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Abstract Objective To evaluate whether three-dimensional (3D) printing increases agreement in the classification of tibial pilon fractures. Methods Orthopedists and traumatologists reviewed radiographs, computed tomography scans with 3D reconstruction, and prototyping 3D printing, and classified the fractures based on the Rüedi-Allgöwer and Arbeitsgemeinschaft für Osteosynthesefragen (AO, Association for the Study of Internal Fixation) Foundation/Orthopedic Trauma Association (AO/OTA) classification systems. Next, data evaluation used Kappa agreement coefficients. Results The use of the 3D model did not improve agreement for tibial pilon fractures regarding the treatment proposed by the groups. Regarding the classification systems, the agreement only improved concerning the AO/OTA classification when the 3D model was used in the assessment by the foot and ankle specialists. Conclusion Although 3D printing is statistically relevant for surgeons specializing in foot and ankle, its values remain lower than optimal.
Resumo Objetivo Avaliar se a impressão tridimensional (3D) aumenta a concordância na classificação de fraturas do pilão tibial. Métodos Foram selecionadas radiografias, tomografias com reconstrução 3D e impressão de prototipagem em impressora 3D. Os exames foram apresentados a profissionais da área de Ortopedia e Traumatologia que classificaram as fraturas com base nas classificações da Arbeitsgemeinschaft für Osteosynthesefragen (AO, Associação para o Estudo da Fixação Interna) Foundation/Orthopedic Trauma Association (AO/OTA) e de Rüedi-Allgöwer. Posteriormente, os dados foram avaliados pelos coeficientes de concordância de Kappa. Resultados O uso do modelo 3D não melhorou a concordância na fratura do pilão tibial quanto ao tratamento proposto pelos grupos. Em relação aos sistemas de classificação, somente a concordância na classificação AO/OTA melhorou quando foi utilizado o modelo 3D na avaliação pelos especialistas em pé e tornozelo. Conclusão Apesar de o uso da impressão 3D ter relevância estatística para os cirurgiões especialistas em pé e tornozelo, ainda apresenta valores menores do que os ideais.
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ObjectivesTo compare the clinical efficacy and complications of anatomic locking titanium plate （hereinafter referred to as “titanium plate screw”） and intramedullary nail in the treatment of distal tibial fractures.Methods From September 2019 to September 2021， 32 patients diagnosed with AO-A fracture of distal tibia at Sun Yat-sen Memorial Hospital of Sun Yat-sen University were included in this study. Of these， 15 cases were treated with titanium plate screws and 17 cases were treated with intramedullary nails. General surgical indexes， fracture healing time and postoperative operation were compared between the two groups.ResultsAll patients were followed up for 10 to 20 months， with an average of 12 months. The operative time and intraoperative fluoroscopy times of intramedullary nail group were longer than those of titanium plate screw group， but the preoperative waiting time and hospitalization days was less or were fewer than those of titanium plate screw group， the difference was statistically significant （P < 0.05）. There was no significant difference in fracture healing time between the two groups （P> 0.05）. At 6 weeks after operation， VAS scores in both groups were lower than those before operation， with statistically significant difference （P<0.05）. There was no significant difference in VAS scores between the intramedullary nail group and the titanium plate screw group （P> 0.05）. AOFAS scores 6 months after surgery， ankle joint motion and complication rate 1 year after surgery in intramedullary screw group were better than those in titanium plate screw group， and the differences were statistically significant （P< 0.05）. There was no significant difference in AOFAS scores between the two groups at 1 year after operation （P> 0.05）.ConclusionTitanium plate screw and intramedullary nail are both effective methods for the treatment of distal tibial AO-A fracture， and there is no significant difference in long-term clinical efficacy. Intramedullary nail has fewer soft tissue complications， less impact on ankle motion， faster recovery and higher safety， while titanium plate screw has a higher probability of postoperative soft tissue infection. We suggest that in clinical work， preoperative evaluation of patients should be done well. Under the premise of grasping the indications， intramedullary nail has fewer complications and certain advantages.
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Objective:To compare the curative effects between modified double-reverse traction technique and traditional open reduction in the treatment of tibial plateau fractures.Methods:A retrospective study was conducted to analyze the data of 70 patients with Schatzker type Ⅳ-Ⅴ tibial plateau fracture who had undergone surgical treatment at The Third Department of Orthopaedics, Zhongshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Traditional Chinese Medicine from January 2017 to December 2022. The patients were divided into an observation group treated with modified double-reverse traction and a control group treated with traditional open reduction. In the observation group of 37 cases, there were 20 males and 17 females with an age of (44.6±13.5) years, and 9 cases of type Ⅳ and 28 cases of type V by the Schatzker classification; in the control group of 33 cases, there were 18 males and 15 females with an age of (45.9±13.7) years, and 10 cases of type Ⅳ and 23 cases of type Ⅴ by the Schatzker classification. The 2 groups were compared in terms of operation time, length of main incision, intraoperative blood loss, Rasmussen imaging score before discharge, and knee function score of American Hospital for Special Surgery (HSS), Visual Analogue Scale (VAS), fracture healing and complications at 6 months postoperatively.Results:There was no significant difference in the preoperative general data between the 2 groups, showing group comparability ( P>0.05). All patients were followed up for (14.3±1.4) months. The observation group was significantly better than the control group in operation time [(113.9±11.4) min versus (151.82±10.37) min], length of main incision [4 (4, 5) cm versus 6 (6, 7) cm], intraoperative blood loss [30 (20, 35) mL versus 55 (50, 65) mL], VAS [0 (0, 0) point versus 0 (0, 1) points] and HSS score [(89.8±3.1) points versus (86.0±3.5) points] ( P<0.05). There were no significant differences between the 2 groups in Rasmussen imaging score before discharge, or fracture healing rate or complication rate at 6 months postoperatively ( P>0.05). Conclusion:In the treatment of Schatzker type Ⅳ-Ⅴ tibial plateau fractures, modified double-reverse traction technique is worthy of clinical application and promotion, because it is advantageous over traditional open reduction in terms of shorter operation time, smaller surgical incision, less intraoperative blood loss, less postoperative pain and better knee function.
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Abstract A middle-aged female patient with a tibial plateau fracture combined with an avulsion of the tibial eminence was treated with a combination of medial plate fixation for the plateau and an arthroscopic aided nonabsorbable suture of the eminence. Our technique for tibial eminence avulsion fractures has no interference with tibial plateau osteosynthesis materials and has proven, once again, to have good results in the treatment of combined and complex injuries of the knee.
Resumo Uma paciente de meia-idade com fratura do platô tibial e avulsão da eminência tibial foi tratada com uma combinação de fixação do platô com placa medial e sutura da eminência com fio não absorvível auxiliada por artroscopia. Nossa técnica para fraturas com avulsão da eminência tibial não interfere nos materiais de osteossíntese do platô tibial e, mais uma vez, teve bons resultados no tratamento de lesões combinadas e complexas do joelho.
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Humans , Female , Middle Aged , Arthroscopy , Tibial Fractures , Fracture Fixation, Internal , Knee InjuriesABSTRACT
Abstract The present study reports a rare case of avulsion fracture of the tibial tuberosity in an adolescent. A 14-year-old male patient sprained his left knee during a soccer match. At the first emergency-room visit, he presented pain in his left knee, 2 +/4+ edema, and inability to walk and flex the affected knee, but no neurovascular changes or signs of compartment syndrome. Radiographs revealed a physeal fracture at the left proximal tibia, classified by Ogden, Tross and Murphy, and modified by Ryu and Debenham, as type IV, and complemented by Aerts et al. as type IV-B. Immobilization was performed with a plaster cast from the inguinal to malleolar regions, followed by analgesia. The patient was operated on the next day, when open reduction and internal fixation using 4.5-mm cannulated screws were performed. The patient was discharged one day after surgery, with plaster cast immobilization and load restraint for four weeks, and bone consolidation was radiologically confirmed three months after the procedure. The patient evolved with a range of motion similar to that of the contralateral limb, no length discrepancy in the lower limbs, and no complaints after one year of follow-up.
Resumo O presente estudo tem como objetivo relatar um caso raro de fratura por avulsão da tuberosidade da tíbia em adolescente. Um paciente de 14 anos, do sexo masculino, sofreu entorse de joelho esquerdo durante partida de futebol. No primeiro atendimento em pronto-socorro, ele apresentava dor no joelho esquerdo, edema 2 +/4 + , incapacidade de deambulação e de flexo-extensão do joelho acometido, sem alterações neurovasculares ou sinais de síndrome compartimental. Nas radiografias, identificou-se fratura fisária na tíbia proximal esquerda, classificada por Ogden, Tross e Murphy, com modificação por Ryu e Debenham, como tipo IV, e complementada por Aerts et al. como tipo IV-B. Foi realizada imobilização com tala gessada inguino-maleolar e analgesia, e o paciente submetido a cirurgia no dia seguinte, com redução aberta e fixação interna utilizando parafusos canulados 4,5 mm. O paciente recebeu alta no dia seguinte à cirurgia, sendo mantida a imobilização com tala gessada e a restrição de carga por quatro semanas, e apresentou consolidação óssea confirmada por radiografia com três meses do pós-operatório. O paciente evoluiu sem discrepância de comprimento dos membros inferiores, arco de movimento igual ao do membro contralateral, e sem queixas no seguimento de um ano.
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Humans , Male , Adolescent , Tibial Fractures , Fractures, Avulsion , Knee InjuriesABSTRACT
Abstract Objectives To describe a series of cases of tibial fractures surgically treated using the posterior approach as described by Carlson, focusing on evaluating its functional results and complication rate. Methods Eleven patients with tibial plateau fractures, who underwent surgical treatment using the Carlson approach from July to December 2019, were followed-up. The minimum follow-up period was defined as 6 months. The American Knee Society Score (AKSS), American Knee Society Score/Function (AKSS/Function) and the Lysholm score were used to check treatment results at 6 months after the fracture. The patients underwent standard anteroposterior and lateral radiographs to assess fracture healing, and clinical healing was determined by the absence of pain during full weight-bearing. Results The mean follow-up period was 12 months (9-16 months). The primary mechanism of trauma was motorcycle accident, and the most prevalent side of fracture was the right side. Eight participants were male. The mean age of the patients was 28 years. All fractures healed, and none of the patients presented complications. The AKSS was excellent in 11 patients, with a mean AKSS/Function of 99.1±3, and Lysholm scores with a median of 95.0±5.6. Conclusions The Carlson approach for posterior fractures of the tibial plateau can be considered safe, presenting a low complication rate and satisfactory functional results.
Resumo Objetivos O objetivo deste trabalho é descrever uma série de casos de fraturas de tíbia submetidas ao tratamento cirúrgico pela via posterior de Carlson para avaliação de resultados funcionais e frequência de complicações. Métodos Onze pacientes com fraturas do platô tibial foram submetidos a tratamento cirúrgico pela via de Carlson de julho a dezembro de 2019 e acompanhados por um período mínimo de 6 meses. As pontuações American Knee Society Score (AKSS), American Knee Society Score/Function (AKSS/Função) e de Lysholm verificaram os resultados do tratamento 6 meses após a fratura. Os pacientes foram submetidos a radiografias comuns em incidência anteroposterior e de perfil para avaliação da consolidação da fratura e a cicatrização clínica foi determinada pela ausência de dor à descarga total de peso. Resultados O período médio de acompanhamento foi de 12 meses (9 a 16 meses). O principal mecanismo de trauma foi acidente motociclístico e a fratura foi mais prevalente no lado direito. Oito pacientes eram do sexo masculino. A média de idade dos pacientes foi de 28 anos. Todas as fraturas cicatrizaram e nenhum paciente apresentou complicações. A AKSS foi excelente em 11 pacientes, com AKSS/Função média de 99,1 ±3, e a mediana das pontuações de Lysholm foi de 95,0 ±5,6. Conclusões Nas fraturas posteriores do platô tibial, a abordagem de Carlson pode ser considerada segura, apresentando baixo índice de complicações e resultados funcionais satisfatórios.
Subject(s)
Humans , Male , Female , Outcome and Process Assessment, Health Care , Tibial Fractures/surgery , Tibial Fractures/complicationsABSTRACT
Objective:To investigate the clinical efficacy of early versus delayed open reduction and internal fixation in the treatment of tibial pilon fracture. Methods:Sixty patients with tibial pilon fractures admitted to Zhejiang Veteran Hospital from May 2018 to May 2021 were included in this study. They were randomly divided into a control group and a study group ( n = 30/group) using the coin-tossing method. Patients in the control group underwent early reduction and internal fixation within 3 days after injury. Patients in the study group underwent delayed reduction and internal fixation during 7-14 days after injury. The time to bone fracture healing and the time to independent weight-bearing walking were recorded. At 3 and 6 months after surgery, the American Orthopedic Foot and Ankle Society score, Visual Analogue Scale score, clinical efficacy, and incidence of complications were compared between the two groups. Results:The time to bone fracture healing and the time to independent weight-bearing walking in the study group were (8.23 ± 0.63) weeks and (11.77 ± 0.82) weeks, respectively, which were significantly shorter than (9.57 ± 0.86) weeks and (13.40 ± 0.93) weeks in the control group ( t = 6.87, 7.21, both P < 0.001). At 3 months after surgery, American Orthopedic Foot and Ankle Society score in the study group was significantly higher than that in the control group, and the Visual Analogue Scale score in the study group was significantly lower than that in the control group ( t = 6.69, 5.16, both P < 0.001). Overall excellent and good rate of clinical efficacy in the study group was significantly higher than that in the control group (86.6% vs. 63.3%, χ2 = 4.35, P = 0.037). At 6 months after surgery, there were no significant differences in American Orthopedic Foot and Ankle Society score and Visual Analogue Scale score between the two groups ( t = 0.96, 1.12, P = 0.339, 0.267). At 6 months after surgery, there was no significant difference in the overall excellent and good rate of clinical efficacy between the study and control groups (96.6% vs. 90.0%, χ2 = 0.26, P = 0.605). The incidence of complications in the study group was significantly lower than that in the control group (3.3% vs. 26.6%, χ2 = 4.70, P = 0.030). Conclusion:Delayed open reduction and internal fixation after reducing injury to the soft tissue of the affected limbs can effectively shorten the rehabilitation cycle of tibial pilon fracture, increase short-term efficacy, and decrease the risk of postoperative complications.
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Objective:To investigate the value of fibroblast growth factor 2 (FGF-2) and microRNA-206 (miR-206) in predicting postoperative delayed union of closed tibial shaft fractures.Methods:The clinical data of 136 patients who underwent closed tibial shaft fracture surgery in Hospital of the 80 th Group Army of Chinese People's Liberation Army Ground Forces from May 2018 to May 2021 were retrospectively analyzed. Eighty-six patients who had delayed union of closed tibial shaft fractures were included in the observation group, and fifty patients who had normal union of closed tibial shaft fractures were included in the control group. Serum FGF-2 level was measured using the enzyme-linked immunosorbent assay, and serum miR-206 expression was detected using the real-time fluorescence polymerase chain reaction. The relationship between FGF-2 expression and miR-206 expression and closed tibial shaft fractures was analyzed. Results:At 1 day, 1, and 4 weeks after surgery, serum FGF-2 level was significantly lower in the observation group than the control group [(14.24 ± 2.15) ng/L vs. (20.36 ± 3.42) ng/L, (21.38 ± 3.27) ng/L vs. (30.45 ± 4.29) ng/L, (23.59 ± 4.36) ng/L vs. (36.67 ± 4.51) ng/L, t = 7.42, 8.42, 16.66, all P < 0.001]. Serum FGF-2 level gradually increased with time in each group. At 1 day after surgery, serum miR-206 expression was significantly lower in the observation group than the control group ( t = 7.50, P < 0.001). At 4 weeks after surgery, serum miR-206 expression was significantly higher in the observation group than the control group ( t = 17.24, P < 0.001). At 1 week after surgery, there was no significant difference in serum miR-206 expression between the two groups ( P > 0.05). Univariate analysis results showed that postoperative infection, FGF-2, and miR-206 were closely related to the delayed union of closed tibial shaft fractures after surgery (all P < 0.05). Multivariate logistic regression analysis results showed that postoperative infection ( OR = 1.93, 95% CI: 1.20-3.07), FGF-2 ( OR = 2.10, 95% CI: 1.31-3.36), miR-206 ( OR = 2.30, 95% CI: 1.35-3.89) were independent risk factors for delayed union of closed tibial shaft fractures after surgery (all P < 0.05). The receiver operating characteristic (ROC) curves plotting serum FGF-2 level and serum miR-206 expression after closed tibial shaft fractures showed that at 4 weeks after surgery, the optimal cut-off value of FGF-2 for predicting delayed union of closed tibial shaft fractures was 29.83 ng/L, with the area under the curve, sensitivity, and specificity of 0.76 (95% CI: 1.23-3.25), 79.34%, and 68.82%, respectively; at 4 weeks after surgery, the optimal cut-off value of miR-206 for predicting delayed union of closed tibial shaft fractures was 0.63, with the area under the curve, sensitivity and specificity of 0.72 (95% CI: 1.10-2.45), 75.33%, and 67.25%, respectively. The area under the curve, the sensitivity, and specificity of combined use of FGF-2 and miR-206 in predicting delayed union of closed tibial shaft fractures were 0.81 (95% CI: 1.35-3.26), sensitivity and specificity were 83.45% and 67.36% respectively. Conclusion:The decrease in serum FGF-2 level and the increase in serum miR-206 expression at 4 weeks after surgery are independent risk factors for delayed union of closed tibial shaft fractures. Combined use of FGF-2 and miR-206 can better predict the delayed union of closed tibial shaft fractures.
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Objective:To establish a three-dimensional model of locking plate fixation for 42A2 type oblique tibial fractures with different fracture line directions and different angles between the fracture line and the long axis of the tibia. Finite element analysis was used to calculate and analyze the biomechanics of locking plate, screw, and tibia, providing theoretical basis for clinical application.Methods:A healthy adult volunteer, 25 years old, male, with a height of 173 cm and a weight of 69.5 kg, was selected to perform computed tomography (CT) scans on the left tibia. Relevant data were obtained to establish a locking steel plate fixation model for 42A2 type tibia with different oblique fracture line directions and different angles between the fracture line and the long axis of the tibia. Eight hole pure titanium plates were used for fixation, respectively. We compared the Mises stress changes of locking plates, screws, and tibia in different angle fracture models.Results:In the case of a 42A2 type fracture in the left oblique direction with a fracture line from outside to inside, the maximum Mises stress in the tibia was 114 MPa, the maximum Mises stress in the screw was 279.8 MPa, and the maximum Mises stress in the locking steel plate was 302.4 MPa; In the case of a 42A2 type fracture in the right oblique fracture with a fracture line from the bottom to the top, the maximum Mises stress of the tibia was 93.41MPa, the maximum Mises stress of the screw was 353.4 MPa, and the maximum Mises stress of the locking steel plate was 411.8 MPa.Conclusions:Regardless of the oblique fractures in both left and right directions, the maximum stress values are: locking plate>screw>tibia; When the position of the locking steel plate is fixed, the maximum stress values of the locking steel plate and screw are both right oblique fracture>left oblique fracture; And the maximum stress values all increase with the increase of angle.
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Objective:To observe the repair effect and possible mechanism of Dipsacus saponins Ⅵ on tibial fracture model rats.Methods:Thirty Sprague Dawley (SD) rats were randomly divided into model group, intervention group, and combination group, with 10 rats in each group, to establish a tibial fracture rat model using the sawing method. On the second day after surgery, the intervention group was intraperitoneally injected with 10 mg/kg of Chuanduduan saponin Ⅵ; The combination group received intraperitoneal injection of Dipsacus saponins Ⅵ 10 mg/kg and XAV939 1 mg/animal; The model group was intraperitoneally injected with 0.2 ml of physiological saline solution and 0.2 ml of dimethylsulfoxide (DMSO) solution; Once a day, continuous intervention for 14 days. After 2 to 4 weeks of intervention, Micro CT scan and X-ray scan were used to observe the fracture healing status; After 4 weeks of intervention, the wet weight of the tibia was detected; Hematoxylin eosin (HE) staining was used to observe the pathological changes of callus tissue; The Western blot method was used to detect the expression level of callus tissue β- catenin (β-catenin), p-β-catenin, glycogen synthase kinase 3β (GSK-3 β) and Runt related transcription factor 2 (Runx2) protein.Results:After 2 and 4 weeks of intervention, the bone volume fraction (BV/TV), number of trabeculae (Tb.N), Lane Sandhu score, and callus volume in the intervention group were higher than those in the model group (all P<0.05); After 2 and 4 weeks of intervention, the BV/TV, Tb.N, Lane Sandhu score, and callus volume in the combined group were lower than those in the intervention group (all P<0.05). The wet weight of the tibia in the intervention group was higher than that in the model group at 4 weeks after intervention ( P<0.05); The wet weight of the tibia in the combined group was lower than that in the intervention group ( P<0.05). The HE staining results showed that the model group had fibrous tissue hyperplasia and more bone trabeculae, but the maturity was not high and the thickening was not significant; The intervention group formed more bony callus, with orderly arrangement of bone trabeculae, partially mature, and obvious mineralization, consistent with the direction of stress; The combined group formed more cartilaginous and fibrous callus, with more mineralization at the edge of the cartilaginous callus and the formation of bone trabeculae. Abundant capillaries can be observed in the gaps. The expression level of Runx2 and p-β-catenin/β-catenin protein in callus tissue of the intervention group was higher than that of the model group, the protein expression GSK-3 β level was lower than that of the model group (all P<0.05); The expression level of Runx2 and p-β-catenin/β-catenin protein in the callus tissue of the combined group was lower than that of the intervention group; the protein expression level of GSK-3β was higher than that of the intervention group (all P<0.05). Conclusions:Dipsacus saponins Ⅵ can effectively promote fracture repair in tibial fracture model rats; It is possible to plays a role by activating the Wnt/β-catenin signaling pathway.
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Objective:To investigate the efficacy of 3D-printed quantitative bone implants assisting second-stage Masquelet technique for the treatment of long-segment bone defect following Gustilo type IIIB and IIIC tibial fractures.Methods:A retrospective case series analysis was made on 26 patients with long-segment bone defect following Gustilo type IIIB and IIIC tibial fractures treated in Wuxi Ninth People′s Hospital from July 2015 to December 2020, including 20 males and 6 females; aged 19-63 years [(46.5±4.5)years]. Gustilo classification was type IIIB in 23 patients and type IIIC in 3. In the first stage, all patients had thoroughly emergent debridement, removal of all free bone pieces, restoration of the length and force line plus externally fixion, and vacuum sealing drainage (VSD) of the residual wound. After 2-7 days, the external fixation was removed and replaced by internal fixation, with the bone cement filling in the defect area and the free flap covering the wound. The length of tibial bone defect was 5-14 cm [(6.3±0.4)cm], and the tibial defect volume was 12.2-73.1 cm 3 [(33.6±9.2)cm 3]. In the second stage (6-19 weeks after injury), the bone cement was removed, followed by autologous bone grafting. Prior to bone grafting, digital technology was used to accurately calculate the bone defect volume, and an equal volume of bone harvesting area was designe to produce the 3D printed osteotomy template. Bone grafting was conducted after bone removal according to the osteotomy template during operation. The success rate of one-time iliac bone extraction, bone harvesting time, and bleeding volume were recorded. Pain in the bone extraction area was evaluated by visual analogue score (VAS) at 1 day and 1 month after operation and at the last follow-up. Wound healing, complications, and bone healing were observed. Life quality was evaluated by health survey brief form (SF-36) including scores of physical component summary (PCS) and mental component summary (MCS) before bone grafting and at the last follow-up. Results:All the patients were followed up for 13-53 months [(32.3±12.5)months]. One-time iliac bone extraction was successful in all the patients. Bone harvesting time was 15-30 minutes [(21.0±2.5)minutes]. The bleeding volume was 50-120 ml [(62.3±29.0)ml]. The VAS was 1-4 points [(1.2±0.9)points] at 1 day after operation, higher than these (0.0±0.0)points at 1 month after operation and at the last follow-up (all P<0.01). Totally, 25 patients obtained wound healing after operation, except for 1 patient with superficial wound infection after bone grafting that was healed by dressing change. There was 1 patient with bone infection after 3 months of bone grafting that was healed by repeated surgery with Masquelet technique in the first and second stage. Besides, 2 patients had symptoms of cutaneous nerve injury in the iliac donor area. The time of bone healing was 4-7 months [(5.8±0.8)months]. The scores of PCS and MCS in SF-36 at the last follow-up were (73.6±12.8)points and (83.6±13.2)points, significantly higher than those before bone grafting [(46.8±0.5)points, (60.7±2.0)points] (all P<0.01). Conclusion:Second-stage Masquelet technique with 3D printed quantitative bone implants for the treatment of long-segment bone defect following Gustilo type IIIB and IIIC tibial fractures is associated with shortened bone harvesting time, attenuated pain, reduced complications, accelerated bone healing and improved function.
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Objective:To study the clinical efficacy of our modified double reverse traction technique in the treatment of tibial plateau fractures.Methods:A retrospective study was conducted of the 66 patients with tibial plateau fracture who had been treated by our modified double reverse traction technique at Articular Department, Zhongshan Hospital of Traditional Chinese Medicine from March 2019 to December 2021. There were 37 males and 29 females, with an age of (44±14) years. The double reverse traction technique was used in all patients for reduction of the tibial plateau fracture, and their collapsed articular surfaces were restored by our self-designed universal high affinity prying technique, or by fibular graft support, or by the hooping technique to restore the transverse diameter of the tibial plateau which had been widened. The outcomes of fracture reduction at 2 days postoperation were recorded and evaluated by Rasmussen imaging assessment. Complications were also recorded. The visual analog scale (VAS) pain scores and Hospital for Special Surgery (HSS) scores were compared between preoperation, 3 and 6 months postoperation and the rates of fracture healing between 3 and 6 months postoperation.Results:This group of 66 patients was followed up for 12.0(8.0, 16.5) months. The Rasmussen imaging assessment at 2 days postoperation: 60 excellent, 4 good, and 2 fair cases, yielding an excellent to good rate of 97.0% (64/66). At 3 and 6 months postoperation, the VAS scores [1 (0, 1) and 0 (0, 1)] and HSS scores [84 (78, 88) and 91 (85, 95)] were significantly improved compared with those before operation [4 (3, 5) and 36 (29, 39)], and the values at 6 months postoperation were significantly improved compared with those at 3 months postoperation ( P<0.05). The rate of clinical fracture healing at 6 months postoperation (100%, 66/66) was significantly higher than that at 3 months postoperation (77.3%, 51/66) ( P<0.05). Perioperatively, no adverse events were observed like incision infection, deep vein thrombosis of lower limbs, or failure or exposure of internal fixation, except for delayed incision healing in only one patient. Conclusion:In the minimally invasive surgery for tibial plateau fractures, our modified double reverse traction technique can result in excellent fracture reduction by imaging assessment, fine functional recovery of the knee joint and relief of pain.
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Objective:To investigate the therapeutic effects of internal fixation via the posterolateral combined posteromedial approach in the treatment of posterior pilon fracture (Klammer type Ⅲ).Methods:A retrospective study was performed to analyze the 69 posterior pilon fractures (Klammer type Ⅲ) which had been treated by internal fixation with hollow screws or a buttress plate at Department of Orthopaedic Trauma, Yantai Shan Hospital from January 2015 to January 2020. There were 36 males and 33 females with an age of (45.3±10.0) years and duration from injury to surgery of (6.0±1.5) d. They were assigned into 2 groups according to different surgical approaches. The observation group (41 cases) was treated through the posterolateral combined posteromedial approach while the control group (28 cases) through the posterolateral approach alone. The therapeutic effects were evaluated by comparing the 2 groups in terms of incision length, intraoperative bleeding, operation time, fracture union time, fracture reduction (evaluated by the Burrwell-Charnley radiological score), the ankle-hindfoot score of American Orthopaedic Foot and Ankle Society (AOFAS) and complications.Results:There was no significant difference in the preoperative general data between the 2 groups, showing comparability ( P>0.05). All the 69 cases were followed up for (16.9±4.0) months, revealing primary healing of all the incisions and no vascular injury or wound infection. The incision length [(11.2±1.8) cm] and operation time [(76.0±6.6) min] in the observation group were significantly shorter than those in the control group [(12.4±1.9) cm and (79.7±6.8) min], the excellent and good rate of reduction in the observation group (97.6%, 40/41) was significantly higher than that in the control group (89.3%, 25/28), and the ankle-hindfoot scores of AOFAS at 1, 3 and 12 months after operation in the observation group [(78.4±5.6), (79.5±2.8) and (86.9±2.1)] were significantly higher than those in the control group [(75.2±5.5), (78.0±3.2) and (85.8±2.3)] (all P<0.05). There was no significant difference in the intraoperative bleeding between the 2 groups ( P>0.05). In the control group, 2 patients developed numbness in the dorsum of foot, which gradually disappeared after 3 months of treatment, but no other complications like persistent pain or flexor contracture within 1 year after operation. Conclusion:In the treatment of Klammer type Ⅲ posterior pilon fracture, the posterolateral combined posteromedial approach can result in satisfactory therapeutic effects, because the surgical approach can fully expose the fracture and facilitate better reduction.
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Objective:To characterize the injury to the ipsilateral ankle joint after low energy spiral fracture of the distal tibia.Methods:A retrospective study was conducted to analyze the 80 patients with distal tibial spiral fracture who had been treated at Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University from March 2010 to March 2021. There were 61 males and 19 females with an age of (43.5±12.5) years. Their mean follow-up time was 67.0 (38.5, 90.0) months. All patients underwent preoperative X-ray examination, 64 ones preoperative CT examination, and 30 ones preoperative MRI examination. Of the 80 patients, 3 received conservative treatment with plaster external fixation, 3 closed reduction and intramedullary nail fixation, and 74 plate fixation. Statistically analyzed were incidence of posterior malleolus fracture, characteristics of posterior malleolus fracture lines, normal matching rate of the ipsilateral ankle joint, positive rate of intraoperative Cotton test or stress external rotation test of ipsilateral ankle joint, positive rates of passive pronation-external rotation and supination-external rotation stress tests during follow-up, incidences of short-term ankle pain (≤2 years) and medium-long term pain (>2 years) after operation, injuries to the anterior inferior tibiofibular ligament, the deep medial malleolus deltoid ligament and the posterior malleolus, and incidence of ankle injury.Results:The diagnostic rate for posterior malleolus fracture was 16.3% (13/80) on X-ray film, 60.9% (39/64) on CT and 76.7% (23/30) on MRI. 74.5% (35/47) of the posterior malleolus fracture lines opened on the lateral side. The normal matching rate of the ipsilateral ankle joint was 96.3% (77/80). The positive rates of intraoperative Cotton test and stress external rotation test were 34.8% (8/23) and 7.1% (1/14), respectively. The positive rates of passive pronation-external rotation and supination-external rotation stress tests during follow-up were 46.2% (12/26) and 34.6% (9/26). The incidences of postoperative short term (≤2 years) and medium-long term (>2 years) ankle pain were 37.7% (29/77) and 20.8% (16/77). MRI examination showed that the rates of injury to the anterior inferior tibiofibular ligament, deep medial malleolus deltoid ligament and posterior malleolus were 80.0% (24/30), 80.0% (24/30) and 76.7% (23/30). The incidence of ankle injury was 88.8% (71/80).Conclusions:It is highly probable that spiral fracture of the distal tibia is complicated with ipsilateral ankle injury. The medial malleolus, lateral malleolus, and posterior malleolus are prone to the following hidden injuries while the ankle joint is normally matched in the most cases: injury to the deep deltoid ligament in different degrees, rupture of the inferior tibiofibular anterior ligament and posterior malleolus fracture. Therefore, the ankle injury is likely to be missed in diagnosis. The secondary torsion injuries to the pronation-external rotation and supination-external rotation at the leg are likely to cause ipsilateral ankle injury.
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Objective:To investigate the relationship between the CT images of a lateral condylar tibial plateau fractures and complete medial collateral ligament (MCL) injury.Methods:Data of 59 patients with lateral condylar fracture of tibial plateau complicated with MCL injury admitted to Tianjin Hospital from January 2020 to November 2021 were collected, including 32 males and 27 females, aged 42.4±12.3 years (range, 19-65 years), there were 26 cases of extension injury and 33 cases of flexion injury. The patients were separated into two groups: those with partial MCL injury and those with total rupture based on preoperative MR examination and intraoperative valgus stress test following fracture fixation. According to the ABC fracture classification of lateral condyle tibial plateau proposed by Sun et al., the fracture locations were determined on CT images, and the lateral plateau collapse depth (LPD) was measured. The relationship between LPD and MCL complete rupture was analyzed by receiver operating characteristic (ROC) curve.Results:Among 59 patients with lateral condylar tibial plateau fracture and MCL injury, 42 had partial injuries and 17 had complete ruptures. According to the ABC fracture classification, there were 26 cases of extension injury (involving area A), 21 cases of AB type, and 5 cases of ABC type; and 33 cases of flexion type injury, 19 cases of B type, 12 cases of BC type, and 2 cases of C type. All the 17 cases of MCL complete fracture occurred in extension injury, including type AB (14 cases) and type ABC (3 cases). The difference between the mean LPDs of the MCL full rupture group and the partial injury group was not statistically significant ( t=0.11, P=0.567), and the mean LPDs of both groups were 11.7±5.3 mm (range, 4.3-28.1 mm) and 11.5±4.8 mm (range, 3.8-23.6 mm), respectively. The area under the curve (AUC) of the ROC curve analysis was 0.504, and there was no statistical correlation between lateral platform collapse depth and MCL injury. Among the 26 patients with extensional injury area, MCL was completely ruptures in 17 cases and partially injury in 9 cases, LPD was 11.7±5.3 mm (range, 4.3-28.1 mm) and 6.6±1.8 mm (range, 3.8-9.4 mm), respectively, and the difference was statistically significant ( t=3.57, P=0.009). The best predictive cut-off value of LPD was 7.25 mm, the sensitivity was 88.2%, the specificity was 77.8%, and the AUC was 0.868. Conclusion:When the lateral condyle fracture of the tibial plateau is located in the extensional injury area (involving the A area in the ABC fracture classification) and the LPD measured on the CT image is greater than 7.25 mm, the complete rupture of the MCL should be considered. Clinical MCL repair is required after the fracture fixation surgery for improved surgical outcomes.
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Objective:To explore the risk factors associated with tibia fractures in children with congenital anterolateral bowing of the tibia (ALBT).Methods:A retrospective analysis was conducted on data from 87 children diagnosed with ALBT at the Children's Hospital of Hunan Province from January 2012 to January 2020. The collected data included age at initial diagnosis, affected limb side, whether there was a concomitant type I neurofibromatosis, whether there was a concomitant fibular pseudoarthrosis, whether there was concomitant ankle joint deformity, whether there was bone cystic change in the region of tibial bowing deformity, location of the apex of the bowing deformity, diameter of the tibial bowing deformity on the affected side, diameter on the healthy side in the same plane as the tibial bowing deformity, angle of lateral bending deformity of the tibia, angle of anterior bending deformity of the tibia, occurrence of tibia fracture, history of trauma before fracture, location of fracture, and age at the time of fracture. The follow-up endpoint was January 2023. Receiver operating characteristic (ROC) curves were used to determine the optimal cutoff values for the angles of lateral and anterior bending deformity of the tibia and the ratio of cross-sectional areas. The correlation between the above factors and tibial fractures in children was analyzed by single factor survival analysis, and the indicators with statistical significance were included in multivariate Cox proportional risk regression analysis to determine the risk factors for tibial fractures in children with ALBT.Results:Of the 87 children diagnosed with ALBT, the median age at initial diagnosis was 14.0 months (range, 1-93 months), with 42 males and 45 females, 44 left-sided and 43 right-sided cases. The median follow-up time for non-fracture cases was 42.0 months (range, 1-124 months). At the last follow-up, 43 children had experienced fractures, while 44 had not. The average time to fracture-free survival was 70.3 months, the median fracture-free survival time was 55.0 months, and the median survival time without fractures was 42.0 months. The ROC curve results indicated a cutoff value of 25.55° for the lateral bending angle of the tibia and 32.63° for the anterior bending angle of the tibia, with no statistically significant significance for the cross-sectional area ratio [AUC=0.54, 95% CI (0.42, 0.66), P=0.530]. Single-factor analysis of fracture-free survival suggested that there were statistically significant differences in the intergroup fracture-free survival rates of four factors: lateral bending angle of the tibia (χ 2=7.06, P=0.008), anterior bending angle of the tibia (χ 2=8.96, P=0.003), history of trauma (χ 2=18.26, P<0.001), and tibial bone cystic change (χ 2=4.30, P=0.038). The results of the multivariate Cox proportional hazards regression analysis showed that a lateral bending angle of the tibia≥25.55° ( HR=2.73, P=0.007), tibial bone cystic change ( HR=2.35, P=0.018), and history of trauma ( HR=2.65, P=0.004) were all positively correlated with fractures. Conclusion:The main risk factors for tibia fractures in children with ALBT include trauma, tibial bowing deformity with concomitant bone cystic change, and lateral bending angle of the tibia≥25.55°.
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Traumatic orthopedics has entered the minimally invasive era. Minimally invasive is not only the pursuit of "small" surgical incisions, but rather a complete treatment system based on the concepts of reducing secondary injury, individualized treatment, and rapid postoperative rehabilitation. Tibial plateau fracture has complex anatomical, functional properties and fracture characteristics, and it is often difficult to achieve both "anatomical reduction" and "minimally invasive treatment" emphasized in traditional treatment concepts. After more than 40 years of continuous exploration and summary, on the basis of homeopathic reduction theory, the core reduction fixation system using homeopathic bidirectional traction reducers for closed reduction, without opening the joint capsule, without damaging the ligament and meniscus, and minimally invasive fixation for the treatment of tibial plateau fractures has been proposed and has been more and more widely recognized. At the same time, it is necessary to pay attention to whether the fracture line involves the core weight-bearing area, follow the principle of "core area is important, minimally invasive is the first, taking into account reduction" and advocate individualized rehabilitation after surgery to minimize trauma and restore knee joint function. The core reduction fixation system for the treatment of tibial plateau fracture with minimally invasive fixation will certainly lead to more thoughts on minimally invasive and innovative results.
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Objective:To explore the clinical efficacy of double traction-assisted reduction internal fixation and open reduction internal fixation in treating tibial plateau fractures.Methods:Data of patients with tibial plateau fracture admitted to West China Hospital of Sichuan University from January 2016 to December 2021 were retrospectively analyzed, and patients were divided into two groups according to treatment method: double traction-closed reduction internal fixation group (referred to as double traction group) and open reduction internal fixation group (referred to as open group). The double traction group included 21 patients, with 15 male and 6 female patients, with a mean age of 56.14±9.24 years (range, 45-72 years). Schatzker classification of fractures: 1 type I, 2 type II, 2 type III, 5 type IV, 6 type V, and 5 type VI. The open group included 29 patients, with 20 male and 9 female patients, with a mean age of 58.97±4.84 years (range, 47-70 years). Schatzker classification of fractures: 2 type I, 4 type II, 8 type III, 4 type IV, 5 type V, and 6 type VI. The surgical time, incision length, intraoperative blood loss, length of hospital stays, fracture healing time, postoperative time to full weight bearing, Rasmussen score, Hospital for Special Surgery (HSS) knee score, and complications were compared between the two groups of patients.Results:Both groups were followed up for 24 to 36 months, with an average of 30 months. There were significant differences in the operation time (92.61±6.22 min vs. 47.92±9.53 min), incision length (4.54±0.56 cm vs. 6.26±0.51 cm), and intraoperative blood loss (47.05±9.72 ml vs. 156.82±4.62 ml) between the group treated with closed reduction and double traction and the group treated with open reduction, with statistical significance ( t=18.83, 10.78, 53.24, P<0.001). There were also significant differences in the hospitalization time (5.35±0.41 d vs. 5.84±0.78 d), fracture healing time (3.72±0.74 months vs. 4.22±0.42 months), and time to full weight-bearing after surgery (11.29±1.10 weeks vs. 15.07±1.96 weeks) between the two groups, with statistical significance ( t=2.30, P=0.026; t=3.38, P<0.001; t=7.96, P<0.001). The HSS score at 6 months after surgery in the group treated with closed reduction and double traction was 81.61±2.32 points, which was higher than the score in the group treated with open reduction (77.66±4.01 points), with statistical significance ( t=4.07, P<0.001); at 12 months after surgery, the Rasmussen score in the group treated with closed reduction and double traction was 16.71±1.00 points, which was higher than the score in the group treated with open reduction (13.79±1.42 points), with statistical significance ( t=8.05, P<0.001). There was no fracture malunion or compartment syndrome occurred in both groups. The incidence of complications was 5% (1/21) in the group treated with closed reduction and double traction, and 10% (3/29) in the group treated with open reduction, with statistical significance (χ 2=0.52, P=0.473). Conclusion:The advantages of double traction-assisted reduction and internal fixation for tibial plateau fractures include minimal trauma, minimal bleeding, early mobilization, and shorter fracture healing time. It is a safe and reliable treatment method.
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Objective:To compare the clinical efficacy of femoral distraction and homeopathic double reverse traction reduction assisted internal fixation in the treatment of Schatzker type IV-VI tibial plateau fractures.Methods:A total of 51 patients (28 males and 23 females) with Schatzker IV-VI tibial plateau fractures treated with femoral distraction or homeopathic double reverse traction reduction from January 2017 to June 2021 in the Second Affiliated Hospital of Wenzhou Medical University were retrospectively analyzed. The average age was 49.6±11.9 years (range, 28-71 years). The time from injury to operation was 4.5±3.0 days (range, 1-15 days). There were 5 cases with combined anterior cruciate ligament injuries and 9 cases with posterior cruciate ligament injuries. Twenty-five cases were treated with femoral distraction reduction (distraction reduction group) and 26 cases with homeopathic double reverse traction reduction (traction reduction group). The operation time, intraoperative blood loss, visual analogue scale (VAS) on the first day after operation, hospitalization time, fracture healing time, and incidence of complications were compared between the two groups. Hospital for Special Surgery (HSS) knee function score at 1, 3, 6, 12 months after operation were also compared.Results:All patients were operated successfully. The operation time was 125.9±35.1 min (range, 60-220 min), and the intraoperative blood loss was 138.4±85.4 ml (range, 30-400 ml). 15 patients received autologous iliac bone grafting and 36 patients received allogeneic bone grafting. The VAS score on the first day after operation was 2.4±0.7 (range, 1-4), the hospital stay was 12.6±3.6 days (range, 7-24 days), and the fracture healing time was 14.6±2.2 weeks (range, 12-21 weeks). All patients were followed up for 16.8±2.8 months (range, 13-25 months). The operation time, intraoperative blood loss and hospital stay in the traction reduction group were 106.2±21.7 min, 86.9±42.6 ml and 11.6±3.3 days, respectively, which were less than 146.4±34.9 min, 192.0±86.2 ml and 13.7±3.6 days in the distraction reduction group. The differences were statistically significant ( P<0.05). The HSS scores of traction reduction group at 1 month and 3 months after operation were 83.8±1.7 and 86.7±2.0, which were higher than those of distraction reduction group (81.0±2.6 and 84.9±2.6), and the differences were statistically significant ( P<0.05). There was no significant difference in HSS score between the two groups at 6 and 12 months after operation ( P>0.05). Conclusion:The internal fixation treatment of Schatzker type IV-VI tibial plateau fracture assisted with homeopathic double reverse traction reduction can reduce the amount of intraoperative blood loss, operation time and hospital stay, and improve the knee function in the early postoperative period.
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Objective:To investigate the therapeutic effect of bidirectional-traction, Steinmann pin poking reduction,anatomic plate and raft technique in the treatment of hyperextension tibial plateau fractures.Methods:The data of 25 patients with hyperextension tibial plateau fractures admitted to Qilu Hospital of Shandong University (Qingdao) from July 2017 to June 2022 were retrospectively analyzed. According to the treatment methods, they were divided into bidirectional-traction group (treated with bidirectional-traction, Steinmann pin poking reduction, anatomic plate and raft technique) and open reduction group (treated with open reduction, bone grafting and two plates fixation). The bidirectional-traction group included 14 patients, with 8 males and 6 females; the age was 50.29±9.23 years (range, 38-61 years). The cause of the injury was a traffic accident in 4 patients, a fall from height in 7 patients and a fall from standing height in 3 patients. According to Schatzker classification, there were 5 Schatzker type V and 9 type VI fractures. The open reduction group included 11 patients (7 males and 4 females); with a mean age of 58.00±10.58 years (range, 48-69 years). 3 cases were injured by traffic accident, 6 cases by falling from height, and 2 cases by falling from standing height. According to Schatzker classification, there were 4 type V and 7 type VI. Preoperative waiting time, operative time, blood loss and percentage of blood loss, incision length, fracture healing time, tibial posterior inclination, medial proximal tibial angle, visual analogue scale (VAS) on the first day after surgery, Hospital for Special Surgery (HSS) score 6 months after surgery were compared between the two groups.Results:Patients in both groups were followed up for more than 6 months. The follow-up time was 7 to 48 months with an average of 22.76 months. There were significant differences in the preoperative waiting time [6 (4, 8) d vs. 8 (7, 11) d, W=114.00, P=0.043], the incision length [15.0 (12.5, 16.0) cm vs. 30.0 (28.0, 31.0) cm, W=154.00, P<0.001], postoperative VAS [4 (3, 4) points vs. 5 (5, 6) points, W=143.00, P<0.001], blood loss [147 (107, 206) ml vs. 267 (191, 362) ml, W=116.00, P=0.033], blood loss percentage [2.95% (2.58%, 5.20%) vs. 6.40% (4.05%, 7.00%), W=118.00, P=0.027] between the bidirectional-traction group and open reduction group. There were not significant differences in the operation time [120 (118, 120) min vs. 119 (101, 154) min, W=68.50, P=0.656], fracture healing time (8.18±1.03 weeks vs. 8.86±1.27 weeks, t=1.49, P=0.149), HSS score (8.43±3.72 vs. 85.18±7.73, t=1.28, P=0.221) and medial proximal tibial angle 6 months after surgery (87.66°±1.53° vs. 86.47°±2.24°, t=1.57, P=0.130) between the two groups. Postoperative tibial posterior inclination was improved in both groups. There was no significant difference in the tibial posterior inclination before surgery, immediately after surgery and 6 months after surgery (-14.96°±6.44°, 5.55°±1.02°, 5.61°±0.82°) in the bidirectional-traction group and -12.26°±2.93°, 7.07°±3.21° and 7.14°±3.17° in the open reduction group, P>0.05). There were no postoperative complications such as acute compartment syndrome or knee stiffness in both groups. Conclusion:The treatment of hyperextension tibial plateau fracture with bidirectional-traction, Steinmann pin poking reduction, anatomic plate and raft technique can shorten preoperative waiting time, reduce incision length, decrease blood loss and lower VAS. It is a minimally invasive, rapid and effective method, which has achieved good clinical results and is worth promoting.