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1.
Harefuah ; 159(3): 158-162, 2020 Mar.
Artigo em Hebraico | MEDLINE | ID: mdl-32186783

RESUMO

INTRODUCTION: With the emergence in recent years of advanced surgical methods for treatment of diaphyseal fractures of the tibia bone, there appears to be a decline in the familiarity and use of the conservative treatment based on weight bearing casts and early weight bearing. This phenomenon, dubbed "the surgery epidemic" by Dr. Sarmiento, one of the forefathers of tibial fractures treatment, refers to orthopedics surgeons' tendency to treat surgically, even in patients viable for conservative treatment. OBJECTIVES: In this study, we examined all the patients with diaphyseal tibial fracture who were treated at the Orthopedic ward at "Rambam" Hospital in the study period (2012-2016), in order to evaluate the results of the conservative functional treatment, to identify the different stages of said treatment, and to create a clear and accessible protocol for treating physicians. In addition, we sought to examine whether there is a preference for surgical treatment among physicians, even in cases where fracture characteristics, according to accepted criteria, would have allowed for conservative treatment. METHODS: Clinical and radiological evaluation of all patients who arrived with tibia bone fractures to "Rambam" hospital in the study period (2012-2106); identifying patients who fit the criteria for conservative functional treatment and were treated either conservatively or surgically. In those who were treated conservatively we documented the course of their treatment until full recovery. RESULTS: A total of 153 patients with tibial bone fracture were admitted in the study period. Of those patients, 15 were treated according to the conservative functional treatment, 33 were treated surgically despite their adherence to the conservative treatment guidelines. Of all the patients adhering to the conservative treatment criteria (48 patients), only 31.2% were treated conservatively, while 68.8% were treated surgically, unnecessarily, some would say. In other words, 25% of all the patients treated surgically for tibial bone fracture, could have been treated conservatively but instead were treated surgically with internal fixation in accordance to their surgeon's preference. DISCUSSION: In this study we observed a clear preference for surgical treatment in tibial bone fractures, even in cases where the fracture position met the accepted criteria for conservative treatment. We found that the conservative functional treatment, as practiced in our hospital, adheres to the highest standard of care. Taking into account surgery and anesthesia complications, and its added cost to the health care system, we believe it is appropriate to increase awareness among physicians to the possibility and benefits of conservative functional treatment that allows for early weight bearing and patient activity.


Assuntos
Fraturas da Tíbia/cirurgia , Algoritmos , Tratamento Conservador , Humanos , Radiografia , Tíbia , Fraturas da Tíbia/epidemiologia , Fraturas da Tíbia/terapia
2.
Mymensingh Med J ; 29(1): 32-36, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31915332

RESUMO

Bone marrow is a source of osteoprogenitor cells which are the most important factor of bone formation and healing of fracture. The aim of the study is to evaluate the outcome of bone marrow injection in the management of delayed union and non-union. This prospective study was performed in the department of Orthopaedics, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from January 2017 to June 2019. In this study 21 patients with delayed union and non-union were treated by bone marrow injection. Bone marrow were aspirated from the anterior or posterior iliac crests then injected percutaneously into the fracture site. Full union was achieved in 15 cases, while failed in the others. No major complications were seen during or after the procedure. It is a safe, easy and a minimally invasive procedure compared to usual open bone graft especially for cases with high risk of anesthesia or risk of infection.


Assuntos
Transplante de Medula Óssea/métodos , Consolidação da Fratura/fisiologia , Fraturas não Consolidadas/terapia , Fraturas da Tíbia/terapia , Bangladesh , Fraturas Ósseas , Fraturas não Consolidadas/fisiopatologia , Humanos , Injeções , Masculino , Estudos Prospectivos , Fraturas da Tíbia/fisiopatologia , Resultado do Tratamento
3.
Pediatr Clin North Am ; 67(1): 153-167, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31779830

RESUMO

Pediatric knee disorders are various and range from trauma and sports injuries to chronic overuse injuries. Because pediatric patients are different from adults, management of pediatric injuries and general knee disorders is also often different. Primary treatment regimen goals focus on a return to the previous level of function, preservation of anatomy, and decreasing potential long-term effects. Long-term complications may include damage to the physis with resultant potential limb length discrepancy or deformity.


Assuntos
Doenças Ósseas , Artropatias , Traumatismos do Joelho , Articulação do Joelho , Tíbia , Fraturas da Tíbia , Doenças Ósseas/diagnóstico , Doenças Ósseas/terapia , Criança , Humanos , Artropatias/diagnóstico , Artropatias/terapia , Traumatismos do Joelho/diagnóstico , Traumatismos do Joelho/terapia , Fraturas da Tíbia/diagnóstico , Fraturas da Tíbia/terapia
4.
Zhongguo Gu Shang ; 32(12): 1173-1176, 2019 Dec 25.
Artigo em Chinês | MEDLINE | ID: mdl-31870082

RESUMO

The posterior condylar fracture of the tibial plateau refers to the fracture of the posterior 1/3 area of the tibial plateau. Compared with other clinical types such as Schatzker and AO, the three-column theory is more widely used in the diagnosis and treatment of the posterior condylar fracture of the tibial plateau. There are advantages and disadvantages in learning curve, intraoperative risk and therapeutic effect of minimally invasive methods such as posterior and lateral related approaches, circular external fixator and balloon dilatation, which are commonly used in open surgery. There is no consensus on the best surgical method. This article reviews the diagnosis, classification and treatment of posterior condylar fracture of tibial plateau.


Assuntos
Fraturas da Tíbia , Fixadores Externos , Fixação Interna de Fraturas , Humanos , Curva de Aprendizado , Tíbia , Fraturas da Tíbia/diagnóstico , Fraturas da Tíbia/terapia
5.
Medicine (Baltimore) ; 98(42): e17338, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31626090

RESUMO

RATIONALE: Unicompartmental knee arthroplasty (UKA) is an effective method to treat single compartment disease of the knee joint. Report about the complications of UKA, especially tibial plateau fractures, is rare. Given its rarity, its pathogenesis is not well described, and a standard of treatment is still not established. Therefore, relevant studies and analysis of this complication have a significant effect on helping physicians avoid risks and guide clinical diagnosis and treatment. PATIENT CONCERNS: The 1st case corresponds to a 70-year-old male patient who complained of knee pain, difficulty walking, nocturnal rest pain, and elevated skin temperature at 3 weeks after the left knee arthroplasty. The second case is a 72-year-old female patient who complained of left knee pain and swelling during movement at 2 weeks after the left knee arthroplasty. DIAGNOSIS: The 1st case showed a fracture of the medial malleolus of the left knee and a secondary depression of the medial tibial plateau in X-rays and the second case showed a fracture of the medial malleolus of the left knee in computed tomography (CT) and X-rays. INTERVENTIONS: The 1st case was treated with plate and screw fixation and the second case was treated conservatively and immobilized using brace and remained nonweight bearing for 6 weeks. OUTCOMES: After 1 year, both patients have good joint activity, and there was no pain or loosening of the prosthesis and fragment displacement. LESSONS: The incidence of tibial plateau fractures (TPF) related to UKA might be low, but fatal and difficult to treat. Its pathogenesis determines procedure-related factors; when fracture develops, treatment should be based on the degree of displacement, stability of implant fixation, etc.


Assuntos
Artroplastia do Joelho/efeitos adversos , Tratamento Conservador/métodos , Fixação Interna de Fraturas/métodos , Complicações Pós-Operatórias/terapia , Fraturas da Tíbia/terapia , Idoso , Idoso de 80 Anos ou mais , Braquetes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/etiologia , Tomografia Computadorizada por Raios X , Resultado do Tratamento
6.
J Orthop Surg Res ; 14(1): 293, 2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31481070

RESUMO

BACKGROUND: Mesenchymal stem cells (MSCs) have great potential for the repair and regeneration of bone fracture, but their optimal origins remain controversial. METHODS: Bone marrow-MSCs (BM-MSCs) and bone-bone marrow-MSCs (B-BM-MSCs) were isolated from 12 SD rats, and the morphology, MSC-associated markers, and proliferative capacity of these cells were compared using an inverted microscope, flow cytometry, and CCK-8 assays, respectively. After 14 days of osteoblastic induction, osteoblast phenotypes were detected by ALP and calcium nodule staining, and the expression of BMP-2 and TGF-ß1 was observed by western blotting. Then, the rat tibia fracture model was established with 3 groups (n = 6 per group), the control, BM-MSC, and B-BM-MSC groups. Computed tomography (CT) imaging was performed to evaluate fracture healing at weeks 2, 4, and 6. Finally, the fractured bones were removed at weeks 4 and 6, and HE staining was performed to evaluate fracture healing. RESULTS: Although the 2 types of MSCs shared the same cellular morphology and MSC-associated markers, B-BM-MSCs had a higher proliferative rate than BM-MSCs from day 9 to day 12 (p < 0.05), and the expression levels of ALP and calcium were obviously higher in B-BM-MSCs than in BM-MSCs after osteogenic induction (p < 0.01 and p < 0.001, respectively). Western blot results showed that the expression levels of BMP-2 and TGF-ß1 in B-BM-MSCs were higher than in BM-MSCs before and after osteogenic induction (p < 0.01). In the animal experiments, CT imaging and gross observation showed that B-BM-MSCs had a greater capacity than BM-MSCs to promote fracture healing, as the Lane-Sandhu scores of B-BM-MSCs at weeks 4 and 6 after operation (3.00 ± 0.81 and 9.67 ± 0.94, respectively) were higher than those of BM-MSCs (1.33 ± 0.47 and 6.67 ± 1.25, respectively; both p < 0.05). The HE staining results further supported this conclusion. CONCLUSIONS: Taken together, our study results proved that MSCs obtained by co-culturing the bone and bone marrow from SD rats had better proliferative, osteogenic differentiation, and fracture healing capacities than BM-MSCs, perhaps suggesting a novel way to obtain MSCs for bone tissue repair.


Assuntos
Medula Óssea/fisiologia , Fêmur/fisiologia , Consolidação da Fratura/fisiologia , Transplante de Células-Tronco Mesenquimais/métodos , Tíbia/fisiologia , Fraturas da Tíbia/terapia , Animais , Técnicas de Cocultura/métodos , Fêmur/citologia , Masculino , Células-Tronco Mesenquimais/fisiologia , Osteoblastos/fisiologia , Osteoblastos/transplante , Osteogênese/fisiologia , Ratos , Ratos Sprague-Dawley , Tíbia/citologia , Fraturas da Tíbia/patologia
7.
Acta Orthop ; 90(6): 610-613, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31328600

RESUMO

Background and purpose - Unnecessary radiographic and clinical follow-ups are common in treatment of pediatric fractures. We hypothesized that follow-up radiographs are unnecessary to monitor union of physeal fractures of the distal tibia.Patients and methods - All 224 (147 boys) children under 16 years old treated for a physeal fracture of the distal tibia during a 5-year period (2010-14) in Helsinki Children's Hospital were included in this study. Peterson type II fractures comprised 55% and transitional fractures (Tillaux and Triplane) 20% of all injuries. Fracture displacement and alignment was measured. Type and place of treatment was recorded. Number of follow-up radiographs and outpatient visits was calculated and their clinical significance was assessed.Results - 109 children had fractures with < 2 mm displacement and no angulation. The other 115 children's mean fracture displacement was 6 mm (2-28). 54% of all children were treated by casting in situ in the emergency room, 20% with manipulation under anesthesia and 26% with surgery (internal 57, external fixation 2). Median 3 (1-7) follow-up appointments and median 3 (0-6) radiographs were taken. Follow-up radiographs at or before cast removal did not alter treatment in any of the patients. 223 patients' fractures healed within 4-9 weeks in good alignment (≤ 5° angulation).Interpretation - Routine radiographic follow-up is unnecessary to monitor alignment and union of physeal fractures of the distal tibia.


Assuntos
Continuidade da Assistência ao Paciente , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/terapia , Procedimentos Desnecessários , Adolescente , Moldes Cirúrgicos , Criança , Pré-Escolar , Diáfises/diagnóstico por imagem , Diáfises/lesões , Diáfises/cirurgia , Epífises/diagnóstico por imagem , Epífises/lesões , Epífises/cirurgia , Feminino , Finlândia , Fixação de Fratura , Consolidação da Fratura , Humanos , Lactente , Masculino , Manipulação Ortopédica , Visita a Consultório Médico/estatística & dados numéricos , Radiografia , Fraturas da Tíbia/classificação
8.
Undersea Hyperb Med ; 46(1): 75-79, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31154688

RESUMO

More blast injuries are encountered in the civilian setting in recent years as terrorist attacks have increased globally. A 17-year-old male patient with severe blast injury of the right lower extremity was admitted to our department on the fifth day after a terrorist bombing attack. Initially he had been admitted to an emergency department with segmental tibia fracture and arterial injury (Gustilo IIIC). An amputation had been foreseen due to ischemia that persisted even after orthopedic fixation and revascularization interventions, followed by fasciotomy incisions. After consultation with our department hyperbaric oxygen (HBO2) therapy was administered twice daily for the first week. Ischemia improved prominently after 10 HBO2 sessions. HBO2 therapy was continued together with antibiotherapy and wound care. The patient underwent a total of 40 HBO2 sessions and two reconstructive operations and healed without amputation. Vascular injuries with concomitant orthopedic trauma cause most of the delayed amputations in bombing attacks since ischemia can persist at the microvascular level even though adequate treatments are applied. HBO2 corrects hypoxia at tissue level and so provides oxygen for the critically ischemic cells in the injured area. HBO2 also enhances host defense and decreases the ischemia reperfusion injury. In this case, HBO2 was effective in survival and functional recovery (salvage) of the extremity together with regular wound care, antibiotherapy and surgical repair.


Assuntos
Traumatismos por Explosões/terapia , Oxigenação Hiperbárica , Isquemia/terapia , Traumatismos da Perna/terapia , Perna (Membro)/irrigação sanguínea , Terrorismo , Adolescente , Pé/irrigação sanguínea , Humanos , Isquemia/etiologia , Masculino , Fraturas da Tíbia/etiologia , Fraturas da Tíbia/terapia
9.
J Pediatr Orthop ; 39(6): 314-317, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31169752

RESUMO

BACKGROUND: The toddler's fracture is a common pediatric nondisplaced spiral tibia fracture that is considered stable with a course of immobilization. However, there is no widely accepted type of immobilization, expected time to weight-bear, nor guidelines for radiographic monitoring. We aimed to compare immobilization type with respect to displacement and time to weight-bear, as well as determine the usefulness of follow-up radiographs. METHODS: A 3-year retrospective chart review of all children aged 9 months to 4 years who had a lower leg radiograph was performed. Those who fulfilled the criteria of a nondisplaced spiral tibia fracture, without fibula or physeal injury, were included in data collection, as were subjects with a negative initial radiograph that were treated presumptively as a toddler's fracture. Subjects were compared with regard to clinical and radiographic presentation; initial and subsequent immobilization; and clinical and radiographic follow-up. RESULTS: There were 606 subjects with lower leg radiographs, with 192 meeting study criteria: 117 (61%) with an initially visible fracture and 75 (39%) without. Of the 75 without initially visible fractures, 70 (93%) had robust periosteal reaction on follow-up, and none were diagnosed as anything further. At final follow-up, 184 (96%) were known to be weight-bearing, with 98% of these by 4 weeks. There was an earlier return to weight-bear for those initially treated in a boot compared with short leg cast (2.5 vs. 2.8 wk, P=0.04), but there were no other differences between immobilization type. No fractures displaced at any time point, including 7 that had received no immobilization. Patients received an average of 2.5 two-radiograph series; no radiographs were noted to affect treatment decisions in follow-up. CONCLUSIONS: In our cohort, initial immobilization of a toddler's fracture in a boot may allow faster return to weight-bearing, but fractures were universally stable regardless of immobilization type, and nearly all regained weight-bearing by 4 weeks. This reliable healing suggests that immobilization type can be at the physician and family's discretion, and that radiographic follow-up may be unnecessary for treatment planning. LEVEL OF EVIDENCE: Level III-this is a retrospective comparative study.


Assuntos
Imobilização/métodos , Radiografia/métodos , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/terapia , Suporte de Carga/fisiologia , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Fraturas da Tíbia/fisiopatologia
10.
Rev. méd. Urug ; 35(2): 137-145, jun. 2019. tab, fig
Artigo em Espanhol | LILACS | ID: biblio-999620

RESUMO

En nuestro país las fracturas del platillo tibial han aumentado en frecuencia y complejidad debido sobre todo a los accidentes de moto. La tomografía ha contribuido en gran medida a la interpretación del patrón fracturario. Como objetivo de este trabajo se propone la utilización de una cuadrícula que toma en cuenta las distintas imágenes y permite realizar un mapeo de los diferentes trazos de fractura. Así podemos definir el o los tipos de abordajes a utilizar, la posición del paciente en la mesa de operaciones y la elección de los implantes. Se hace hincapié en los abordajes posteromedial y posterolateral de reciente utilización en nuestro medio. En el Centro de Asistencia Médica de Young (CAMY) de Young, departamento de Río Negro, entre enero de 2015 y junio de 2017 se trataron 16 pacientes con fractura del platillo tibial estudiados con radiografías simples y tomografía computada. Se utilizó la clasificación de Schatzker pero ampliada, teniendo en cuenta las lesiones en el plano axial. Fue necesario recurrir al abordaje posteromedial en nueve casos y al posterolateral en dos. Todas las fracturas consolidaron y la movilidad articular fue completa en todos los casos. Dos pacientes tuvieron infección profunda y uno de ellos quedó con una parálisis definitiva del nervio ciático poplíteo externo. Como conclusión, la cuadrícula propuesta nos resultó muy útil para el análisis previo de estas lesiones y se destaca la importancia de los abordajes posterolateral y posteromedial en los compromisos posteriores de la meseta tibial.


Tibial plateau fractures have increased in our country in terms of frequency and complexity, mainly due to motorbike accidents. CT scans have generally contributed to interpreting the fracture pattern. The study aims to use a grid that includes the different images and allows for the mapping of the different fracture traces. In this way we may define the kind or kinds of approaches to the fracture, the patient's position on the surgical table and the selection of implants. We emphasize on the posteromedial and posterolateral approaches, recently used in our country. 16 patients with tibial plateau fractures were treated at CAMY health care institution in the city of Young, between January 2015 and June 2017, having studied them with simple x-rays and CT scans. The Schatzker classification was used, although a wider one, which also considered axial plane lesions. In 9 cases it was necessary to perform a posteromedial approach and in 2 cases a posterolateral approach was the one used. All fractures consolidated and articular mobility was complete in all cases. Two patients suffered a deep infection and one of them presented a final external popliteal sciatic nerve paralysis. To conclude, the grid proposed was very useful for the preliminary analysis of these lesions and we point out the importance of the posterolateral and posteromedial approaches when the tibial plateau is compromised.


As fraturas do platô tibial aumentaram em frequência e complexidade no Uruguai sobretudo devido aos acidentes com motocicletas. A tomografia contribuiu em grande parte à interpretação do padrão da fratura. Como objetivo propõe-se a utilização de uma quadrícula que inclui as diferentes imagens e permite realizar o mapeamento dos diferentes traços da fratura. Dessa forma é possível definir o tipo de abordagem, a posição do paciente na mesa de operação e a seleção dos implantes. Destacam-se as abordagens póstero-medial e póstero lateral de recente utilização no nosso meio. Entre janeiro de 2015 e junho de 2017, em CAMY, instituição de assistência à saúde da cidade de Young, 16 pacientes com fratura do platô tibial foram estudados com radiografias simples e tomografia computada. A classificação de Schatzker ampliada considerando as lesoes no plano axial foi empregada. Em 9 casos foi necessário fazer a abordagem póstero-medial y em 2 a póstero lateral. Todas as fraturas consolidaram e a mobilidade articular foi completa em todos os casos. Dois pacientes apresentaram infecção profunda sendo que um ficou com paralisia definitiva do nervo ciático poplíteo externo. Conclui-se que a quadricula proposta foi muito útil para a análise prévia destas lesões e destaca-se a importância das abordagens póstero lateral e póstero-medial nos compromissos posteriores do platô tibial.


Assuntos
Humanos , Fraturas da Tíbia/classificação , Fraturas da Tíbia/terapia , Fraturas da Tíbia/cirurgia
11.
Biomed Res Int ; 2019: 4265782, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31111053

RESUMO

Treatment of pilon fractures remains challenging due to the difficulty of fracture reduction and associated soft tissue complications. The aim of this study was to evaluate the pitfalls and strategies of posterior column reduction in the treatment of complex tibial pilon fractures (AO/OTA 43-C3). Thirteen AO/OTA classification 43-C3 type pilon fractures treated between January 2013 and January 2016 were retrospectively analyzed. Nine cases were treated by external fixation within 26 hours (range, 6-56 hours) after injury. The definitive open reduction and internal fixation (ORIF) was performed after the wound was healed without infection and soft tissue swelling had subsided. During the delayed/second-stage operation, the articular surface of the distal tibial plafond was reduced through the posterolateral and anterior approaches. X-ray and CT scans were performed pre- or postoperatively. The reduction quality was evaluated using Burwell-Charnley's radiographic criteria. The follow-up was performed routinely and all complications were recorded. Ankle function was evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. During the delayed/second-stage operation, primary reduction of the posterior column was performed entirely through posterolateral approaches. However, poor posterior column reduction was revealed by fluoroscopy in four cases, three of which were readjusted through the posterolateral and anterior approaches, and the fourth was adjusted directly through the anterior approach. Postoperative CT scan revealed that the step-off of the articular surface was less than 2 mm in 12 cases, and in only one case the step-off was greater than 2 mm but less than 5 mm. The satisfactory rate was 92.3% according to Burwell-Charnley's reduction criteria. Eleven patients were followed up regularly; superficial infections occurred in two cases but healed after wound care treatment in 3 and 5 weeks, respectively. All eleven fractures were healed within an average of 3.6 months (range, 2.6-5 months). The average range of ankle motion was 19° of dorsiflexion and 28° of plantar-flexion. The mean AOFAS ankle-hindfoot score was 82 (range, 61-92). In our opinion, we suggest that the reduction of the articular surface should be performed through combined posterolateral and anterior approaches in a delayed operation, with flexible fixation of the posterior column. If the posterior column is poorly reduced, the articular surface can easily be manipulated through anterior approaches. According to this strategy, satisfactory outcomes of AO/OTA C3 pilon fractures would be anticipated.


Assuntos
Fraturas do Tornozelo/terapia , Fixação Interna de Fraturas/métodos , Fraturas da Tíbia/terapia , Adulto , Fraturas do Tornozelo/diagnóstico por imagem , Traumatismos do Tornozelo/terapia , Articulação do Tornozelo , Placas Ósseas , Fixadores Externos , Feminino , Fixação de Fratura , Fraturas Expostas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Estudos Retrospectivos , Tíbia , Fraturas da Tíbia/diagnóstico por imagem , Tomógrafos Computadorizados , Resultado do Tratamento
12.
Clin Orthop Relat Res ; 477(4): 789-801, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30901004

RESUMO

BACKGROUND: During recent wars, 26% of combat casualties experienced open fractures and these injuries frequently are complicated by infections, including osteomyelitis. Risk factors for the development of osteomyelitis with combat-related open tibia fractures have been examined, but less information is known about recurrence of this infection, which may result in additional hospitalizations and surgical procedures. QUESTIONS/PURPOSES: (1) What is the risk of osteomyelitis recurrence after wartime open tibia fractures and how does the microbiology compare with initial infections? (2) What factors are associated with osteomyelitis recurrence among patients with open tibia fractures? (3) What clinical characteristics and management approaches are associated with definite/probable osteomyelitis as opposed to possible osteomyelitis and what was the microbiology of these infections? METHODS: A survey of US military personnel injured during deployment between March 2003 and December 2009 identified 215 patients with open tibia fractures, of whom 130 patients developed osteomyelitis and were examined in a retrospective analysis. No patients with bilateral osteomyelitis were included. Twenty-five patients meeting osteomyelitis diagnostic criteria were classified as definite/probable (positive bone culture, direct evidence of infection, or symptoms with culture and/or radiographic evidence) and 105 were classified as possible (bone contamination, organism growth in deep wound tissue, and evidence of local/systemic inflammation). Patients diagnosed with osteomyelitis were treated with débridement and irrigation as well as intravenous antibiotics. Fixation hardware was retained until fracture union, when possible. Osteomyelitis recurrence was defined as a subsequent osteomyelitis diagnosis at the original site ≥ 30 days after completion of initial treatment. This followup period was chosen based on the definition of recurrence so as to include as many patients as possible for analysis. Factors associated with osteomyelitis recurrence were assessed using univariate analysis in a subset of the population with ≥ 30 days of followup. Patients who had an amputation at or proximal to the knee after the initial osteomyelitis were not included in the recurrence assessment. RESULTS: Of 112 patients meeting the criteria for assessment of recurrence, 31 (28%) developed an osteomyelitis recurrence, of whom seven of 25 (28%) had definite/probable and 24 of 87 (28%) had possible classifications for their initial osteomyelitis diagnosis. Risk of osteomyelitis recurrence was associated with missing or devascularized bone (recurrence, 14 of 31 [47%]; nonrecurrence, 22 of 81 [28%]; hazard ratio [HR], 3.94; 1.12-13.81; p = 0.032) and receipt of antibiotics for 22-56 days (recurrence, 20 of 31 [65%]; nonrecurrence: 37 of 81 [46%]; HR, 2.81; 1.05-7.49; p = 0.039). Compared with possible osteomyelitis, definite/probable osteomyelitis was associated with localized swelling at the bone site (13 of 25 [52%] versus 28 of 105 [27%]; risk ratio [RR], 1.95 [1.19-3.19]; p = 0.008) and less extensive skin and soft tissue injury at the time of trauma (9 of 22 [41%; three definite/probably patients missing data] versus 13 of 104 [13%; one possible patient missing data]; RR, 3.27 [1.60-6.69]; p = 0.001). Most osteomyelitis infections were polymicrobial (14 of 23 [61%; two patients with missing data] for definite/probable patients and 62 of 105 [59%] for possible patients; RR, 1.03 [0.72-1.48]; p = 0.870). More of the definite/probable patients received vancomycin (64%) compared with the possible patients (41%; p = 0.046), and the duration of polymyxin use was longer (median, 38 days versus 16 days, p = 0.018). Time to definitive fracture fixation was not different between the groups. CONCLUSIONS: Recurrent osteomyelitis after open tibia fractures is common. In a univariate model, patients with an intermediate amount of bone loss and those treated with antibiotics for 22 to 56 days were more likely to experience osteomyelitis recurrence. Because only univariate analysis was possible, these findings should be considered preliminary. Osteomyelitis recurrence rates were similar, regardless of initial osteomyelitis classification, indicating that diagnoses of possible osteomyelitis should be treated aggressively. LEVEL OF EVIDENCE: Level III, therapeutic study.


Assuntos
Fraturas Expostas/microbiologia , Medicina Militar , Osteomielite/microbiologia , Fraturas da Tíbia/microbiologia , Administração Intravenosa , Adulto , Antibacterianos/administração & dosagem , Desbridamento , Feminino , Fraturas Expostas/complicações , Fraturas Expostas/diagnóstico , Fraturas Expostas/terapia , Humanos , Masculino , Osteomielite/diagnóstico , Osteomielite/terapia , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Irrigação Terapêutica , Fraturas da Tíbia/complicações , Fraturas da Tíbia/diagnóstico , Fraturas da Tíbia/terapia , Fatores de Tempo , Resultado do Tratamento , Guerra , Adulto Jovem
13.
Eur J Orthop Surg Traumatol ; 29(5): 1073-1079, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30729308

RESUMO

Fractures of the anterior tibial tubercle are infrequent lesions. They often occur in male adolescent athletes, usually in relation with sports involving powerful jumps. We present a retrospective study of 10 patients, with an average age of 15.1 years, all of them males, and a total of 11 acute avulsions of the anterior tibial tubercle. We analyzed the etiology of the lesion, the type of treatment used as well as non-weight bearing period, protected immobilization period, and time until sports reincorporation. We obtained 11 acute avulsions: one case of type I; three cases of type II; four cases of type III; and three cases of type IV. Five cases were treated conservatively, including the three cases of type IV, and surgery was only performed in six cases since an anatomical reduction was not obtained with closed reduction. The results were satisfactory in all cases, with 100% percentage of sport reincorporation in less de 25 weeks. We registered only one complication, intolerance of material, which did not require additional surgeries. These fractures, although rare, have an excellent prognosis. Even if they are often treated surgically, we have obtained good results with the conservative treatment in patterns previously reported as surgical.


Assuntos
Redução Fechada , Redução Aberta , Tíbia/lesões , Fraturas da Tíbia , Adolescente , Traumatismos em Atletas/diagnóstico , Traumatismos em Atletas/terapia , Redução Fechada/métodos , Redução Fechada/reabilitação , Fratura Avulsão/etiologia , Fratura Avulsão/terapia , Humanos , Masculino , Redução Aberta/métodos , Redução Aberta/reabilitação , Seleção de Pacientes , Prognóstico , Volta ao Esporte , Fraturas da Tíbia/etiologia , Fraturas da Tíbia/reabilitação , Fraturas da Tíbia/cirurgia , Fraturas da Tíbia/terapia , Resultado do Tratamento
14.
J Pediatr Orthop B ; 28(6): 572-578, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30741748

RESUMO

The incidence and risk factors of distal tibia/fibula fracture, an uncommon complication during Ponseti manipulation, are unknown. We evaluated 222 virgin clubfeet of patients aged less than 3 years for fractures of distal tibia/fibula. Incidence rate was found to be 1.3% per year. Associated risk factors were identified as neglected, syndromic clubfeet, feet requiring greater than 10 casts, post-tenotomy dorsiflexion less than 10° and casting by physician with less than 3 years of casting experience, with odds ratios of 14, 28, 4.9, 3.7 and 3.4, respectively. Most of these fractures healed without consequences; however, it is still advisable not to forcefully dorsiflex while casting, which may result in the fracture of distal tibia/fibula.


Assuntos
Moldes Cirúrgicos/tendências , Pé Torto Equinovaro/epidemiologia , Pé Torto Equinovaro/terapia , Fíbula/lesões , Fraturas da Tíbia/epidemiologia , Fraturas da Tíbia/terapia , Moldes Cirúrgicos/efeitos adversos , Pré-Escolar , Pé Torto Equinovaro/diagnóstico por imagem , Feminino , Fíbula/diagnóstico por imagem , Humanos , Doença Iatrogênica/epidemiologia , Doença Iatrogênica/prevenção & controle , Incidência , Lactente , Masculino , Estudos Prospectivos , Fatores de Risco , Fraturas da Tíbia/diagnóstico por imagem , Resultado do Tratamento
15.
Biomater Sci ; 7(4): 1675-1685, 2019 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-30742145

RESUMO

Accelerating the healing of bone fractures by local delivery of growth factors possessing osteoinductive activity has been extensively demonstrated. Unfortunately, for some complex clinical fractures, such as osteoporotic vertebral compression fracture, it is not possible to adopt such a strategy because of access restrictions. Systemic administration of growth factors is considered to be an appropriate alternative method due to its easy operability and precise spatiotemporal compatibility at fracture sites. But this therapy method was hampered by the poor in vivo stability, inefficient distribution at the fracture site and potential side effects of growth factors. To address these challenges, we conceived a systemic delivery platform of growth factors based on nanocapsules, taking advantage of the unique physiological character of bone fracture, i.e., the malformed blood vessels and the over-expression of matrix metalloproteinases (MMPs). In this work, bone morphogenetic protein-2 (BMP-2), 2-(methacryloyloxy)ethyl phosphorylcholine (MPC) and the bisacryloylated VPLGVRTK peptide were respectively used as the model growth factor, monomer, and MMP-cleavable crosslinker. Nanocapsules were formed by in situ free radical polymerization on the surface of BMP-2 with MPC and peptides. The structure and function of BMP-2 were well maintained during the preparation process. BMP-2 nanocapsules (n(BMP-2)) were of uniform small size (∼30 nm) possessing a long circulation time (half-life is ∼48 h) and could be passively targeted to the fracture site through malformed blood vessels after systemic administration. Once accumulated at the fracture site, the shells of nanocapsules could be degraded by MMP and thus BMP-2 was released. Animal experiments proved that n(BMP-2) showed a better ability of bone repair than native BMP-2. In addition, n(BMP-2) showed a much lower inflammatory irritation. The results demonstrated that the systemic administration of growth factor nanocapsules could enhance their in vivo stability and fracture site delivery efficiency, realizing the efficient repair of a bone fracture. This rational delivery system may expand the bone repair types which can be administered with growth factors. Furthermore, the concept of taking advantage of the malformed vascular structure to deliver drugs potentially inspires researchers for the therapy of other diseases, especially sudden disease (such as cerebral hemorrhage).


Assuntos
Proteína Morfogenética Óssea 2/metabolismo , Regeneração Óssea , Metaloproteinase 9 da Matriz/metabolismo , Nanocápsulas/uso terapêutico , Fraturas da Tíbia/terapia , Animais , Proteína Morfogenética Óssea 2/administração & dosagem , Linhagem Celular , Modelos Animais de Doenças , Humanos , Metaloproteinase 9 da Matriz/administração & dosagem , Camundongos , Nanocápsulas/química , Osteogênese , Tamanho da Partícula , Células RAW 264.7 , Ratos , Fraturas da Tíbia/metabolismo , Fraturas da Tíbia/patologia
16.
Eur J Med Res ; 24(1): 2, 2019 Jan 19.
Artigo em Inglês | MEDLINE | ID: mdl-30660181

RESUMO

BACKGROUND: Multi-drug-resistant bacteria (e.g. Carbapenem-resistant Acinetobacter baumannii, extended-spectrum betalactamase or carbapenemase-producing enterobacteriaceae) are emerging in early-onset infections. So far, there is no report describing the eradication of these bacteria in a osseous infection of an open proximal tibial fracture in combination with the hexapod technology to address both osseous consolidation and closed drop foot correction. CASE PRESENTATION: After sustaining a proximal tibial fracture (Gustilo 3B), a 41-year-old man was primarily treated with open reduction and internal fixation by a locking plate and split-thickness skin graft in the home country. At the time of admission to our hospital there was a significant anterolateral soft tissue defect covered with an already-necrotic split-thickness graft and suspicious secretion. CAT and MRI scans revealed no signs of osseous healing, intramedullary distinctive osteomyelitis, as well as a large abscess zone in the dorsal compartment. Multiple wound smears showed multi-drug-resistant bacteria: Acinetobacter baumannii (Carbapenem resistant) as well as Enterobacter cloacae complex (AmpC overexpression). After implant removal, excessive osseous and intramedullary debridements using the Reamer Irrigator Aspirator (RIA®) as well as initial negative pressure wound therapy were performed. Colistin hand-modelled chains and sticks were applied topically as well as an adjusted systemic antibiotic scheme was applied. After repetitive surgical interventions, the smears showed bacterial eradication and the patient underwent soft tissue reconstruction with a free vascularized latissimus dorsi muscle flap. External fixation was converted to a hexapod fixator (TSF®) to correct primary varus displacement, axial assignment and secure osseous healing. A second ring was mounted to address the fixed drop foot in a closed fashion without further intervention. At final follow-up, 12 months after trauma, the patient showed good functional recovery with osseous healing, intact soft tissue with satisfactory cosmetics and no signs of reinfection. CONCLUSIONS: A multidisciplinary approach with orthopaedic surgeons for debridement, planning and establishing osseous and joint correction and consolidation, plastic surgeons for microvascular muscle flaps for soft tissue defect coverage as well as clinical microbiologists for the optimized anti-infective treatment is essential in these challenging rare cases. LEVEL OF EVIDENCE: Level IV.


Assuntos
Infecções por Acinetobacter , Infecções por Enterobacteriaceae , Neuropatias Fibulares/terapia , Infecção da Ferida Cirúrgica/terapia , Fraturas da Tíbia/terapia , Infecções por Acinetobacter/etiologia , Infecções por Acinetobacter/terapia , Acinetobacter baumannii , Adulto , Antibacterianos/administração & dosagem , Desbridamento/métodos , Farmacorresistência Bacteriana Múltipla , Enterobacter cloacae , Infecções por Enterobacteriaceae/etiologia , Infecções por Enterobacteriaceae/terapia , Fixadores Externos , Fixação Interna de Fraturas/efeitos adversos , Humanos , Fixadores Internos , Masculino , Tratamento de Ferimentos com Pressão Negativa/métodos , Redução Aberta/efeitos adversos , Redução Aberta/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Retalhos Cirúrgicos
17.
Cir Cir ; 87(1): 18-22, 2019.
Artigo em Espanhol | MEDLINE | ID: mdl-30600804

RESUMO

Introduction: Long bones fractures are responsible for prolonged periods of incapacity and economic losses. New therapies for shortening the time of consolidation are needed. Thus, the purpose of this clinical study was to evaluate the efficacy of noise plus weight-bearing over the bone consolidation of tibial shaft fractures. Methods: In this clinical trial, 12 patients with tibial shaft fractures were recruited during a 24-month period. Participants were treated with intramedullary nails and randomized to two groups: an experimental group and a control group. Both groups underwent a rehabilitation program consisting of two daily walking sessions with progressive weight-bearing. Simultaneously, the experimental group received a noise stimulus on the fracture site with intensities of 0.1-0.6 N and frequencies of 0.1-50 Hz. Radiographic consolidation was evaluated by Radiographic Unión Scale of Tibia. Results: X-ray consolidation was achieved at 18.6 ± 3.6 weeks and 27.2 ± 6.9 weeks, for experimental and control group, respectively (p < 0.05). Recovery of mobility ranges in the knee and ankle was faster in the experimental group than in the control group. Conclusions: This new method to stimulate fracture consolidation has the following advantages: it is effective, portable, easy to use, and inexpensive.


Assuntos
Consolidação da Fratura , Ruído , Modalidades de Fisioterapia , Fraturas da Tíbia/terapia , Suporte de Carga , Adulto , Terapia Combinada , Feminino , Fixação Intramedular de Fraturas , Humanos , Masculino , Fatores de Tempo , Adulto Jovem
18.
Injury ; 50(2): 497-502, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30401540

RESUMO

AIMS: To assess current national practice in the management of severe open tibial fractures against national standards, using data collected by the Trauma and Audit Research Network. MATERIALS AND METHODS: Demographic, injury-specific, and outcome data were obtained for all grade IIIB/C fractures admitted to Major Trauma Centres in England from October 2014 to January 2016. RESULTS: Data was available for 646 patients with recorded grade IIIB/C fractures. The male to female ratio was 2.3:1, mean age 47 years. 77% received antibiotics within 3 h of admission, 82% were debrided within 24 h. Soft tissue coverage was achieved within 72 h of admission in 71%. The amputation rate was 8.7%. 4.3% of patients required further theatre visits for infection during the index admission. The timing of antibiotics and surgery could not be correlated with returns to theatre for early infection. There were significant differences in the management and outcomes of patients aged 65 and over, with an increase in mortality and amputation rates. CONCLUSIONS: Good outcomes are reported from the management of IIIB/C fractures in Major Trauma Centres in England. Overall compliance with national standards is particularly poor in the elderly. Compliance did not appear to affect rates of returning to theatre or early infection. Appropriately applied patient reported outcome measures are needed to enhance the evidence-base for management of these injuries.


Assuntos
Amputação/estatística & dados numéricos , Antibacterianos/uso terapêutico , Fixação Interna de Fraturas/métodos , Fraturas Expostas/terapia , Lesões dos Tecidos Moles/terapia , Infecção da Ferida Cirúrgica/prevenção & controle , Fraturas da Tíbia/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Auditoria Clínica , Desbridamento , Inglaterra/epidemiologia , Feminino , Fraturas Expostas/diagnóstico por imagem , Fraturas Expostas/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica , Estudos Prospectivos , Lesões dos Tecidos Moles/epidemiologia , Lesões dos Tecidos Moles/microbiologia , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/microbiologia , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/epidemiologia , Centros de Traumatologia , Índices de Gravidade do Trauma , Técnicas de Fechamento de Ferimentos , Adulto Jovem
19.
Phys Sportsmed ; 47(1): 47-59, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30345867

RESUMO

The purpose of this review is to describe and critically evaluate current knowledge regarding diagnosis, assessment, and management of chronic overload leg injuries which are often non-specific and misleadingly referred to as 'shin splints'. We aimed to review clinical entities that come under the umbrella term 'Exercise-induced leg pain' (EILP) based on current literature and systematically searched the literature. Specifically, systematic reviews were included. Our analyses demonstrated that current knowledge on EILP is based on a low level of evidence. EILP has to be subdivided into those with pain from bone stress injuries, pain of osteo-fascial origin, pain of muscular origin, pain due to nerve compression and pain due to a temporary vascular compromise. The history is most important. Questions include the onset of symptoms, whether worse with activity, at rest or at night? What exacerbates it and what relieves it? Is the sleep disturbed? Investigations merely confirm the clinical diagnosis and/or differential diagnosis; they should not be solely relied upon. The mainstay of diagnosing bone stress injury is MRI scan. Treatment is based on unloading strategies. A standard for confirming chronic exertional compartment syndrome (CECS) is the dynamic intra-compartmental pressure study performed with specific exercises that provoke the symptoms. Surgery provides the best outcome. Medial tibial stress syndrome (MTSS) presents a challenge in both diagnosis and treatment especially where there is a substantial overlap of symptoms with deep posterior CECS. Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors. Surgery should be considered in recalcitrant cases. MRI and MR angiography are the primary investigative tools for functional popliteal artery entrapment syndrome and when confirmed, surgery provides the most satisfactory outcome. Nerve compression is induced by various factors, e.g., localized fascial entrapment, unstable proximal tibiofibular joint (intrinsic) or secondary by external compromise of the nerve, e.g., tight hosiery (extrinsic). Conservative is the treatment of choice. The localized fasciotomy is reserved for recalcitrant cases.


Assuntos
Traumatismos em Atletas/diagnóstico , Traumatismos em Atletas/terapia , Traumatismos da Perna/diagnóstico , Traumatismos da Perna/terapia , Dor/etiologia , Síndrome do Compartimento Anterior/complicações , Síndrome do Compartimento Anterior/diagnóstico , Síndrome do Compartimento Anterior/terapia , Atletas , Traumatismos em Atletas/complicações , Síndromes Compartimentais/diagnóstico , Síndromes Compartimentais/cirurgia , Síndromes Compartimentais/terapia , Tratamento Conservador , Diagnóstico Diferencial , Exercício Físico/fisiologia , Fasciotomia , Fraturas de Estresse/complicações , Fraturas de Estresse/diagnóstico , Fraturas de Estresse/terapia , Humanos , Traumatismos da Perna/complicações , Masculino , Síndromes de Compressão Nervosa/complicações , Síndromes de Compressão Nervosa/diagnóstico , Síndromes de Compressão Nervosa/terapia , Dor/diagnóstico , Fraturas da Tíbia/complicações , Fraturas da Tíbia/diagnóstico , Fraturas da Tíbia/terapia
20.
Eur J Orthop Surg Traumatol ; 29(3): 537-543, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30368617

RESUMO

Open tibial fractures can have devastating long-term effects. In our centre, these patients are followed up in a multidisciplinary Orthoplastic Research Clinic. To improve patient comprehension of information, we have developed personalised information leaflets. This study determines patients' views on these. The leaflet was completed during clinic visits and its role explained. At their next appointment, patients were given anonymised feedback forms, adapted from previously published questionnaires, to complete on their views and use of the leaflet. During the study period, 48 new patients attended clinic; 40 completed questionnaires and were analysed. A majority of patients (39) self-reported improved understanding of their condition, and 11 patients used the information leaflet to improve communication with other healthcare professionals. A majority of patients (34) wished to receive the information leaflet on discharge. The majority of patients in this study felt the leaflet improved their knowledge of their injuries and management.


Assuntos
Fraturas Expostas/terapia , Conhecimentos, Atitudes e Prática em Saúde , Folhetos , Educação de Pacientes como Assunto/métodos , Fraturas da Tíbia/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Comunicação , Compreensão , Feminino , Letramento em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Inquéritos e Questionários , Adulto Jovem
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