 0.51 for the Blake & McBryderating. Among the 10 R3, theagreement index was higher for both classifications: 0.72 for the Fraser and 0.71 for the Blake & McBryde classification. Considering the 3 groups (R1, R2, R3) as one large group, the general Kappa index was calculated, which resulted in 0.63for the Fraser classification and 0.56 for the Blake & McBryde classification. In the group of traumaand orthopedic knee specialists, in turn, an agreement of 0.597 was obtained for the Blake and McBryde classification and of 0.843 for the Fraser classification. Conclusion Comparatively, the two classifications presented a weak to moderate degree of agreement. Fraser classification had better agreement in both groups. The agreement was higher when evaluating orthopedic trauma physicians.

Resumo Objetivo Avaliar a concordância interobservador de duas classificações para joelho flutuante: Fraser e Blake & Mcbryde. Método Trinta e dois observadores, subdivididos de acordo com o grau de titulação (26 médicos residentes e seis médicos ortopedistas especialistas em trauma ortopédico) classificaram 15 fraturas de fêmur e tíbia ipsilaterais. A concordância interobservador foi avaliada pelo coeficiente Kappa. Resultado Ao avaliar a concordância entre os 9 R1, obteve-se índice Kappa para classificação de Fraser de 0,58 e para a classificação de Blake & McBryde de 0,46. Entre os 7 R2, obteve-se índice de 0,59 para a classificação de Fraser e 0,51 para a classificação de Blake & McBryde. Entre os 10 R3, o índice de concordância foi maior para as duas classificações: 0,72 para a classificação de Fraser e 0,71 para a de Blake & McBryde. Considerando os 3 grupos (R1, R2, R3) como um só grande grupo, calculou-se o índice Kappa geral, que teve como resultado 0,63 para a classificação de Fraser e 0,56 para a classificação de Blake & McBryde. No grupo dos traumato-ortopedistas especialistas em joelho, por sua vez, obteve-se uma concordância para a classificação de Blake e McBryde de 0,597 e para a de Fraser de 0,843. Conclusão Comparativamente, as duas classificações apresentaram grau de concordância fraco a moderado. A classificação de Fraser teve melhor concordância em ambos os grupos. A concordância foi maior quando se avaliou médicos ortopedistas especialistas em trauma ortopédico.

Fracturas diafisiarias de tibia tratadas con placa lateral por técnica mínimamente invasiva / Lateral minimally invasive plate osteosynthesis technique for tibial shaft fractures

Las técnicas quirúrgicas mínimamente invasivas ayudan a que el proceso natural de la consolidación ósea ocurra proporcionando estabilidad biomecánica suficiente para obtener los mejores resultados. El objetivo de este trabajo es mostrar los resultados clínicos y radiológicos del tratamiento de las fracturas diafisiarias de tibia con osteosíntesis mínimamente invasiva con placa por cara lateral. Se realizó un estudio clínico observacional, prospectivo, longitudinal y no concurrente. Se incluyeron pacientes mayores de 18 años, de ambos sexos, con diagnósticos de fracturas diafisiarias de tibia 42A, 42B ó 42C, abiertas o cerradas. Se estableció tiempo de seguimiento mínimo de 6 meses. Se incluyeron 23 pacientes, 82,60% de sexo masculino. Promedio de edad de 21±5,63(16­49) años. La fractura más frecuente fue la 42B2 en 26,00% de los casos, y 34,80% fracturas fueron abiertas. A las 12 semanas, 65,10% habían alcanzado consolidación Montoya III; y para la semana 16, 91,30% de los pacientes. De acuerdo a la escala ASAMI, se alcanzaron resultados excelentes en 100,00% pacientes para la semana 16. No se presentaron complicaciones como infección, aflojamiento séptico o aséptico del implante, ni fatiga del mismo. El uso de la técnica MIPO para tratamiento de fracturas diafisiarias de la tibia, por cara lateral es una técnica efectiva y segura, con alta tasas de consolidación, mínimas complicaciones y buenos resultados finales(AU)

Minimally invasive surgical techniques help the natural bone healing process to occur, by providing enough biomechanical stability to obtain the best results. The objective is to show the clinical and radiological results of the treatment of diaphyseal tibial fractures with minimally invasive osteosynthesis with lateral plating. An observational, prospective, longitudinal and non-concurrent clinical study was made. Patients older than 18 years, both sexes, with diagnoses of open or closed tibial shaft fractures 42A, 42B or 42C, were included. A minimum follow-up time of 6 months was established. 23 patients were included, 82,60% male. Average age of 21 years. The most frequent fracture was 42B2 in 26,00% cases, and 34,80% were open fractures. At 12 weeks, 65,10% had reached Montoya III consolidation criterias; and for week 16, 91,30% of the patients. According to the ASAMI scale, excellent results were achieved in 100,00% patients. There were no complications such as infection, septic or aseptic loosening of the implant, or fatigue of the implant. The use of the MIPO technique for the treatment of diaphyseal fractures of the tibia on the lateral aspect is an effective and safe technique, with high rates of union, minimal complications and good final results(AU)

A Case of Reconstruction of a Type IIIc Open Tibial Fracture with Bone Loss and Warm Ischemia Time of 13 Hours: Quality of Life and Review of the Literature.

BACKGROUND The management of open Gustilo IIIC fractures can be challenging even for experienced orthopedic surgeons. The decision between limb salvage and amputation is extremely difficult and the scoring systems do not seem to affect it significantly. Although ischemic time has been proven to be a major factor, attempts at reconstruction of limbs with ischemic time over 6 hours have been made in past decades. A simultaneous management of skeletal, soft-tissues, and vascular injury should be performed. This requires an orthoplastic surgeon who is capable of doing all the necessary operations by him/herself with hand-surgery and microsurgery expertise. CASE REPORT We present a case of a 49-year-old man with a type IIIC open tibial fracture with bone loss and warm ischemia time of 13 hours, who underwent revascularization and reconstruction with good radiological and functional results after a follow-up of 3 years. A few similar cases have been presented in the literature but none of them had a combination of bone loss, severe soft tissue injury, and complete vascular disruption after a crush injury. CONCLUSIONS The treatment of type IIIC open fractures of the tibia can be a demanding and time-consuming process. Detailed information about the necessity of multiple surgical interventions must be explained and fully understood by the patient in order to have realistic expectations.

Anterior Cruciate Ligament Tear Following Operative Treatment of Pediatric Tibial Eminence Fractures in a Multicenter Cohort.

BACKGROUND: Postoperative ipsilateral anterior cruciate ligament (ACL) tears after tibial eminence fracture fixation has been previously noted in the literature. This study aims to describe the prevalence of and risk factors for postoperative ACL tears in a cohort of patients operatively treated for tibial eminence fracture. METHODS: A retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary care children's hospitals was performed. The primary outcome of interest was subsequent ACL rupture. Incidence of ACL tear was recorded for the entire cohort. Patients who sustained a postoperative ACL tear were compared with those without ACL tear and analyzed for demographics and risk factors. A subgroup analysis was performed on patients with a minimum of 2-year follow-up data or those who had met the primary outcome (ACL tear) before 2 years. RESULTS: A total of 385 pediatric patients were reviewed. 2.6% of the cohort experienced a subsequent ACL tear. The median follow-up time was 6.5 months (SD=6.4 mo). Subsequent ACL tears occurred at a median of 10.2 months (SD=19.5 mo) postoperatively. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL tear (P=0.01). Patients with a subsequent ACL tear were older on average (13.5 vs. 12.2 y old), however, this difference was not statistically significant (P=0.08). Subgroup analysis of 46 patients who had a 2-year follow-up or sustained an ACL tear before 2 years showed a 21.7% incidence of a subsequent ACL tear. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL rupture (P=0.006) in this subgroup. Postoperative ACL tears occurred in patients who were older at the time that they sustained their original tibial eminence fracture (13.4 vs. 11.3 y old, P=0.035). CONCLUSIONS: Ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 2.6%. However, in those with at least 2 years of follow-up, the incidence was 21.7%. Subsequent ACL tear was more likely in those with completely displaced (type III or IV) tibial eminence fractures and older patients. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Open reduction and internal fixation for displaced Salter-Harris type II fractures of the distal tibia: a retrospective study of sixty-five cases in children.

BACKGROUND: The treatment for displaced Salter-Harris II (S-H II) distal tibia fractures remains controversial. The purpose of this study was to review S-H II distal tibia fractures and evaluate the rate of premature physeal closure (PPC) treated by open reduction and internal fixation (ORIF). METHODS: We reviewed the charts and radiographs of S-H II fractures of the distal tibia with displacement > 3 mm between 2012 and 2019 treated by ORIF. Patients were followed up for a minimum of 6 months. CT scans of injured side or contralateral ankle radiograph were obtained if there was any evidence of PPC. Any angular deformity or shortening of the involved leg was documented. Multivariable logistic regression was performed to identify risk factors for the occurrence of PPC. RESULTS: A total of 65 patients with a mean age of 11.8 years were included in this study. The mean initial displacement was 8.0 mm. All patients but one were treated within 7 days after injury and the mean interval was 3.7 days. Supination-external rotation injuries occurred in 50 patients, pronation-eversion external rotation in 13, and supination-plantar flexion in two. The residual gap was less than 1 mm in all patients following ORIF and all fractures healed within 4-6 weeks. Superficial skin infection developed in one patient. Ten patients complained of the cosmetic scar. The rate of PPC was 29.2% and two patients with PPC developed a varus deformity of the ankle. Patients with associated fibular fracture had 7 times greater odds of developing PPC. Age, gender, injured side, mechanism of injury, amount of initial displacement, interval from injury to surgery, or energy of injury did not significantly affect the rate of PPC. CONCLUSIONS: ORIF was an effective choice of treatment for S-H II distal tibia fractures with displacement > 3 mm to obtain a satisfactory reduction. PPC is a common complication following ORIF. The presence of concomitant fibula fracture was associated with PPC.

Management of Gustilo type IIIB open tibial shaft fractures with limited resources: experience from an African trauma center.

PURPOSE: We sought to evaluate the management of Gustilo type IIIB open tibia diaphyseal fractures in an African trauma center with respect to soft tissue defect management and bone union achievement. Functional outcome assessment was the secondary objective. METHODS: A retrospective review was conducted including patients treated for open tibia fractures requiring flap coverage between 2007 and 2011. As plastic surgeons were lacking in availability, all procedures were performed by orthopedic surgeons trained in completing nonmicrosurgical flap transfers. RESULTS: Twenty-seven patients with a mean age of 36 years were included. Although the mean time to debridement was 11 h, early infection occurred in 16 (59%) patients. The mean time to flap coverage was 27 days. Among the 29 primary local flap transfers performed, only 4 failed. Secondary amputation was required in one patient after flap failure. Bone reconstruction procedures were required in nine patients and were performed after a mean period of 97 days. At the mean follow-up time of 13 months, 23 (88%) of the 26 remaining fractures had united. There were three septic nonunions and two cases of chronic osteomyelitis. Functional result was negatively influenced by the soft tissue defect area and low-quality flap coverage. CONCLUSIONS: To our knowledge, this is the first series reporting flap reconstructions performed by orthopedic surgeons for Gustilo type IIIB tibia fractures in an African hospital. Local pedicled flap transfers permitted the achievement of soft tissue coverage and bone union in most cases. Subsequent bone grafting was required in one-third of the cases.

Classification and Treatment of Pediatric Tibial Spine Fractures: Assessing Reliability Among a Tibial Spine Research Interest Group.

BACKGROUND: Treatment decisions for patients with tibial spine fractures depend heavily on radiographic measurements. The purpose of this study was to determine whether existing classification systems and radiographic measurements are reliable among a multicenter tibial spine research interest group. A secondary purpose was to evaluate agreement in treatment of tibial spine fractures. METHODS: Using a deidentified radiographic imaging series and identical imaging software, we examined the interobserver and intraobserver reliability of the Meyers and McKeever classification, as well as a cohort of measurements of tibial spine fractures and treatment recommendations. Forty patients were included based on previous reliability studies. Interobserver and intraobserver data were analyzed using kappa and intraclass correlation coefficient reliability measures for categorical and continuous variables, respectively. RESULTS: Good interobserver reliability was seen with superior displacement measurements of the anterior portion of the tibial spine fracture (0.73, 0.78) and excellent intraobserver reliability with an intraclass correlation coefficient of 0.81. Several measurements demonstrated moderate interobserver and intraobserver reliability including posterior-proximal displacement, and length and height of the tibial spine fracture. Moderate intraobserver reliability was seen with a majority of measurements and classification schemata (0.42 to 0.60) except for a poor agreement in posterior-sagittal displacement (0.27). Classifying tibial spine fractures according to the original Meyers and McKeever classification demonstrated fair agreement [κ=0.35, 0.33 (inter); 0.47 (intra)]. When combining Type III and IV, agreement increased for both reviews [κ=0.42, 0.44 (inter); 0.52 (intra)]. A total of 24 (60%) fractures were classified as 3 different types. There was fair agreement in both reviews regarding open reduction (either open or arthroscopic) versus closed reduction for initial treatment [κ=0.33, 0.38 (inter); 0.51 (intra)]. CONCLUSIONS: Measurement of superior displacement of the anterior portion of tibial spine fractures on the lateral images is the only radiographic assessment with good interobserver and intraobserver reliability. Reliability of radiographic measurements and a modified classification for tibial spine fractures remains fair, and perhaps unacceptable, even among a group of pediatric sports medicine specialty-trained surgeons. LEVEL OF EVIDENCE: Level III-diagnostic reliability study of nonconsecutive patients.

Posterior Malleolar Fractures: A Critical Analysis Review.

In patients with ankle fractures, the presence of a posterior malleolar fracture has a negative impact on the prognosis. Computed tomography (CT) scanning is essential for fracture classification and treatment planning, as the indication for surgery depends on the 3-dimensional fragment outline and displacement, incisura involvement, and the presence of joint impaction. Anatomic reduction of a posterior malleolar fragment restores the incisura, facilitating reduction of the distal part of the fibula, and it also restores the integrity of the posterior portion of the syndesmosis, reducing the need for additional syndesmotic stabilization. Direct open reduction and fixation of posterior malleolar fragments from a posterior orientation is biomechanically more stable and provides a more accurate reduction than does indirect reduction and anterior-to-posterior screw fixation. Intra-articular step-off of >=2 mm is an independent risk factor for an inferior outcome and the development of posttraumatic arthritis, irrespective of the fragment size.

A novel arthroscopically assisted reduction technique for three patterns of posterolateral tibial plateau fractures.

BACKGROUND: Posterolateral tibial plateau fractures (PTPF) remain a challenge for orthopedics surgeons because the special anatomical structures of the posterolateral corner of knee joint including the fibular head, the lateral collateral ligament, and the peroneal nerve, which impedes the exposure of the fracture fragments and need irregular implants to get a stable fixation. The purpose of present study was to introduce a new articular fracture fragments restoration technique for three patterns of PTPF and investigate the relationship between associated soft injuries and fracture patterns. METHODS: From May 2016 to April 2018, 31 patients with PTPF who had undertaken arthroscopically assisted reduction and fixation (AARF) were enrolled in present study. Demographic data, pre-operation, and post-operation X plan films, three-dimensional computed tomography (CT) scans and magnetic resonance imaging (MRI) were reviewed. Present samples were divided into three patterns with lateral inclination (LI), posterior inclination (PI), and parallel compression (PC) according to the orientation of the articular fragment inclination. Rasmussen anatomical score was used to assess the radiological results. Rasmussen functional score, Hospital for Special Surgery knee-rating Score (HSS), and range of motion (ROM) of the knee joint at the final follow-up were measured to evaluate the clinical outcomes. RESULTS: In this series, the post-operation tibial plateau angle (TPA) was 9.7° ± 3.5°(range 4.0°-15.8°) and the Rasmussen anatomical score was 17.7 ± 0.7(range 16-18); clinical outcomes showed that the HSS score was 92.7 ± 21.8 (range 90-96) and the Rasmussen functional score was 27.9 ± 1.0 (range 26-30). Of all the patients, the anterior cruciate ligament (ACL) injuries including the ACL tibial attachment ruptures occurred in 16 patients (51.6%), meniscus lesions happened in 19 patients (61.3%), medial collateral ligament (MCL) injuries were founded in 13 patients (41.9%). The number of ACL injuries including the ACL tibial attachment ruptures in the PI fracture pattern (12 cases) is significantly higher than LI (2 cases) and PC (2 cases) fracture pattern (p < 0.05). CONCLUSION: Profound understanding the different patterns of PTPF and using our reduction technique will facilitate to restore the main articular fracture fragments. The PI fracture patterns have a significant high incidence of the ACL ruptures. LEVEL OF EVIDENCE: Therapeutic study, Level IV.

Arthroscopic treatment of tibial eminence fractures using double-loop endobutton device: Surgical technique and short-term treatment outcomes.

OBJECTIVES: This study aims to explain the arthroscopic surgical technique of double-loop endobutton device for tibial eminence fractures and share the outcomes of this treatment method. PATIENTS AND METHODS: Thirteen patients (10 males, 3 females; mean age 19.9±5.6 years; range, 14 to 34 years) with tibial eminence fractures type II, IIIa, and IIIb were analyzed retrospectively between March 2017 and March 2019. Knee laxity, Tegner Lysholm knee scores, the International Knee Documentation Committee (IKDC) scores, knee mobility, Lachman test, and bone union were analyzed after the arthroscopic fracture fixation with double-loop endobutton device at first and sixth months after surgery. RESULTS: First month mean IKDC scores were 38.0±7.0 and mean Tegner Lysholm scores were 50.3±5.8. Sixth month mean IKDC scores were 80.2±4.0 and mean Tegner Lysholm scores were 87.1±5.4. All patients showed negative Lachman test and negative pivot-shift test at final follow-up. Radiological bone union without reduction loss was also seen in all patients. CONCLUSION: Using double-loop endobutton device provides successful results to fix tibial eminence fractures.

Pediatric tibial shaft and distal metaphyseal fractures.

OBJECTIVES: This study aims to investigate the effects of associated factors like age, fracture level, accompanying fibular fractures and wound condition on healing by determining and comparing union scores of pediatric tibial fractures (PTFs). PATIENTS AND METHODS: Forty-five patients with 46 PTFs (32 males, 13 females; mean age 9.5 years; range 2 to 16 years) who were treated by closed reduction and casting or operated between January 2016 and January 2019 were retrospectively evaluated. The union scores were evaluated at the end of fourth, sixth and eighth weeks and compared to each other. Effects of the age, associated fibular fractures, wound condition, fracture level and treatment type to union score were analyzed. RESULTS: Twenty-eight (60.9%) out of 46 PTFs had associated fibular fractures and 18 (39.1%) did not. Motor vehicle accident was the most frequent etiologic factor (47.8%). Thirty-four out of 46 fractures were closed tibial fractures (73.9%) and 12 had open wound (26.1%). There was a negative correlation between age and the union scores (p<0.001 for each week). No significant difference was observed between the union score of diaphyseal and metaphyseal fractures at the fourth, sixth, and eighth weeks. The union scores of each week were higher in the conservative group compared to operative group (p<0.001 for each week). Associated fibular fracture group had lower union scores compared to isolated tibial fracture group at fourth, sixth and eighth weeks. Likewise, the union scores of the open fracture group were lower than the closed fracture group (p<0.05 for each week). CONCLUSION: Associated fibular fractures, open fractures and aging negatively affect union scores of PTFs. Attention should be paid, particularly in these conditions, during the selection of the operation type and the follow-up period of PTFs.

The Medial Eminence Line for Predicting Tibial Fracture Risk after Unicompartmental Knee Arthroplasty.

BACKGROUD: Tibial fracture after cementless Oxford unicompartmental knee arthroplasty (OUKA) is a rare but serious complication. It is reported more frequently in Asian countries. The aim of this retrospective study was to assess the morphological characteristics of the tibia by using a simple novel measurement method in patients with tibial fractures after OUKA. METHODS: Six knees (all women) with tibial fractures after cementless OUKA (fracture group) and 150 knees without an obvious complication after cementless OUKA (control group) were examined retrospectively at our institution between January 2016 and April 2017. We drew a medial eminence line (ME line) defined as a line extending from the tip of the medial intercondylar eminence parallel to the tibial axis. The ME line was classified into two types (intramedullary type [type I] and extramedullary type [type E]), and the proportion of each type was compared between fracture patients and controls. RESULTS: In the fracture group, there were four (66.7%) type E cases and two (33.3%) type I cases; in the control group, there were 18 (12%) type E cases and 132 (88%) type I cases. Fisher exact tests showed that the proportion of type E was higher in the fracture group than in the control group (p < 0.01). CONCLUSIONS: Measurement of the ME line can be recommended as a useful method to assess the risk of postoperative fracture after cementless OUKA.

Epidemiological Study of Tibial Plateau Fractures Combined with Intercondylar Eminence Fractures.

OBJECTIVE: To investigate the epidemiological characteristics of tibial plateau fractures combined with intercondylar eminence fractures and identify the risk factors. METHODS: This retrospective study enrolled patients with tibial plateau fractures who were treated in the third hospital of Hebei Medical University from January 2015 to December 2018; 1020 patients (693 [68%] men and 327 [32%] women) meeting the inclusion and exclusion criteria had a mean age of 45.2 ± 13.8 years. In total, 506 (50%) cases were left injuries, 495 (48%) were right injuries, and 19 (2%) were bilateral injuries. Among them, 458 (44.9%) with a mean age of 47.0 ± 13.9 years had intercondylar eminence fractures, including 324 men and 134 women. A total of 562 (55.1%) patients were identified without intercondylar eminence fractures, including 369 (65.7%) men and 193 (34.3%) women with an average age of 43.8 ± 13.6 years. The distribution characteristics of tibial plateau fractures with intercondylar eminence involved were identified. The potential associations among fractures and various other factors, such as age, gender, occupation, and mechanism of injury, were explored. RESULTS: The highest proportion age group of tibial plateau fractures included the ages 35-54 years, with more men than women for both age groups. For males, the highest proportion age group was 35-44 years, and for females, it was 55-64 years (χ 2 = 71.336, P < 0.01). According to Schatzker classification, type IV tibial plateau fractures had the highest risk of intercondylar eminence being involved (70.6%) without significance with type V (69.5%) and VI (68.2%) but with greater significance with types I (11.9%), II (39.2%), and III (9.4%, χ 2 = 280.187, P < 0.01). Multiple analysis showed that simple fractures, including types I, II, and III (OR 0.108, 95% CI: 0.080-0.145), were less likely to involve intercondylar eminence fractures than complex fractures, including types IV, V, and VI. Patients aged >74 years were more likely to have intercondylar eminence fractures compared with other age groups. Retired patients (OR 4.332, 95% CI: 1.147-16.362) were more likely to have fractured intercondylar eminence. CONCLUSION: The current study revealed the characteristics of tibial plateau fractures, especially those involving intercondylar eminence fractures, as well as their proportion, distribution, and risk factors, which can be used as reference data for clinical assessment and surgical protocol selection.