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1.
Bone Joint J ; 103-B(3): 456-461, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33641428

RESUMO

AIMS: To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (ß-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes. METHODS: A review of the medical records was conducted of consecutive 35 lower limbs (30 males and five females; median age 46 years (interquartile range (IQR) 40 to 61)) treated with IMT using ß-TCP between 2014 and 2018. Lower Extremity Functional Score (LEFS) was examined preoperatively and at final follow-up to clarify patient-centered outcomes. Bone healing was assessed radiologically, and time from the second stage to bone healing was also evaluated. Patients were divided into ≥ 50 mm and < 50 mm defect groups and into femoral reconstruction, tibial reconstruction, and ankle arthrodesis groups. RESULTS: There were ten and 25 defects in the femur and tibia, respectively. Median LEFS improved significantly from 8 (IQR 1.5 to 19.3) preoperatively to 63.5 (IQR 57 to 73.3) at final follow-up (p < 0.001). Bone healing was achieved in all limbs, and median time from the second stage to bone healing was six months (IQR 5 to 10). Median time to bone healing, preoperative LEFS, or postoperative LEFS did not differ significantly between the defect size groups or among the treatment groups. CONCLUSION: IMT using ß-TCP provided satisfactory clinical and radiological outcomes for segmental bone defects in the lower limbs; surgical outcomes were not influenced by bone defect size or operated part. Cite this article: Bone Joint J 2021;103-B(3):456-461.


Assuntos
Transplante Ósseo/métodos , Fosfatos de Cálcio/farmacologia , Fêmur/cirurgia , Ílio/transplante , Procedimentos Cirúrgicos Reconstrutivos/métodos , Tíbia/cirurgia , Adulto , Artrodese , Desbridamento , Feminino , Fêmur/lesões , Fêmur/patologia , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Polimetil Metacrilato , Estudos Retrospectivos , Tíbia/lesões , Tíbia/patologia , Cicatrização/efeitos dos fármacos
2.
Bone Joint J ; 103-B(2): 294-298, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33517721

RESUMO

AIMS: The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols. METHODS: A biomechanical model of distal metaphyseal tibial fractures was created using a fourth-generation composite bone model. Three fracture patterns were tested: spiral, oblique, and multifragmented. Each fracture extended to within 4 cm to 5 cm of the plafond. The models were nearly-anatomically reduced and stabilized with an intramedullary nail and three distal locking screws. Cyclic loading was performed to simulate normal gait. Loading was completed in compression at 3,000 N at 1 Hz for a total of 70,000 cycles. Displacement (shortening, coronal and sagittal angulation) was measured at regular intervals. RESULTS: The spiral and oblique fracture patterns withstood simulated weight-bearing with minimal displacement. The multifragmented model had early implant failure with breaking of the distal locking screws. The spiral fracture model shortened by a mean of 0.3 mm (SD 0.2), and developed a mean coronal angulation of 2.0° (SD 1.9°) and a mean sagittal angulation of 1.2° (SD 1.1°). On average, 88% of the shortening, 74% of the change in coronal alignment, and 75% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. The oblique fracture model shortened by a mean of 0.2 mm (SD 0.1) and developed a mean coronal angulation of 2.4° (SD 1.6°) and a mean sagittal angulation of 2.6° (SD 1.4°). On average, 44% of the shortening, 39% of the change in coronal alignment, and 79% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. CONCLUSION: For spiral and oblique fracture patterns, simulated weight-bearing resulted in a clinically acceptable degree of displacement. Most displacement occurred early in the test period, and the rate of displacement decreased over time. Based on this model, we offer evidence that early weight-bearing appears safe for well reduced oblique and spiral fractures, but not in multifragmented patterns that have poor bone contact. Cite this article: Bone Joint J 2021;103-B(2):294-298.


Assuntos
Deambulação Precoce , Fixação Intramedular de Fraturas/métodos , Cuidados Pós-Operatórios/métodos , Fraturas da Tíbia/cirurgia , Fenômenos Biomecânicos , Pinos Ortopédicos , Parafusos Ósseos , Fixação Intramedular de Fraturas/instrumentação , Fixação Intramedular de Fraturas/reabilitação , Humanos , Modelos Anatômicos , Tíbia/lesões , Tíbia/fisiologia , Tíbia/cirurgia , Fraturas da Tíbia/reabilitação , Suporte de Carga
3.
Am J Sports Med ; 49(2): 404-409, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33411563

RESUMO

BACKGROUND: Bone contusions are commonly observed on magnetic resonance imaging (MRI) in individuals who have sustained a noncontact anterior cruciate ligament (ACL) injury. Time from injury to image acquisition affects the ability to visualize these bone contusions, as contusions resolve with time. PURPOSE: To quantify the number of bone contusions and their locations (lateral tibial plateau [LTP], lateral femoral condyle [LFC], medial tibial plateau [MTP], and medial femoral condyle [MFC]) observed on MRI scans of noncontact ACL-injured knees acquired within 6 weeks of injury. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We retrospectively reviewed clinic notes, operative notes, and imaging of 136 patients undergoing ACL reconstruction. The following exclusion criteria were applied: MRI scans acquired beyond 6 weeks after injury, contact ACL injury, and previous knee trauma. Fat-suppressed fast spin-echo T2-weighted MRI scans were reviewed by a blinded musculoskeletal radiologist. The number of contusions and their locations (LTP, LFC, MTP, and MFC) were recorded. RESULTS: Contusions were observed in 135 of 136 patients. Eight patients (6%) had 1 contusion, 39 (29%) had 2, 41 (30%) had 3, and 47 (35%) had 4. The most common contusion patterns within each of these groups were 6 (75%) with LTP for 1 contusion, 29 (74%) with LTP/LFC for 2 contusions, 33 (80%) with LTP/LFC/MTP for 3 contusions, and 47 (100%) with LTP/LFC/MTP/MFC for 4 contusions. No sex differences were detected in contusion frequency in the 4 locations (P > .05). Among the participants, 50 (37%) had medial meniscal tears and 52 (38%) had lateral meniscal tears. CONCLUSION: The most common contusion patterns observed were 4 locations (LTP/LFC/MTP/MFC) and 3 locations (LTP/LFC/MTP).


Assuntos
Lesões do Ligamento Cruzado Anterior , Contusões , Fêmur/lesões , Tíbia/lesões , Lesões do Ligamento Cruzado Anterior/diagnóstico por imagem , Contusões/diagnóstico por imagem , Estudos Transversais , Humanos , Imagem por Ressonância Magnética , Estudos Retrospectivos
4.
Ann Surg ; 273(3): e108-e113, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33378296

RESUMO

OBJECTIVE: To demonstrate the role of advanced orthoplastic techniques in harnessing the full potential of elective amputation as a functionally restorative procedure. SUMMARY OF BACKGROUND DATA: Once considered the unfortunate consequence of failed reconstructive efforts, recent outcomes studies have prompted a re-evaluation of the role of amputation in the management of complex extremity trauma. However, even as amputation is appropriately afforded greater consideration as part of the reconstructive algorithm, reconstructive techniques that are commonly utilized in pursuit of limb salvage are rarely applied to amputation. METHODS: The following case demonstrates the successful application of orthoplastic reconstructive techniques to achieve optimal pain and functional outcomes in a 41-year-old active duty soldier who underwent an elective transtibial amputation after prolonged, limb salvage. RESULTS: The patient presented with a large osteocutaneous proximal tibial defect secondary to trauma and subsequent osteomyelitis. The patient underwent a free scapular-parascapular fasciocutaneous flap to provide soft tissue coverage and facilitate the skeletal reconstruction necessary for either continued limb salvage or amputation. Due to tibial allodynia and severely limited ankle function, the patient subsequently elected for amputation in favor of continued limb salvage. Thus, a transtibial amputation was performed concurrently with a pedicled vascularized fibula to address the proximal tibial defect. A modified agonist-antagonist myoneural interface procedure was used to maximize post-amputation function, with creation of regenerative peripheral nerve interface constructs to prophylax against neurogenic pain. After the operation, the patient achieved improved function of the extremity with the use of a prosthesis and reported substantially improved pain while remaining on active duty in a warfighting military occupational specialty. CONCLUSIONS: By addressing all of the reconstructive components commonly considered in limb salvage, an orthoplastic approach to amputation surgery can minimize pain and maximize the rehabilitative potential of the amputee.


Assuntos
Amputação/tendências , Salvamento de Membro/tendências , Militares , Adulto , Humanos , Masculino , Manejo da Dor , Tíbia/lesões , Tíbia/cirurgia
5.
Cell Prolif ; 53(11): e12904, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32997394

RESUMO

OBJECTIVES: Most bone fracture heals through enchondral bone formation that relies on the involvement of periosteal progenitor cells. However, the identity of periosteal progenitor cells and the regulatory mechanism of their proliferation and differentiation remain unclear. The aim of this study was to investigate whether Gli1-CreERT2 can identify a population of murine periosteal progenitor cells and the role of TGF-ß signalling in periosteal progenitor cells on fracture healing. MATERIALS AND METHODS: Double heterozygous Gli1-CreERT2 ;Rosa26-tdTomatoflox/wt mice were sacrificed at different time points for tracing the fate of Gli1+ cells in both intact and fracture bone. Gli1-CreERT2 -mediated Tgfbr2 knockout (Gli1-CreERT2 ;Tgfbr2flox/flox ) mice were subjected to fracture surgery. At 4, 7, 10, 14 and 21 days post-surgery, tibia samples were harvested for tissue analyses including µCT, histology, real-time PCR and immunofluorescence staining. RESULTS: Through cell lineage-tracing experiments, we have revealed that Gli1-CreER T2 can be used to identify a subpopulation of periosteal progenitor cells in vivo that persistently reside in periosteum and contribute to osteochondral elements during fracture repair. During the healing process, TGF-ß signalling is continually activated in the reparative Gli1+ periosteal cells. Conditional knockout of Tgfbr2 in these cells leads to a delayed and impaired enchondral bone formation, at least partially due to the reduced proliferation and chondrogenic and osteogenic differentiation of Gli1+ periosteal cells. CONCLUSIONS: TGF-ß signalling plays an essential role on fracture repair via regulating enchondral bone formation process of Gli1+ periosteal cells.


Assuntos
Consolidação da Fratura , Osteogênese , Periósteo/citologia , Proteína Smad2/metabolismo , Fator de Crescimento Transformador beta/metabolismo , Proteína GLI1 em Dedos de Zinco/metabolismo , Animais , Diferenciação Celular , Feminino , Masculino , Camundongos , Periósteo/metabolismo , Transdução de Sinais , Células-Tronco/citologia , Células-Tronco/metabolismo , Tíbia/lesões , Tíbia/fisiologia
6.
J Pediatr Orthop ; 40(9): 487-491, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32931690

RESUMO

BACKGROUND: The vast majority of pediatric distal-third tibial shaft fractures can be treated with closed reduction and casting. If conservative measures fail, then these fractures are usually treated with 2 antegrade flexible intramedullary nails. A postoperative cast is usually applied because of the tenuous fixation of the 2 nails. Recent studies have described the use of 4 nails to increase the stability of the fixation, a technique that may preclude the need for postoperative casting. The purpose of this biomechanical study is to quantify the relative increase in stiffness and load to failure when using 4 versus 2 nails to surgically stabilize these fractures. METHODS: Short, oblique osteotomies were created in the distal third of small fourth-generation tibial sawbones and stabilized with 2 (double) or 4 (quadruple) flexible intramedullary nails. After pilot testing, 5 models per fixation method were tested cyclically in axial compression, torsion, and 4-point bending in valgus and recurvatum. At the end of the study, each model was loaded to failure in valgus. Stiffness values were calculated, and yield points were recorded. The data were compared using Student's t tests. Results are presented as mean±SD. The level of significance was set at P≤0.05. RESULTS: Stiffness in valgus 4-point bending was 624±231 and 336±162 N/mm in the quadruple-nail and double-nail groups, respectively (P=0.04). There were no statistically significant differences in any other mode of testing. CONCLUSIONS: The quadruple-nail construct was almost 2 times as stiff as the double-nail construct in resisting valgus deformation. This provides biomechanical support for a previously published study describing the clinical success of this fixation construct.


Assuntos
Pinos Ortopédicos , Fixação Intramedular de Fraturas/instrumentação , Tíbia/lesões , Fraturas da Tíbia/cirurgia , Fenômenos Biomecânicos , Criança , Diáfises/lesões , Diáfises/cirurgia , Fixação Intramedular de Fraturas/métodos , Humanos , Masculino , Desenho de Prótese , Tíbia/cirurgia , Fraturas da Tíbia/fisiopatologia
7.
Unfallchirurg ; 123(9): 687-693, 2020 Sep.
Artigo em Alemão | MEDLINE | ID: mdl-32767067

RESUMO

BACKGROUND: Various options are available for treatment of bone defects of the tibia. Bone segment transport is carried out relatively rarely because the surgical technique is not easy and there is a learning curve. OBJECTIVE: This article gives an overview of the history, indications, planning and surgical technique of bone segment transport of the tibia. MATERIAL AND METHODS: A technique using unilateral external fixation in combination with a locking plate osteosynthesis is described. RESULTS: The technique and results are explained exemplified by a case report and in particular pitfalls during surgery and the aftercare concept are outlined. CONCLUSION: Bone segment transport of the tibia using an external fixator and a locking plate is a reliable and practicable technique for treatment of bone defects of the tibia.


Assuntos
Placas Ósseas , Fixação Interna de Fraturas , Tíbia , Fixadores Externos , Humanos , Tíbia/lesões , Tíbia/cirurgia , Resultado do Tratamento
8.
Am J Sports Med ; 48(7): 1673-1681, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32383965

RESUMO

BACKGROUND: The incidence of meniscocapsular junction tears of the medial meniscus posterior horn, known as ramp lesions, is reported to be 9.3% to 23.9%. However, these lesions are not consistently diagnosed with routine arthroscopic exploration and magnetic resonance imaging (MRI). PURPOSE: To determine risk factors associated with ramp lesions in anterior cruciate ligament-injured knees. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 275 patients undergoing anterior cruciate ligament reconstruction between June 2011 and March 2019 were included in this study. Exclusion criteria were revisions, fracture histories, and multiple-ligament injuries other than medial collateral ligament injury. Patients were divided into 2 groups, those with and without ramp lesions according to arthroscopic diagnosis. Binary logistic regression was used to analyze risk factors: age, sex, body mass index, time from injury to surgery (<3 or ≥3 months), mechanism of injury (contact/noncontact), Segond fracture, side-to-side laxity, location of bone contusion, medial and lateral tibial/meniscal slope, and mechanical axis angle. Receiver operating characteristic curves and area under the curve were evaluated. A prediction model was developed by multivariable regression with generalized estimating equations. RESULTS: Overall, 95 patients (34.5%) were confirmed as having a ramp lesion. The sensitivity of MRI for ramp lesions was 85.3%, and specificity was 78.3%. Significant risk factors for ramp lesion were as follows: posterior medial tibial plateau bone contusion on MRI (odds ratio [OR], 4.201; 95% CI, 2.081-8.482; P < .001), ≥3 months from injury (OR, 4.818; 95% CI, 2.158-10.757; P < .001), varus knee >3° (OR, 2.339; 95% CI, 1.048-5.217; P = .038), steeper medial tibial slope (OR, 1.289; 95% CI, 1.002-1.66; P = .049) and meniscal slope (OR, 1.464; 95% CI, 1.137-1.884; P = .003), and gradual lateral tibial slope (OR, 0.775; 95% CI, 0.657-0.914; P = .002). The area under the curve for the prediction model developed by logistic regression was 0.779 (sensitivity, 75.8%; specificity, 71.7%; P < .001) for ramp lesions. CONCLUSION: Care should be taken with patients who have significant risk factors for ramp lesions, including bone contusion at the posterior medial tibial plateau, chronic injury, steeper medial tibial and meniscal slope, gradual lateral tibial slope, and varus knee >3°.


Assuntos
Lesões do Ligamento Cruzado Anterior/complicações , Lesões do Menisco Tibial/complicações , Adolescente , Adulto , Lesões do Ligamento Cruzado Anterior/diagnóstico por imagem , Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior , Contusões/complicações , Contusões/diagnóstico por imagem , Estudos Transversais , Feminino , Fêmur/diagnóstico por imagem , Fêmur/lesões , Humanos , Joelho/anatomia & histologia , Imagem por Ressonância Magnética , Masculino , Estudos Retrospectivos , Fatores de Risco , Tíbia/diagnóstico por imagem , Tíbia/lesões , Lesões do Menisco Tibial/diagnóstico por imagem , Lesões do Menisco Tibial/cirurgia , Fatores de Tempo , Adulto Jovem
9.
Ulus Travma Acil Cerrahi Derg ; 26(3): 425-430, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32436969

RESUMO

BACKGROUND: Distal tibial epiphyseal fractures damage to epiphyseal growth plate. Epiphyseal growth arrest (EGA), reflex sympathetic dystrophy and ankle joint stiffness may also occur after distal tibial epiphyseal injury. This study aims to evaluate the role of trauma mechanism, fracture pattern and fixation technique on clinical outcomes and EGA in the surgically treated distal tibial epiphyseal fractures. METHODS: Twenty seven patients who underwent surgery for distal tibial epiphyseal fracture between the 2011 and 2017 were evaluated retrospectively. The effects of trauma mechanism, fixation technique, preoperative duration, fracture patterns on the clinical results and EGA were examined. AOFAS (The American Orthopedic Foot and Ankle Score) and MOXFQ (The Manchester-Oxford Foot Questionaire) were used for clinical evaluation. RESULTS: Twenty seven patients (17 male and 10 female) were included in this study. The most important complication of epiphyseal injury was the growth pause in eight patients. No statistically significant difference was observed concerning clinical scores and complications according to trauma mechanism, fixation techniques and fracture patterns (p>0.05). CONCLUSION: Regardless of the trauma mechanism, fracture pattern and the fixation material, an anatomical reduction should be obtained in distal tibial epiphyseal fractures to reduce complications and prevent the EGA.


Assuntos
Epifise Deslocada , Tíbia , Fraturas da Tíbia , Epifise Deslocada/fisiopatologia , Epifise Deslocada/cirurgia , Feminino , Humanos , Masculino , Estudos Retrospectivos , Tíbia/crescimento & desenvolvimento , Tíbia/lesões , Tíbia/cirurgia , Fraturas da Tíbia/fisiopatologia , Fraturas da Tíbia/cirurgia
10.
Medicine (Baltimore) ; 99(9): e19328, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32118764

RESUMO

We assessed factors associated with premature physeal closure (PPC) and outcomes after closed reduction of Salter-Harris type II (SH-II) fractures of the distal tibia. We reviewed patients with SH-II fractures of the distal tibia treated at our center from 2010 to 2015 with closed reduction and a non-weightbearing long-leg cast. Patients were categorized by immediate postreduction displacement: minimal, <2 mm; moderate, 2 to 4 mm; or severe, >4 mm. Demographic data, radiographic data, and Lower Extremity Functional Scale (LEFS) scores were recorded.Fifty-nine patients (27 girls, 31 right ankles, 26 concomitant fibula fractures) were included, with a mean (±SD) age at injury of 12.0 ±â€Š2.2 years. Mean maximum fracture displacements were 6.6 ±â€Š6.5 mm initially, 2.7 ±â€Š2.0 mm postreduction, and 0.4 ±â€Š0.7 mm at final follow-up. After reduction, displacement was minimal in 23 patients, moderate in 21, and severe in 15. Fourteen patients developed PPC, with no significant differences between postreduction displacement groups. Patients with high-grade injury mechanisms and/or initial displacement ≥4 mm had 12-fold and 14-fold greater odds, respectively, of PPC. Eighteen patients responded to the LEFS survey (mean 4.0 ±â€Š2.1 years after injury). LEFS scores did not differ significantly between postreduction displacement groups (P = .61).The PPC rate in this series of SH-II distal tibia fractures was 24% and did not differ by postreduction displacement. Initial fracture displacement and high-grade mechanisms of injury were associated with PPC. LEFS scores did not differ significantly by postreduction displacement.Level of Evidence: Level IV, case series.


Assuntos
Fixação de Fratura/normas , Fraturas Salter-Harris/terapia , Adolescente , Criança , Feminino , Fixação de Fratura/métodos , Fixação de Fratura/estatística & dados numéricos , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos Retrospectivos , Tíbia/anatomia & histologia , Tíbia/lesões , Tíbia/fisiopatologia , Resultado do Tratamento
11.
Traffic Inj Prev ; 21(2): 163-168, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32023127

RESUMO

Objective: The tibia is the most commonly fractured long bone in a pedestrian-vehicle collision. The standard injury assessment tool is the "legform," a device that mimics the human lower limb under impact loads. These devices are designed to identify the impact load that will cause the onset of injury, rather than replicate the type and severity of fracture. Thus, this study is the first to determine if composite tibias made by Sawbones (Pacific Research Labs, Vashon, WA, USA) designed for orthopedic biomechanics research, could also potentially be used for traffic safety research by simulating both the damage tolerance of human cadaveric tibias for peak force and bending moment and the fracture patterns themselves, thereby more accurately predicting injury type during real-world pedestrian-vehicle collisions.Methods: Synthetic tibias (n = 6) and human cadaveric tibias (n = 6) were impacted at midshaft at 8.3 m/s (i.e., 30 km/h) under 3-point bending using a pneumatic impacting apparatus. Fracture force, bending moment, and fracture patterns were compared between the two groups, and Weibull survivability curves generated for force and moment results, to identify injury risk thresholds.Results: There was no difference for synthetic vs. cadaveric tibias regarding impact force (4271+/-938 N vs. 4889+/-993 N, p = 0.44) or bending moment at fracture (275+/-64 Nm vs. 302+/-107 Nm, p = 0.69). Force-time curves for all tibias were similar in shape based on the first three Principal Components (p > 0.14). Weibull survivability curves had differences in shape and in the 10% risk of fracture limits, with force thresholds of 2873 N for the synthetic vs. 3386 N for the cadaveric, and bending moment limits of 180 Nm for the synthetic compared to 157 Nm for the cadaveric. All fracture patterns were clinically realistic, but not consistent between groups. The coefficient of variation for synthetic tibias was >0.2 for both peak force and bending moment, which precludes their use as a reproducible test surrogate for injury prediction.Conclusions: Synthetic composite tibias offer the potential for developing a frangible test surrogate, and matched cadaveric response in several respects. However, the repeatability was not high enough for them to be used in their present form for injury prediction.


Assuntos
Acidentes de Trânsito/estatística & dados numéricos , Substitutos Ósseos , Pedestres , Tíbia/lesões , Tíbia/fisiologia , Idoso , Fenômenos Biomecânicos , Cadáver , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Risco
12.
Gait Posture ; 77: 190-194, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32058282

RESUMO

BACKGROUND: Military personnel are required to run while carrying heavy body-borne loads, which is suggested to increase their risk of tibial stress fracture. Research has retrospectively identified biomechanical variables associated with a history of tibial stress fracture in runners, however, the effect that load carriage has on these variables remains unknown. RESEARCH QUESTION: What are the effects of load carriage on running biomechanical variables associated with a history of tibial stress fracture? METHODS: Twenty-one women ran at 3.0 m/s on an instrumented treadmill in four load carriage conditions: 0, 4.5, 11.3, and 22.7 kg. Motion capture and ground reaction force data were collected. Dependent variables included average loading rate, peak absolute free moment, peak hip adduction, peak rearfoot eversion, and stride frequency. Linear mixed models were used to asses the effect of load carriage and body mass on dependent variables. RESULTS: A load x body mass interaction was observed for stride frequency only (p = 0.017). Stride frequency increased with load carriage of 22.7-kg, but lighter participants illustrated a greater change than heavier participants. Average loading rate (p < 0.001) and peak free moment (p = 0.015) were greater in the 22.7-kg condition, while peak rearfoot eversion (p ≤ 0.023) was greater in the 11.3- and 22.7-kg conditions, compared to the unloaded condition. Load carriage did not affect peak hip adduction (p = 0.67). SIGNIFICANCE: Participants adapted to heavy load carriage by increasing stride frequency. This was especially evident in lighter participants who increased stride frequency to a greater extent than heavier participants. Despite this adaptation, running with load carriage of ≥11.3-kg increased variables associated with a history of tibial stress fracture, which may be indicative of elevated stress fracture risk. However, the lack of concomitant change amongst variables as a function of load carriage may highlight the difficulty in assessing injury risk from a single measure of running biomechanics.


Assuntos
Fraturas de Estresse/fisiopatologia , Marcha , Corrida/lesões , Corrida/fisiologia , Tíbia/lesões , Fraturas da Tíbia/fisiopatologia , Adulto , Fenômenos Biomecânicos , Índice de Massa Corporal , Teste de Esforço , Feminino , Fraturas de Estresse/etiologia , Humanos , Modelos Lineares , Militares , Medição de Risco , Fatores de Risco , Tíbia/fisiopatologia , Fraturas da Tíbia/etiologia , Suporte de Carga , Adulto Jovem
13.
J Am Acad Orthop Surg ; 28(18): e810-e814, 2020 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-32011544

RESUMO

INTRODUCTION: Tibia fractures are common injuries that can often be effectively treated with intramedullary nail (IMN) fixation. The ideal starting point for IMN reaming and nail placement is well described and regarded as a crucial aspect in the technique. The purpose of this study is to determine the accuracy and precision with which the starting point is established and if this is maintained after nail insertion during fracture fixation. METHODS: Fifty consecutive tibia fractures treated by IMN fixation sized 9 to 13 mm through an infrapatellar or medial parapatellar approach and 50 treated with a suprapatellar approach were evaluated. The starting point for reaming and IMN placement was measured using intraoperative fluoroscopy. Postoperative radiographs were used to determine the center of the IMN after placement. The distance between the measured points and the ideal starting point was measured. RESULTS: Deviation from the ideal entry point on intraoperative fluoroscopy averaged 4.6 ± 4.0 mm medially, 2.9 ± 3.7 mm anteriorly, and 2.7 ± 3.3 mm distally. In 30% of cases, the final IMN position varied from the entry point by greater than one SD in the coronal or sagittal plane. No difference between approaches was appreciated. DISCUSSION: Although the ideal starting point for tibial IMN fixation is known, this is frequently not the starting point accepted in practice. Final position of the IMN is independent of IMN size or approach and is not markedly different than the obtained starting point. LEVEL OF EVIDENCE: Therapeutic level III.


Assuntos
Pinos Ortopédicos , Fixação Intramedular de Fraturas/métodos , Cirurgia Assistida por Computador/métodos , Tíbia/diagnóstico por imagem , Tíbia/lesões , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Humanos , Sensibilidade e Especificidade
14.
Am J Sports Med ; 48(3): 545-553, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31917606

RESUMO

BACKGROUND: Bone bruising of the posterolateral tibial plateau and the lateral femoral condyle sulcus terminalis has a well-established association with anterior cruciate ligament (ACL) tears. Impaction fractures of the femur and tibia may occur in these locations; however, there is a paucity of literature describing these fractures. PURPOSE: The primary objective was to quantify the incidence, size, and location of impaction fractures of the posterolateral tibial plateau and lateral femoral condyle in patients with primary ACL tears. The secondary objective was to investigate the association between impaction fractures and concomitant meniscal and ligamentous injuries. STUDY DESIGN: Case series; Level of evidence 4. METHODS: Patients with available magnetic resonance imaging (MRI) scans who were treated for primary ACL tear by a single surgeon were identified. MRI scans were reviewed with denotation of posterolateral tibial and femoral condylar contusions and displaced impaction fractures. Measurements of the lateral tibial plateau were taken in all patients with displaced lateral tibial plateau fractures and in a subset of control patients without tibial plateau fracture present to characterize the size and location of the bony lesion. Associations of impaction fractures with concomitant meniscal or ligamentous injuries were evaluated through use of chi-square testing. RESULTS: There were 825 knees identified with available MRI scans. Lateral tibial plateau bone bruising was present in 634 knees (76.8%), and lateral femoral condyle bone bruising was present in 407 knees (49.3%). Posterolateral tibial plateau impaction fractures were present in 407 knees (49.3%), and lateral femoral condylar impaction fractures were present in 214 knees (25.9%). Patients with posterolateral tibial plateau impaction fractures were older than patients without these fractures (42.6 vs 32.7 years; P < .001), whereas patients with lateral femoral condylar impaction fractures were younger (23.8 vs 32.7 years; P < .001). There were 71 knees (8.6%) with a posterolateral tibial plateau impaction fracture with greater than 10% loss of lateral tibial plateau depth, and this group had an increased incidence of lateral meniscus posterior root tears (22.1% vs 12.0%; P = .02). CONCLUSION: Posterolateral tibial plateau impaction fractures occurred with a high incidence (49.3%) in patients with primary ACL tears and demonstrated an increased association with lateral meniscus posterior horn root tears as their size increased. Lateral femoral condylar impaction fractures occurred in 25.9% of patients with primary ACL tears and entailed an increased incidence of lateral meniscal tears and medial meniscal ramp lesions.


Assuntos
Lesões do Ligamento Cruzado Anterior/epidemiologia , Fêmur/lesões , Traumatismos do Joelho/patologia , Tíbia/lesões , Lesões do Ligamento Cruzado Anterior/diagnóstico por imagem , Humanos , Incidência , Articulação do Joelho/patologia , Imagem por Ressonância Magnética , Tíbia/patologia
15.
Int J Orthop Trauma Nurs ; 36: 100722, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31839387

RESUMO

PURPOSE: For permanent wound coverage of compound fractures, the wound surface should have 100% granulation tissue without any discharge or necrotic slough. Negative pressure wound therapy (NPWT) is a well known modality in the management of open fractures, and post-operative wound problems. This study was conducted to compare the outcome of NPWT and traditional dressing in wound healing of open fractures. MATERIAL AND METHODS: A prospective study of 100 cases was conducted to compare the wound healing outcomes of open fracture following vacuum assisted closure (VAC) dressing (50 cases) and traditional wound dressing (50 cases). Patients included in the study underwent initial debridement to remove necrotic slough and tissue when indicated. Foam dressings were used to cover the wounds using aseptic conditions in the VAC group. Dressings were changed daily for patients in traditional dressing group using hydrogen peroxide, normal saline and povidone iodine in a sequential manner and every 3-4 days in the VAC dressing group. Patients were evaluated clinically for appearance of granulation tissue, duration of hospital stay and reduction in wound surface area using appropriate statistical methods. RESULT: There was a significant difference between the rate of wound healing in the group NPWT/VAC group compared to the traditional wound dressings group in terms of appearance of granulation tissue, reduction in wound surface area and duration of hospital stay. CONCLUSION: Vacuum assisted dressing is more effective than traditional wound dressing in wound healing of open fractures.


Assuntos
Bandagens , Fêmur/lesões , Fraturas Expostas/terapia , Tratamento de Ferimentos com Pressão Negativa/métodos , Tíbia/lesões , Cicatrização/fisiologia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
16.
Knee ; 27(1): 192-197, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31883759

RESUMO

BACKGROUND: The purpose of this study was to investigate the healing process of synthetic bone grafts in opening wedge high tibial osteotomy (OWHTO) and to identify the factors that affect bone healing in OWHTO. It was hypothesized that lateral hinge fracture (LHF) is associated with delayed bone healing after OWHTO with synthetic bone grafting. METHODS: The subjects included 350 knees of 283 patients who underwent OWHTO using two wedged blocks of beta-tricalcium phosphate (ß-TCP) with 60% porosity. The healing of the osteotomy gap using a radiologic rating system for OWHTO with synthetic bone grafts and the presence of an LHF were assessed up to postoperative 24 months. RESULTS: LHFs were found in 49 knees (14%). The osteotomy gap showed slower progression of radiographic healing with an LHF than without an LHF (P < .05). In the knees with LHFs, initial radiographic change in the osteotomy gap was observed almost at the same time as healing of the LHF. Multivariate logistic regression analysis identified LHF as the factor preventing the progression of bone healing (OR = 46.78, P < .05). CONCLUSIONS: LHF is associated with delayed bone healing after OWHTO with synthetic bone grafting.


Assuntos
Transplante Ósseo/métodos , Fosfatos de Cálcio/administração & dosagem , Osteoartrite do Joelho/cirurgia , Osteotomia/efeitos adversos , Tíbia/diagnóstico por imagem , Tíbia/cirurgia , Fraturas da Tíbia/diagnóstico por imagem , Idoso , Materiais Biocompatíveis/administração & dosagem , Substitutos Ósseos/administração & dosagem , Feminino , Consolidação da Fratura , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/diagnóstico por imagem , Osteoartrite do Joelho/fisiopatologia , Osteotomia/métodos , Tíbia/lesões , Fraturas da Tíbia/etiologia , Fraturas da Tíbia/fisiopatologia
17.
Vet Clin North Am Small Anim Pract ; 50(1): 183-206, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31733670

RESUMO

Fractures of the tibia and fibula are common in dogs and cats and occur most commonly as a result of substantial trauma. Tibial fractures are particularly amenable to treatment using minimally invasive fracture repair (MIFR) techniques that preserve blood supply to comminuted fracture fragments, accelerating bone callus production and speeding fracture healing. Treatment of tibial fractures using MIFR techniques has been found to reduce surgical time, reduce the time for fracture healing, and to decrease patient morbidity, while at the same time reducing complications compared with traditional open reduction and internal fixation.


Assuntos
Fíbula/cirurgia , Fixação Interna de Fraturas/veterinária , Fraturas Ósseas/veterinária , Membro Posterior/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/veterinária , Tíbia/cirurgia , Animais , Fíbula/lesões , Fixação Interna de Fraturas/métodos , Fraturas Ósseas/cirurgia , Membro Posterior/lesões , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Tíbia/lesões
18.
Int Orthop ; 44(1): 187-193, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31485681

RESUMO

BACKGROUND: Treatment goals for pathologic fractures about the knee include pain relief and unrestricted weight bearing. In cases of condylar destruction, these fractures may not be amenable to internal fixation, and arthroplasty may be considered. The purpose of this study was to analyze the outcomes of knee arthroplasty for primary treatment of impending or pathologic fractures of the distal femur or proximal tibia. METHODS: Fifteen (8 males and 7 females) patients, mean age 62 ± nine years, undergoing arthroplasty for management of a pathologic peri-articular distal femur (n = 11) or proximal tibia (n = 4) fracture between 2001 and 2017 were reviewed. Implants included tumour endoprostheses (n = 11) and rotating hinged total knees (n = 4). Pathology included metastatic disease (n = 14) and lymphoma (n = 1). Eight (53%) patients presented with a fracture while the remainder had large impending lesions. RESULTS: Mean follow-up was 19 months. At final follow-up, 11 patients had died with overall five year survival of 33%. Two (13%) patients required re-operation; including wound irrigation and debridement (n = 1) and above knee amputation for local recurrence (n = 1). An additional two (13%) patients developed post-operative VTE. MSTS, KSS, and KSS-F scores improved from a mean 12 ± 16%, 30 ± 11, and 14 ± 24 pre-operatively to 69 ± 26%, 75 ± 16, and 67 ± 25 at final follow-up, respectively (P < 0.001). Thirteen (87%) patients had severe pain prior to surgery with no patients (0%, P < 0.001) reporting severe pain at last follow-up. CONCLUSION: Knee arthroplasty provided improved function and full weight-bearing making it an effective treatment for pathologic periarticular fractures of the distal femur and proximal tibia.


Assuntos
Artroplastia do Joelho , Fraturas do Fêmur/cirurgia , Fraturas Espontâneas/cirurgia , Fraturas Intra-Articulares/cirurgia , Articulação do Joelho/cirurgia , Fraturas da Tíbia/cirurgia , Idoso , Neoplasias Ósseas/complicações , Neoplasias Ósseas/cirurgia , Feminino , Fêmur/lesões , Fêmur/cirurgia , Humanos , Traumatismos do Joelho/cirurgia , Prótese do Joelho , Linfoma/complicações , Linfoma/cirurgia , Masculino , Pessoa de Meia-Idade , Reoperação , Tíbia/lesões , Tíbia/cirurgia , Resultado do Tratamento , Suporte de Carga
19.
J Knee Surg ; 33(2): 213-222, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30650438

RESUMO

Infected nonunion and malunion of tibial plateau are rare injuries with no standardized protocols for treatment. This study assessed the outcome of chronic infected intra-articular proximal tibial fractures with and without metaphyseal bone loss managed with the Ilizarov ring fixator. A series of six patients of intra-articular infected nonunion of the tibial plateau and two patients with malunited plateau with metaphyseal nonunion were treated in a tertiary care hospital. Three of these eight patients had a metaphyseal bone loss or bone gap after debridement and underwent internal transport with distal corticotomy to obtain the bone length. The remaining five patients underwent static ring fixation after correction of the articular deformity. Clinical evaluation was done by Knee Society Score, Rasmussen radiological and Association for the Study and Application of Methods of Ilizarov scores. All patients but one achieved union with the ring fixator. The average follow-up was 33 months (range, 12-120 months). Average time to achieve union was 11.5 months (range, 3-30). The scores were good in four patients and poor in the rest four, out of which three had undergone internal transport. Proximal tibia intra-articular infected nonunion and malunion with or without metaphyseal bone loss can be treated successfully with the Ilizarov fixator. Malunion of the tibial plateau has to be addressed in cases with varus alignment of the limb or articular step-off of ≥ 5mm between the two tibial surfaces. Patients with associated metaphyseal bone loss tend to have complications and take a longer duration to heal. Single-stage treatment avoids intra-articular malunion and loss of limb alignment.


Assuntos
Fraturas Mal-Unidas/cirurgia , Fraturas não Consolidadas/cirurgia , Técnica de Ilizarov/instrumentação , Infecções/cirurgia , Fraturas Intra-Articulares/cirurgia , Fraturas da Tíbia/cirurgia , Adulto , Doença Crônica , Desbridamento , Fixadores Externos , Feminino , Consolidação da Fratura , Fraturas Mal-Unidas/etiologia , Fraturas não Consolidadas/etiologia , Humanos , Infecções/complicações , Fraturas Intra-Articulares/complicações , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tíbia/lesões , Tíbia/cirurgia , Resultado do Tratamento , Adulto Jovem
20.
Skeletal Radiol ; 49(3): 425-434, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31420694

RESUMO

OBJECTIVE: To compare the diagnostic performance and inter-reader agreement of an abbreviated (5 min) MR protocol compared to a complete (25 min) protocol, for evaluation of suspected tibial bone stress injury. MATERIALS AND METHODS: This IRB-approved retrospective study consisted of 95 consecutive MR examinations in 88 patients with suspected tibial bone stress injury. Three musculoskeletal radiologists independently classified all examinations utilizing both an abbreviated protocol consisting only of axial T2-weighted images with fat suppression, and after a washout period again classified the complete examinations. Accuracy was calculated as proportion of cases classified exactly, within 1 grade, within 2 grades, and also utilizing a simplified "clinically relevant" classification combining grades 2, 3, and 4A into a single group. Significance testing was performed with the chi-test, and a post-hoc power analysis was performed. Inter-reader agreement was calculated with Kendall's coefficient of concordance, with significance testing performed utilizing the z-test after bootstrapping to obtain the standard error. RESULTS AND CONCLUSIONS: There was no significant difference in accuracy of grading tibial bone stress injuries between complete and abbreviated examinations. For complete exams, pooled exact accuracy was 47.8%; accuracy within 1 grade was 82.8%; and accuracy within 2 grades was 96.1%. For the abbreviated protocol, corresponding accuracies were 50.2, 82.0, and 93.9%. With the "clinically relevant" simplified classification, accuracy was 58.6% for complete exams and 64.2% for abbreviated exams. There was no significant difference in inter-reader agreement, with substantial agreement demonstrated for both complete (Kendall coefficient of concordance 0.805) and abbreviated examinations (coefficient of 0.767).


Assuntos
Traumatismos em Atletas/classificação , Traumatismos em Atletas/diagnóstico por imagem , Imagem por Ressonância Magnética/métodos , Tíbia/diagnóstico por imagem , Tíbia/lesões , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
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