Speed and surface steepness affect internal tibial loading during running.

BACKGROUND: Internal tibial loading is influenced by modifiable factors with implications for the risk of stress injury. Runners encounter varied surface steepness (gradients) when running outdoors and may adapt their speed according to the gradient. This study aimed to quantify tibial bending moments and stress at the anterior and posterior peripheries when running at different speeds on surfaces of different gradients. METHODS: Twenty recreational runners ran on a treadmill at 3 different speeds (2.5 m/s, 3.0 m/s, and 3.5 m/s) and gradients (level: 0%; uphill: +5%, +10%, and +15%; downhill: -5%, -10%, and -15%). Force and marker data were collected synchronously throughout. Bending moments were estimated at the distal third centroid of the tibia about the medial-lateral axis by ensuring static equilibrium at each 1% of stance. Stress was derived from bending moments at the anterior and posterior peripheries by modeling the tibia as a hollow ellipse. Two-way repeated-measures analysis of variance were conducted using both functional and discrete statistical analyses. RESULTS: There were significant main effects for running speed and gradient on peak bending moments and peak anterior and posterior stress. Higher running speeds resulted in greater tibial loading. Running uphill at +10% and +15% resulted in greater tibial loading than level running. Running downhill at -10% and -15% resulted in reduced tibial loading compared to level running. There was no difference between +5% or -5% and level running. CONCLUSION: Running at faster speeds and uphill on gradients ≥+10% increased internal tibial loading, whereas slower running and downhill running on gradients ≥-10% reduced internal loading. Adapting running speed according to the gradient could be a protective mechanism, providing runners with a strategy to minimize the risk of tibial stress injuries.

Physeal Bar Formation After Pediatric Medial Malleolus Fractures.

Pediatric medial malleolus fractures are commonly Salter-Harris (SH) type III or IV fractures of the distal tibia and are associated with a risk of physeal bar formation and subsequent growth disturbance. The purpose of this study was to determine the incidence of physeal bar formation following pediatric medial malleolus fracture and evaluate for patient and fracture characteristics predictive of physeal bar formation. Seventy-eight consecutive pediatric patients during a 6-year period who had either an isolated medial malleolar or a bimalleolar ankle fracture were retrospectively reviewed. Forty-one of 78 patients had greater than 3 months of radiographic follow-up and comprised the study population. Medical records were reviewed for demographic information, mechanism of injury, treatment, and need for further surgery. Radiographs were reviewed to assess for initial fracture displacement, adequacy of fracture reduction, SH type, percentage of the physeal disruption from the fracture, and physeal bar formation. Twenty-two of 41 patients (53.7%) developed a physeal bar. The mean time to diagnosis of physeal bar was 4.9 months (range, 1.6-11.8 months). Twenty-seven percent (6 of 22) of bars were diagnosed at greater than 6 months from injury. Adequacy of reduction was predictive of physeal bar formation, although all patients were reduced to within 2 mm. The mean residual displacement of patients with a bar was 1.2 mm compared with 0.8 mm for those without a bar (P=.03). Because the bar formation rate is greater than 50% on radiographs, routine radiographic assessment of all pediatric medial malleolar fractures should continue for at least 12 months after injury. [Orthopedics. 2024;47(1):e33-e37.].

Effect of three different running gait cues on vertical tibial acceleration.

BACKGROUND: Repetitive impacts during running are associated with some running injuries. Tibial acceleration is a proxy for tibial loading, and interventions that can decrease it are likely to be of interest to the running community. RESEARCH QUESTION: What effect do running gait cues have on peak vertical tibial acceleration at a comfortable and moderate running pace, and how will these cues be executed? METHODS: Twenty-seven participants ran on a treadmill according to the following cues in random order: run softly and lightly, run with shorter steps, and increase preferred step rate by 7.5 %. Participants maintained each condition for one minute before returning to their 'preferred' running pattern for two minutes. Two tibia-mounted inertial measurement unit sensors were used to collect tibial acceleration data at a 'comfortable' and 'moderate' run pace. A repeated measures analysis of variance test was used to compare the means between running conditions. RESULTS: Compared to preferred running, the decrease step length (-8 %, p = 0.002, Cohen's d=0.33) and run softly and lightly (-9 %, p = 0.040, Cohen's d=0.38) cues provided a significant reduction in peak vertical tibial acceleration during a comfortable run pace. No significant difference was observed with an increase in step rate. Compared to preferred running, there was no significant difference in peak vertical tibial acceleration with any of the running gait cues during a moderate run pace. SIGNIFICANCE: Instructing runners to decrease step length or run softly and lightly can result in small reductions in peak vertical tibial acceleration during a comfortable run pace, but running gait cues during a moderate run pace provide no effects. Differences in the execution of each cue are likely to influence overall tibial loading throughout the stride cycle. These findings provide novel biomechanical evidence for the potential effects of running retraining strategies for reducing tibial accelerations at different running paces.

Docking site complications analysis of Ilizarov bone transport technique in the treatment of tibial bone defects.

BACKGROUND: Treating long bone defects of the extremities caused by trauma, infection, tumours, and nonunion has been challenging for clinical orthopaedic surgeons. Bone transport techniques have the potential to treat bone defects. However, inevitable docking site complications related to bone transport techniques have been reported in many studies. The purpose of this study was to investigate the risk factors associated with docking site complications in patients who underwent the Ilizarov bone transport technique for the treatment of tibial bone defects. METHODS: This retrospective study included 103 patients who underwent bone transport for the treatment of large bone defects in the tibia from October 2012 to October 2019. Patient demographic data, complications and clinical outcomes after a minimum of 2 years of follow-up were collected and retrospectively analysed. Additionally, univariate analysis and logistic regression analysis were used to analyse the factors that may affect the development of docking site complications in patients with tibial bone defects treated with the Ilizarov bone transport technique. The clinical outcomes were evaluated using the Association for the Study and Application of the Ilizarov criteria (ASAMI) at the last clinical follow-up. RESULTS: All 103 patients with an average follow-up of 27.5 months. The docking site complications rate per patient was 0.53, and delayed union occurred in 22 cases (21.4%), axial deviation occurred in 19 cases (18.4%) and soft tissue incarceration occurred in 10 cases (9.7%). According to the results of the logistic regression analysis, the bone defect length (P = 0.001, OR = 1.976), and bone defect of distal 1/3 (P = 0.01, OR = 1.976) were significantly correlated with delayed union. Bone defect length (P < 0.001, OR = 1.981) and external fixation time (P = 0.012, OR = 1.017) were significantly correlated with axial deviation. Soft tissue defects (P = 0.047, OR = 6.766) and the number of previous operations (P = 0.001, OR = 2.920) were significantly correlated with soft tissue incarceration. The ASAMI bone score at the last follow-up showed a rate of excellent and good bone results of 95.1% and a rate of excellent functional results of 90.3%. CONCLUSION: The Ilizarov bone transport technique is a practical and effective method for the treatment of tibial bone defects. However, the incidence of complications at the docking site is high, of which bone defect length, external fixation time, the number of previous operations, soft tissue defects and the bone defect of distal 1/3 are statistically significantly associated with the occurrence of docking site complications.

[Comparative study of the effects of intramedullary nail fixation and minimally invasive percutaneous plate internal fixation technique on platelet activation and serum transforming growth factor-ß1(TGF-ß) 1 and bone morphogenetic protein-2 (BMP-2) in patients with tibial and fibular fracture].

OBJECTIVE: To investigate the effect of intramedullary nail fixation (IMN) and minimally invasive percutaneous plate internal fixation (MIPPO) techniques on tibiofibular fractures and their effect on platelet activation and serum transforming growth factor-ß1 (TGF-ß1) and bone morphogenetic protein-2 (BMP-2). METHODS: Total of 105 patients with tibiofibular fractures from February 2019 to February 2020 were selected and divided into 53 cases in the MIPPO group and 52 cases in the IMN group. There were 29 males and 24 females with an average age of (41.74±6.05) years old in MIPPO group;in IMN group, 31 males and 21 females with an average age of (40.59±5.26) years old. The perioperative surgical indexes, postoperative complications, ankle function recovery at 12 months postoperatively, platelet activation indexes at 3 and 7 days preoperatively and postoperatively, and serum TGF-ß1 and BMP-2 levels at 4 and 8 weeks preoperatively and postoperatively were compared between the two groups. RESULTS: The operating time and fracture healing time in the MIPPO group were shorter than those in the IMN group(P<0.05); Compared with the preoperative period, the levels of GMP-140, PAC-1, CD63, and CD61 increased in both groups at 3 and 7 days after surgery, but were lower in the MIPPO group than in the IMN group(P<0.05);the levels of serum TGF-ß1 and BMP-2 increased in both groups at 4 and 8 weeks after surgery compared with the preoperative period, and the postoperative complication rate in the MIPPO group was lower than that in the IMN group(P<0.05);the difference was not statistically significant in the excellent rate of ankle function recovery at 12 months follow-up after surgery between two groups(P>0.05). CONCLUSION: Both intramedullary nail fixation and MIPO technique for treatment of tibia and fibula fractures can improve ankle joint function, but the latter has the advantages of short operation time, fast fracture healing, fewer complications, and light platelet activation. Serum TGF-ß1, BMP-2 level improves quickly.

Iatrogenic Flexion-Related Classic Metaphyseal Lesion of the Distal Tibia: Three Cases.

BACKGROUND: Classic metaphyseal lesions (CMLs) should raise concern for nonaccidental trauma. However, iatrogenic causes for CMLs have increasingly been described and warrant close consideration. Increasing the clinical understanding of CML mechanics and their relation to often routine medical procedures will enhance provider awareness and expand the differential diagnosis when these otherwise highly concerning injuries are identified. CASE REPORTS: We describe three clinical cases where suspected iatrogenic dorsiflexion or plantar flexion resulted in an isolated distal tibia CML. Respectively, we present heel-stick testing and i.v. line placement as clinical correlates of these two mechanisms. Although prior reports have aimed to describe iatrogenic CML etiologies, they have not focused on dorsiflexion or plantar flexion as predominant mechanisms of injury. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians are critical to the surveillance and identification of nonaccidental trauma. Given that children oftentimes present to the emergency department with subtle yet concerning signs of maltreatment, an emergency physician must be aware of the potential causes of injury as well as the recommended response. Although avoiding missed cases of abuse and improving the detection of injuries is crucial for child health and well-being, failing to consider or recognize alternative explanations could also have serious implications for a child and their caregivers.

El uso de artroscopia no aumenta la incidencia de complicaciones en el manejo de fracturas de mesetas tibiales Schatzker IV-VI / The use of arthroscopy does not increase the incidence of complications in the management of Schatzker IV-VI tibial plateau fractures

Antecedentes y objetivo: El uso de asistencia artroscopica en fracturas de mesetas tibiales tipos I-III según la clasificación de Schatzker se ha popularizado; sin embargo aún existe controversia con respecto a su uso en fracturas Schatzker IV-VI por el potencial riesgo de complicaciones. El objetivo de este trabajo es comparar la tasa de complicaciones intra o postoperatorias entre pacientes con fracturas de mesetas tibiales de este tipo tratados con y sin artroscopia al momento de la reducción y osteosíntesis definitiva. Materiales y métodos: Estudio de cohortes retrospectivo. Se incluyeron pacientes con diagnóstico de fractura de mesetas tibiales Schatzker IV-VI, sometidos a reducción y osteosíntesis definitiva, y al manejo de lesiones asociadas con o sin el uso de artroscopia evaluando la aparición de síndrome compartimental, trombosis venosa profunda e infección relacionada a fractura con seguimiento mínimo de 12 meses posterior a la cirugía definitiva. Resultados: Se incluyeron 288 pacientes: 86 operados con asistencia artroscópica y 202 sin asistencia artroscópica. La tasa de complicaciones total en el grupo con y sin asistencia artroscópica fue del 18,60 y 26,73%, respectivamente (p=0,141). No hubo asociación estadísticamente significativa entre el uso de asistencia artroscópica y el desarrollo de las complicaciones analizadas. Discusión y conclusiones: El uso de artroscopia de rodilla como apoyo de la reducción o como adyuvancia para el tratamiento simultáneo de lesiones intraarticulares concomitantes no aumentó el riesgo de complicaciones en el postoperatorio inmediato ni tras 12 meses de seguimiento.(AU)

Background and objective: The use of arthroscopy for tibial plateau fractures type I, II and III according to Schatzker classification has increased, yet its employment for tibial plateau fractures Schatzker IV, V and VI is controversial due to the potential risk of compartment syndrome, deep vein thrombosis and infection. We aimed to compare the rate of operative and postoperative complications among patients with these types of tibial plateau fractures treated with and without arthroscopy at the time of definitive reduction and osteosynthesis. Methods: Retrospective cohort study. Patients with diagnosis of tibial plateau fracture Schatzker IV, V or VI who underwent reduction and definitive osteosynthesis with or without the use of arthroscopy were included. The development of compartment syndrome, deep vein thrombosis, and fracture-related infection was evaluated up to 12 months after the definitive surgery. Results: Two hundred eighty-eight patients were included: 86 with arthroscopic assistance and 202 without it. The overall complication rate in the group with and without arthroscopic assistance was 18.60% and 26.73%, respectively (P=.141). No statistical association was found between the use of arthroscopic assistance and the development of the analyzed complications. Discussion and conclusion: The use of arthroscopy to support reduction or addressing concomitant intra-articular injuries did not increase the risk of complications in patients with high-energy tibial plateau fractures at 12 months of follow up.(AU)

[Translated article] The use of arthroscopy does not increase the incidence of complications in the management of Schatzker IV–VI tibial plateau fractures / El uso de artroscopia no aumenta la incidencia de complicaciones en el manejo de fracturas de mesetas tibiales Schatzker IV-VI

Antecedentes y objetivo: El uso de asistencia artroscopica en fracturas de mesetas tibiales tipos I-III según la clasificación de Schatzker se ha popularizado; sin embargo aún existe controversia con respecto a su uso en fracturas Schatzker IV-VI por el potencial riesgo de complicaciones. El objetivo de este trabajo es comparar la tasa de complicaciones intra o postoperatorias entre pacientes con fracturas de mesetas tibiales de este tipo tratados con y sin artroscopia al momento de la reducción y osteosíntesis definitiva. Materiales y métodos: Estudio de cohortes retrospectivo. Se incluyeron pacientes con diagnóstico de fractura de mesetas tibiales Schatzker IV-VI, sometidos a reducción y osteosíntesis definitiva, y al manejo de lesiones asociadas con o sin el uso de artroscopia evaluando la aparición de síndrome compartimental, trombosis venosa profunda e infección relacionada a fractura con seguimiento mínimo de 12 meses posterior a la cirugía definitiva. Resultados: Se incluyeron 288 pacientes: 86 operados con asistencia artroscópica y 202 sin asistencia artroscópica. La tasa de complicaciones total en el grupo con y sin asistencia artroscópica fue del 18,60 y 26,73%, respectivamente (p=0,141). No hubo asociación estadísticamente significativa entre el uso de asistencia artroscópica y el desarrollo de las complicaciones analizadas. Discusión y conclusiones: El uso de artroscopia de rodilla como apoyo de la reducción o como adyuvancia para el tratamiento simultáneo de lesiones intraarticulares concomitantes no aumentó el riesgo de complicaciones en el postoperatorio inmediato ni tras 12 meses de seguimiento.(AU)

Background and objective: The use of arthroscopy for tibial plateau fractures type I, II and III according to Schatzker classification has increased, yet its employment for tibial plateau fractures Schatzker IV, V and VI is controversial due to the potential risk of compartment syndrome, deep vein thrombosis and infection. We aimed to compare the rate of operative and postoperative complications among patients with these types of tibial plateau fractures treated with and without arthroscopy at the time of definitive reduction and osteosynthesis. Methods: Retrospective cohort study. Patients with diagnosis of tibial plateau fracture Schatzker IV, V or VI who underwent reduction and definitive osteosynthesis with or without the use of arthroscopy were included. The development of compartment syndrome, deep vein thrombosis, and fracture-related infection was evaluated up to 12 months after the definitive surgery. Results: Two hundred eighty-eight patients were included: 86 with arthroscopic assistance and 202 without it. The overall complication rate in the group with and without arthroscopic assistance was 18.60% and 26.73%, respectively (P=.141). No statistical association was found between the use of arthroscopic assistance and the development of the analyzed complications. Discussion and conclusion: The use of arthroscopy to support reduction or addressing concomitant intra-articular injuries did not increase the risk of complications in patients with high-energy tibial plateau fractures at 12 months of follow up.(AU)

Complications associated with single-level bone transport for the treatment of tibial bone defects caused by fracture-related infection.

BACKGROUND: The purpose of this study was to report the outcomes of single-level bone transport with a unilateral external fixator for treatment of proximal, intermediate and distal tibial bone defects caused by fracture-related infection (FRI) and compare their complications. METHODS: The clinical records and consecutive X-ray photographs of patients with tibial bone defects treated by single-level bone transport using a unilateral external fixator (Orthofix Limb Reconstruction System) were analyzed retrospectively, from January 2012 to December 2018. Patients were divided into the proximal group (P, n = 19), intermediate group (I, n = 25), and distal group (D, n = 18) according to the location of the tibial bone defect. The Association for the Study and Application of the Method of Ilizarov (ASAMI) standard was applied to assess the bone and functional outcomes and postoperative complications evaluated by the Paley classification. RESULTS: A total of 62 participants were included in this study, with a median age of 36 ± 7.14 years. Sixty patients with tibial bone defects caused by FRI were successfully treated by single-level bone transport using a unilateral external fixator, with a mean bone union time (BUT) of 7.3 ± 1.71 months. According to the ASAMI criteria, there were statistical differences in bone and function results between the three groups (P vs. I vs. D, P < 0.001). The excellent and good rate of bone result in the intermediate group was higher than the other (P vs. I vs. D, 73.6% vs. 84% vs. 66.7%), and the excellent and good rate of function result in the proximal group was the highest (P vs. I vs. D, 84.2% vs. 80% vs. 73.3%). Complications were observed in 29 out of 62 patients (46.7%), with pin tract infection being the most common (14.8%), followed by axial deviation (14.8%), muscle contractures (12.7%), joint stiffness (12.7%), and soft tissue incarceration (12.7%). Other complications included delayed consolidation (12.7%), delayed union (6.3%), nonunion (4.2%), and neurological injury (8.5%). Two patients (3.2%) required below-knee amputation due to uncontrollable infection and previous surgery failure. CONCLUSIONS: Pin tract infection was the most common complication in tibial bone transport using an external fixator. Complications of distal tibial bone transport are more severe and occur at a higher rate than in other parts. Axial deviation mostly occurred in the intermediate tibial bone transport.

Fat Embolism Syndrome Complicated by Diffuse Alveolar Hemorrhage After a Minimally Displaced Tibia Fracture: A Case Report.

CASE: A 26-year-old man with a minimally displaced tibial shaft fracture after an all-terrain vehicle crush injury rapidly developed fat embolism syndrome (FES), leading to diffuse alveolar hemorrhage (DAH) preoperatively. He was treated with an intramedullary rod 10 days after injury after a complicated clinical course and went on to full union with no long-term mental or systemic sequelae. CONCLUSIONS: FES is a known complication of long bone fractures, frequently presenting with hypoxemia. DAH is a rare complication of the condition. This case demonstrates the need for a high index of suspicion both for FES and DAH as complications of orthopaedic trauma.

Systemic effects of oral tolerance in bone healing.

Bone fractures cause acute inflammation that, despite being important for initial repair, may delay the healing of the damaged bone. Parenteral injection of dietary protein has been shown to decrease inflammation and accelerate the repair of skin wounds and other inflammatory pathologies. Thus, our aim was to evaluate whether the intraperitoneal (i.p.) immunization with zein, an abundant protein in rodent chow, would favor bone healing. Wistar rats received i.p. immunization: saline (SG), adjuvant (AG) and zein associated with adjuvant (ZG). Then, a 2 mm of defect bone was performed on the right tibia, and on days 7, 14, 28 and 45 thereafter, analyses were performed. The results showed that the injection of zein reduced inflammation without impairing bone mineralization. Moreover, biomechanical tests demonstrated higher levels of maximum force (N) in ZG, indicating better mechanical resistance in relation to the others. The computerized tomography also indicated lower levels of medullary content in the ZG than in the SG, suggesting the absence of trabeculae in the medullary region in the ZG. These findings suggest that the injection of zein in previously tolerated animals may improve bone repair, leading to mechanically functional bone formation.

A Young Skier with Leg Pain.

BACKGROUND: Proximal tibiofibular joint (PTFJ) dislocation is a rare injury that can disrupt the proximal tibia-fibula joint. The abnormalities in knee x-ray imaging can be subtle and difficult to detect, requiring careful assessment. This rare cause of lateral knee pain requires a high level of suspicion for diagnosis. Treatment is closed reduction; unstable PTFJ dislocations often require surgical intervention. CASE REPORT: A 17-year-old young man presented to the emergency department (ED) with right lateral knee pain and difficulty walking after colliding with another skier 2 days prior. The examination showed right lateral ecchymosis and tenderness over the lateral proximal fibula. He remained neurovascularly intact with a full passive and active range of motion. X-ray studies were obtained. The patient was referred by his outpatient orthopedic surgeon after the initial knee x-ray study was concerning for PTFJ dislocation and unsuccessful reduction. In the ED, the patient underwent moderate sedation and successful orthopedic-guided reduction via medial force on the lateral fibular head, while hyper-flexing the knee and holding the foot dorsiflexed and everted. Post-reduction radiographs showed improved proximal tibiofibular alignment without fracture. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: PTFJ dislocation is a rare injury that can be missed easily and requires a high level of suspicion when presented with an acute traumatic knee pain. Closed reduction of PTFJ dislocation can be achieved in the ED and early identification can prevent long-term sequelae.

TREATMENT OF FRACTURES OF THE PROXIMAL TIBIAL METAEPIPHYSIS.

OBJECTIVE: The aim: Analyze the literature data on the treatment of fractures of the proximal metaphysis of the tibia. PATIENTS AND METHODS: Materials and methods: The article used data from domestic and foreign scientific literature. Research methods such as bibliosemantic and information¬al-analytical were applied. CONCLUSION: Conclusions: Tibial condyle fractures are serious injuries that lead to a decrease in quality of life. The congruence of the joint surface and axis must be restored as accurately as possible during the treatment of tibial condyle fractures, which requires constant improvement of fracture treatment methods.

Multiligament stifle injury, a multicenter retrospective study in 26 dogs.

OBJECTIVES: To describe multiligament stifle injury in dogs and report complications and long-term outcomes. METHODS: Medical records of dogs surgically treated for multiligament stifle injury were reviewed from six veterinary hospitals. Long-term follow-up was collected from referring veterinarians. RESULTS: Twenty-six client-owned dogs and 26 stifles were included. Road traffic accidents and limb entrapment were the most common causes of injury. Cranial cruciate and lateral collateral ligament rupture was the most common combination of injury (10 cases). The caudal cruciate ligament was damaged in 12/23 cases but was surgically addressed in only 2 cases. Cranial cruciate ligament rupture was present in all cases and was managed using TPLO (6 cases), extracapsular suture (15 cases) and TTA (2 cases). Postoperative immobilisation with a transarticular external skeletal fixator was used in 4/26 cases. Intraoperative complications were reported in 2/23 cases, short-term complications in 17/25 cases, of which eight were major, and long-term complications in 7/18, of which two were major. Patella luxation was seen in one case and is a previously unreported complication. The overall outcome was excellent in 9/24 cases, good in 5/24 cases, fair in 7/24 cases and poor in 3/24 cases. Follow-up time ranged from 1.5 months to 9 years with the median (IQR) of 9.5 (4.0 to 28.5) months. CONCLUSIONS: Multiligament stifle injury in dogs is associated with a high rate of major complications. The overall outcome was good to excellent in just over half of the dogs.

Antibiotic cement-coated rigid locked nails in infected femoral and tibial nonunion. Reoperation rates of commercial versus custom-made nails.

INTRODUCTION: The objective of this study is to assess bone union, infection control, and reoperation rates in a series of patients with infected femoral or tibial nonunion treated with antibiotic-cement-coated rigid nails and to compare the results obtained with custom-made nails versus commercial nails. METHODS: We retrospectively analyzed a series of consecutive patients with infected nonunion of the femur or the tibia treated with antibiotic-cement-coated rigid nails between January 2010 and 2020. We assessed patients' distinctive characteristics, initial injury, type of nail used (custom-made nail with vancomycin or commercial nail with gentamicin), success rate (bone union + infection control), reoperation rate, and failure rate. Comparative analyses were conducted between reoperated and non-reoperated patients regarding the type of nail used. A multivariate regression analysis was performed to assess the risk variables that impacted reoperation rates. RESULTS: We included 54 patients with 22 (40.74%) infected femoral nonunions and 32 (59.25%) tibial nonunions, who were treated with 38 (70.37%) custom-made antibiotic-cement coated nails and 16 (29.62%) commercial nails. Bone union and infection control were achieved in 51 (94.44%) cases. The reoperation rate was 40.74% (n = 22), and the failure rate was 5.55% (n = 3). The use of custom-made nails was associated with a higher risk of reoperation (Odds Ratio 4.71; 95% Confidence Interval 1.10 - 20.17; p = 0.036). CONCLUSION: Antibiotic-cement-coated nails reached a 94.44% success rate. Nails manufactured in the OR coated with vancomycin cement were associated with a higher risk of reoperation than commercial nails loaded with gentamicin cement. LEVEL OF EVIDENCE: III comparative, observational, non-randomized.

Retrospective Review of Radiographic Imaging of Tibial Bony Stress Injuries in Adolescent Athletes With Positive MRI Findings: A Comparative Study.

BACKGROUND: It is difficult to diagnose and grade bony stress injury (BSI) in the athletic adolescent population without advanced imaging. Radiographs are recommended as a first imaging modality, but have limited sensitivity and, even when findings are present, advanced imaging is often recommended. HYPOTHESIS: It was hypothesized that the significance of radiographs is underestimated for BSI in the adolescent with positive clinical examination and history findings. STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 4. METHODS: A total of 80 adolescent athletes with a history of shin pain underwent clinical examination by an orthopaedic surgeon. On the day of clinical examination, full-length bilateral tibial radiographs and magnetic resonance imaging (MRI) scans were obtained. MRI scans were reviewed using Fredericson grading for BSI. At the completion of the study, radiographic images were re-evaluated by 2 musculoskeletal (MSK) radiologists, blinded to MRI and clinical examination results, who reviewed the radiographs for evidence of BSI. Radiographic results were compared with clinical examination and MRI findings. Sensitivity, specificity, negative predictive value, and positive predictive value were calculated based on comparison with MRI. RESULTS: All radiographs were originally read as normal. Of the tibia studied, 80% (127 of 160) showed evidence of BSI on MRI. None of the original radiographs demonstrated a fracture line on initial review by the orthopaedic surgeons. Retrospective review by 2 MSK radiologists identified 27% of radiographs (34 of 127) with evidence of abnormality, which correlated with clinical examination and significant findings on MRI. Review of radiographs found evidence of new bone on 0 of 28 Fredericson grade 0, 0 of 19 Fredericson grade I, 11 of 80 (13.7%) Fredericson grade II, 18 of 28 (64%) Fredericson grade III, and 5 of 5 (100%) Fredericson grade IV. Sensitivity of radiographs showed evidence of new bone on 27% (34 of 127) of initial radiographs, with presence more common with greater degree of BSI, as 23 of 33 (70%) were higher-grade injuries (III of IV) of BSI. Specificity and positive predictive value were 100%, while negative predictive value was 17%. CONCLUSION: These findings highlight the importance of initial radiographs in identifying high-grade BSI. As radiographs are readily available in most office settings of sports medicine physicians, this information can influence the management of adolescent athletic BSI without the need to delay treatment to obtain an MRI. CLINICAL RELEVANCE: Adolescent athletes with radiographic evidence of BSI should be treated in a timely and more conservative manner, given the likelihood of higher-grade BSI. In addition, clinicians knowledgeable of the radiographic findings of high-grade BSI should feel more confident that a negative initial radiograph is not likely to be a high-grade BSI and can modify their treatment plans accordingly.

Can we predict size, Haraguchi type and preoperative displacement of posterior malleolar fractures in association with tibial shaft fractures?

PURPOSE: To (1) determine if any injury characteristics or radiographic parameters of tibial shaft fractures (TSFs) could predict posterior malleolar fracture (PMF) size, and (2) identify characteristics of PMFs that were fixed versus those that were not in a cohort of ipsilateral TSFs that underwent intramedullary nailing. METHODS: A cross-sectional radiographic study was performed at a single academic institution. Demographic and radiographic parameters of TSFs were recorded, including fracture obliquity angle (FOA) and distance from distal extent of fracture to plafond (DFP). Using CT, the PMFs were evaluated for Haraguchi classification, size measurements, and preoperative displacement. Multivariate regression analysis was used to identify independent predictors of PMF Harachuchi classification, size parameters, and preoperative displacement. Univariate differences between PMF that were fixed and not fixed were identified. RESULTS: 47 (50%) PMF underwent surgical fixation with 47 treated conservatively. There were no demographic differences between groups. Multivariate linear regression demonstrated increasing DFP and high energy injury mechanism as independent variables correlated with plafond surface area involvement, PMF height and width on sagittal CT cuts. Increasing DFP alone was correlated with PMF width on axial CT cuts and extent > 50% into incisura. Haraguchi type II fractures were associated with high energy injury mechanism (OR = 4.2 [95% CI = 1.3-14.5]; p = 0.02). Odds of Haraguchi type 3 fractures increased 9% per increased year of age (OR = 1.09 [95% CI = 1.04-1.16]; p = 0.006) and decreased 13% per 1% increase in relative DFP (OR = 0.87 [95% CI = 0.75-0.98]; p = 0.04). CONCLUSIONS: An increasing DFP of TSFs and high energy injury mechanism were independent predictors of PMF size, and high energy injury mechanism was also correlated with Haraguchi type II fracture patterns. Increasing age and decreasing DFP of TSFs predict Haraguchi type III PMF patterns. These radiographic parameters should prompt surgeons to plan for fixation in scenarios in which CT scan is not available. LEVEL OF EVIDENCE: Diagnostic Level III.

Intra-articular fracture patterns associated with tibial shaft fractures: more than just the posterior malleolus.

BACKGROUND: The association of tibial shaft fractures (TSFs) with posterior malleolar fractures is well described. The purpose of this study was to identify specific radiographic parameters that are predictive of any pattern of associated distal intra-articular fractures in TSFs. METHODS: All TSFs presenting over a 6-year period were identified. A radiographic review of plain radiographs and CT scans included: identification of any associated ankle fracture, classification using the OTA System, measurements of the TSF obliquity angle (FOA), relative distance from distal extent of the TSF to plafond (DFP%), and presence and level of any associated fibular fractures. Patients with and without associated ankle fractures were statistically compared. Multivariate logistic regression determined independent predictors of associated ankle fractures. RESULTS: 405 TSFs in 397 patients were identified, with 145 TSFs with associated distal intra-articular fractures. There were 94 (23.2%) posterior malleolar fractures, 19 (13.1%) medial malleolar fractures, 42 (29.0%) lateral malleolar fractures involving the syndesmosis and 14 (9.7%) Chaput fragments. Multivariate regression demonstrated AO/OTA classification type 42-A1, 42-B1 or 42-C1 (OR 2.3 [95% CI 1.3-4.0]; p = 0.003), FOA greater than 45° (OR 2.7 [95% CI 1.5-4.8]; p = 0.001) and DFP% less than 33% (OR 4.1 [95% CI 2.0-9.0]; p = 0.005) were independent correlates of associated ankle fractures regardless of mechanism of injury. CONCLUSIONS: Different patterns of intra-articular fractures beyond posterior malleolar fractures can occur in TSFs. Fracture angles greater than 45° and extent into the distal 33% of the tibial shaft are independent predictors of distal intra-articular fractures in TSFs regardless of mechanism of injury. LEVEL OF EVIDENCE: Diagnostic Level III.