Removal Rate of the Tomofix® System after High Tibial Osteotomy is Higher Than Reported / A taxa de remoção do sistema Tomofix® após a osteotomia tibial alta é superior à relatada

Abstract Objective Medial open wedge high tibial osteotomy (MOWHTO) significantly relieves pain in the medial joint line in medial compartment osteoarthritis of the knee. But some patients complain of pain over the pes anserinus even 1 year after the osteotomy, which may require implant removal for relief. This study aims to define the implant removal rate after MOWHTO due to pain over the pes anserinus. Methods One hundred and three knees of 72 patients who underwent MOWHTO for medial compartment osteoarthritis between 2010 and 2018 were enrolled in the study. Knee injury and osteoarthritis outcome score (KOOS), Oxford knee score (OKS), and visual analogue score (VAS) were assessed for pain in the medial knee joint line (VAS-MJ) preoperatively, 12 months postoperatively, and yearly thereafter; adding VAS for pain over the pes anserinus (VAS-PA). Patients with VAS-PA ≥ 40 and adequate bony consolidation after 12 months were recommended implant removal. Results Thirty-three (45.8%) of the patients were male and 39 (54.2%) were female. The mean age was 49.4 ± 8.0 and the mean body mass index was 27.0 ± 2.9. The Tomofix medial tibial plate-screw system (DePuy Synthes, Raynham, MA, USA) was used in all cases. Three (2.8%) cases with delayed union requiring revision were excluded. The KOOS, OKS, and VAS-MJ significantly improved 12 months after MOWHTO. The mean VAS-PA was 38.3 ± 23.9. Implant removal for pain relief was needed in 65 (63.1%) of the103 knees. The mean VAS-PA decreased to 4.5 ± 5.6 3 months after implant removal (p < 0.0001). Conclusion Over 60% of the patients may need implant removal to relieve pain over the pes anserinus after MOWHTO. Candidates for MOWHTO should be informed about this complication and its solution.

Resumo Objetivo A osteotomia tibial alta com cunha de abertura medial (MOWHTO, do inglês medial open wedge high tibial osteotomy) alivia de forma significativa a dor na linha articular medial em casos de osteoartrite do compartimento medial do joelho. Alguns pacientes, porém, se queixam de dor nos tendões dos músculos sartório, grácil e semitendinoso (pata de ganso) mesmo 1 ano após a osteotomia, o que pode exigir a remoção do implante. Este estudo define a taxa de remoção do implante após a MOWHTO devido à dor nos tendões dos músculos sartório, grácil e semitendinoso. Métodos Cento e três joelhos de 72 pacientes submetidos à MOWHTO para tratamento da osteoartrite do compartimento medial entre 2010 e 2018 foram incluídos no estudo. A pontuação de desfecho de lesão no joelho e osteoartrite (KOOS, do inglês Knee Injury and Osteoarthritis Outcome Score), a pontuação dejoelho de Oxford (OKS, do inglês Oxford Knee Score) e a escala visual analógica (EVA) de dor na linha articular medial do joelho (EVA-MJ) foram avaliados antes da cirurgia. A EVA nos tendões dos músculos sartório, grácil e semitendinoso (EVA-PA) foi adicionada a essas avaliações, também realizadas 12 meses após o procedimento e, a seguir, anualmente. A remoção do implante foi recomendada em pacientes com EVA-PA ≥ 40 e consolidação óssea adequada em 12 meses. Resultados Trinta e três (45,8%) pacientes eram homens e 39 (54,2%), mulheres. A média de idade foi de 49,4 ±8,0, e o índice de massa corpórea (IMC) médio foi de 27,0 ± 2,9. O sistema placa-parafuso tibial medial Tomofix (DePuy Synthes, Raynham, MA, EUA) foi utilizado em todos os casos. Três (2,8%) casos foram excluídos devido ao retardo de consolidação e à necessidade de revisão. Os resultados nas escalas KOOS, OKS e EVA-MJ melhoraram significativamente 12 meses após a MOWHTO. A EVA-PA média foi de 38,3 ± 23,9. A remoção do implante para alívio da dor foi necessária em 65 (63,1%) dos 103 joelhos. Três meses após a remoção do implante, a EVA-PA média diminuiu para 4,5 ± 5,6 (p < 0,0001). Conclusão A remoção do implante pode ser necessária em mais de 60% dos pacientes para alívio da dor nos tendões dos músculos sartório, grácil e semitendinoso após a MOWHTO. Os candidatos à MOWHTO devem ser informados sobre esta complicação e sua resolução.

Effect of ascorbic acid and epidermal growth factor in a rat tibia defect

Purpose: Bone repair aims to restore the anatomical, biomechanical, and functional integrity of the affected structure. Here we study the effects of ascorbic acid (AA) and epidermal growth factor (EGF) applied in a single dose and in combination on the repair of a noncritical bone defect model. Methods: Twenty-four rats were divided into four groups: an intact G-1 control group, and three groups that underwent a noncritical bone defect in the right tibia: G-2 treated with AA, G-3 treated with EGF, and G-4 treated with AA in combination with EGF. After 21 days of treatment, rats were sacrificed, the tibias were dissected and a destructive biomechanical analysis of three-point flexion test was performed in a universal testing machine; the values of stiffness, resistance, maximum energy, and energy at maximum load were statistically compared. Results: G-3 and G-4 recovered the biomechanical properties of strength and stiffness of an intact tibia 3 weeks after their application. Not so the energy and energy at maximum load. For G-2, only the stiffness of an intact tibia was recovered. Conclusion: EGF and AA-EGF applied to a noncritical bone defect in the rat tibia favors the recovery of bone resistance and stiffness.

Arthroscopic fixation of chronic bicruciate tibial avulsion fractures: A case report / 中华创伤杂志(英文版)

A cruciate ligament avulsion is a much less common form of injury than a cruciate ligament tear. Simultaneous tibial avulsion fractures of both cruciate ligaments occur even more rarely. Over the last decades, many studies have described arthroscopic fixation of acute cruciate tibial avulsion fractures, but arthroscopic treatment in a late presenting patient has not been reported in the literature. This case report presents a 32-year-old female with a chronic tibial avulsion fracture of both anterior cruciate ligament and posterior cruciate ligament. Simultaneous fixation of both fractures was performed arthroscopically at week four post-injury. At one year of follow-up, the patient had demonstrated full knee range of motion and stable knee with no complaints, and achieved excellent clinical outcomes. Radiographs showed union of both fractures, and the patient had resumed high-impact exercises.

Value of personalized osteotomy in primary total knee arthroplasty for severe varus knee osteoarthritis / 中国骨伤

OBJECTIVE@#To explore application value and efficacy of personalized osteotomy in primary total knee arthroplasty (TKA) for severe varus knee osteoarthritis.@*METHODS@#From June 2018 to January 2020, 36 patients (49 knees) with severe varus knee osteoarthritis were treated, including 15 males (21 knees) and 21 females (28 knees), aged from 59 to 82 years old with an average of (67.6 ± 6.5) years old;the course of disease ranged from 9.5 to 20.5 years with an average of (15.0 ± 5.0) years;11 patients (15 knees) with Kellgren-Lawrence grade Ⅲ and 25 patients (34 knees) with grade Ⅳ according to Kellgren-Lawrence grading. According to AORI clsssification of tibial bone defects, 8 patients (15 knees) were typeⅠTa and 16 patients (18 knees) were typeⅡ T2a. All patients' femor-tibial angle (FTA) was above 15°, and received primary TKA with personalized osteotomy. Thirty-three patients (45 knees) were treated with posterior-stabilized (PS) prostheses, 13 patients (15 knees) with PS prostheses combined with a metal pad and extension rod on the tibial side, and 3 patients (4 knees) with legacy constrained condylar knee (LCCK) prostheses. FTA, posterior condylar angle (PCA), medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA) before and after operation at 1 month were measured and compared by using picture archiving and communication systems (PACS). Recovery of lower limbs before and after operation at 12 months was evaluated by American Knee Society Score(KSS), and complications were observed and recorded.@*RESULTS@#All 36 patients (49 knees) were followed up from 15 to 40 months with an average of (23.46±7.65) months. FTA, MPTA were corrected from preoperative (18.65±4.28)° and (83.75±3.65)° to postoperative (2.35±1.46)° and (88.85±2.25)° at 1 month, respectively (P<0.001). PCA was decreased from (2.42±2.16)° before operation to (1.65±1.35)° at 1 month after operation, LDFA improved from (89.56 ± 3.55)° before operation to (91.63±3.38)° at 1 month after operation (P<0.05). KSS increased from (67.58±24.16) before opertion to(171.31±15.24) at 12 months after operation, 14 patients (19 knees) got excellent result, 19 (26 knees) good, and 3 (4 knees) fair.@*CONCLUSION@#Personalized osteotomy is helpful for recovery of axial alignment of lower limbs and correct placement of prosthesis, could effectively relieve pain of knee joint, recover knee joint function.

Correction of tibial multiplanar deformities using single Taylor external fixator combined with biplanar osteotomy / 中国修复重建外科杂志

OBJECTIVE@#To investigate the effectiveness of single Taylor external fixator combined with biplanar osteotomy on correction of tibial multiplanar deformities.@*METHODS@#Between October 2016 and December 2021, 11 patients with tibial multiplanar deformities (20 sides) were treated with single Taylor external fixator and biplanar osteotomy. Of them, 4 were male and 7 were female; the average age ranged from 13 to 33 years (mean, 21.9 years). Diagnosis included rickets severe genu varum deformity (7 cases, 14 sides), rickets severe genu valgum deformity (2 cases, 4 sides), multiple osteochondromatosis calf deformity (1 case, 1 side), neurofibromatosis medial lower leg anterior arch deformity with short of leg (1 case, 1 side). After fibular osteotomy and tibial multiplanar osteotomy, a Taylor external fixator was installed. After operation, the deformities were corrected successively and fixed completely. The osteotomy healed, then the external fixator was removed. Before operation and at 12 months after operation, the full-length X-ray films were taken. The leg-length discrepancy, medial proximal tibial angle (MPTA), lateral distal tibial angle (LDTA), posterior proximal tibial angle (PPTA), anterior distal tibial angle (ADTA), and tibial rotation angle were measured. The degree of lower limb deformity was scored with reference to a customized tibial mechanical axis scoring table.@*RESULTS@#Osteotomy was successfully completed without neurovascular injury and other complications. The external fixator was adjusted for 28-46 days, with an average of 37 days, and the external fixator was worn for 136-292 days, with an average of 169 days. Mild needle infection during the fixation period occurred in 3 sides, refracture at the distal tibial osteotomy in 1 side after removing the external fixator, and nonunion of the distal fibular osteotomy in 1 side. All patients were followed up 369-397 days (mean, 375 days). At 12 months after operation, the lower limb discrepancy decreased, but there was no significant difference ( P>0.05). MPTA, LDTA, PPTA, ADTA, and tibial rotation angle improved, and the differences in LDTA, ADTA, and tibial rotation angle were significant ( P<0.05). The score of lower limb deformity was significantly higher than that before operation ( P<0.05), and the results were excellent in 9 sides, good in 8 sides, fair in 3 sides, with the excellent and good rate of 85%.@*CONCLUSION@#Single Taylor external fixator combined with biplanar osteotomy is effective in the correction of tibial multiplanar deformities.

Establishment of finite element model of varus-type ankle arthritis and biomechanical analysis of different correction models for tibial anterior surface angle / 中国修复重建外科杂志

OBJECTIVE@#To establish the finite element model of varus-type ankle arthritis and to implement the finite element mechanical analysis of different correction models for tibial anterior surface angle (TAS) in supramalleolar osteotomy.@*METHODS@#A female patient with left varus-type ankle arthritis (Takakura stage Ⅱ, TAS 78°) was taken as the study object. Based on the CT data, the three-dimensional model of varus-type ankle arthritis (TAS 78°) and different TAS correction models [normal (TAS 89°), 5° valgus (TAS 94°), and 10° valgus (TAS 99°)] were created by software Mimics 21.0, Geomagic Wrap 2021, Solidworks 2017, and Workbench 17.0. The 290 N vertical downward force was applied to the upper surface of the tibia and 60 N vertical downward force to the upper surface of the fibula. Von Mises stress distribution and stress peak were calculated.@*RESULTS@#The finite element model of normal TAS was basically consistent with biomechanics of the foot. According to biomechanical analysis, the maximum stress of the varus model appeared in the medial tibiotalar joint surface and the medial part of the top tibiotalar joint surface. The stress distribution of talofibular joint surface and the lateral part of the top tibiotalar joint surface were uniform. In the normal model, the stress distributions of the talofibular joint surface and the tibiotalar joint surface were uniform, and no obvious stress concentration was observed. The maximum stress in the 5° valgus model appeared at the posterior part of the talofibular joint surface and the lateral part of the top tibiotalar joint surface. The stress distribution of medial tibiotalar joint surface was uniform. The maximum stress of the 10° valgus model appeared at the posterior part of the talofibular joint surface and the lateral part of the top tibiotalar joint surface. The stress on the medial tibiotalar joint surface increased.@*CONCLUSION@#With the increase of valgus, the stress of ankle joint gradually shift outwards, and the stress concentration tends to appear. There was no obvious obstruction of fibula with 10° TAS correction. However, when TAS correction exceeds 10° and continues to increase, the obstruction effect of fibula becomes increasingly significant.

Early effectiveness of a new minimally invasive plate in treatment of varus-type ankle arthritis / 中国修复重建外科杂志

OBJECTIVE@#To evaluate the early effectiveness of a new minimally invasive plate in the treatment of varus-type ankle arthritis.@*METHODS@#A clinical data of 15 patients with varus-type ankle arthritis who met the selection criteria between March 2021 and October 2021 were retrospectively analyzed. All the patients were treated with medial open-wedge supramalleolar osteotomy and fibular osteotomy. The osteotomies were fixed with the new minimally invasive plate. There were 7 males and 8 females with an average age of 49.8 years (range, 16-71 years). The causes of ankle arthritis included post-fracture deformity in 1 case, sprain in 8 cases, and acquired clubfoot in 1 case; and 5 cases were without obvious factors. The disease duration ranged from 1 to 12 years, with an average of 4.1 years. Comparisons were made between pre-operation and the last follow-up in the Takakura staging, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, foot function index (FFI), visual analogue scale (VAS) score, tibial anterior surface angle (TAS), tibial lateral surface angle (TLS), and talar tilt (TT).@*RESULTS@#All incisions healed by first intention. All patients were followed up 7-18 months (mean, 12.8 months). At last follow-up, the AOFAS ankle-hindfoot score, FFI, VAS score, and Takakura staging significantly improved when compared with the preoperative ones ( P<0.05). X-ray films showed that the osteotomy healed at 3 months after operation. At last follow-up, TAS significantly increased and TT decreased when compared with the preoperative ones ( P<0.05), and the difference in TLS between pre- and post-operation was not significant ( P>0.05). Complications included 1 case of intraoperative screw breakage and 2 cases of nerve injury of the affected foot. None of the patients complained of significant discomfort at the plate placement during follow-up, and no loosening of the internal fixator occurred. Eleven patients were very satisfied with the effeectiveness, while 4 were relatively satisfied.@*CONCLUSION@#The new minimally invasive plate for the varus-type ankle arthritis has good early effectiveness in relieving ankle pain, correcting deformity, improving limb alignment and ankle function, and reducing the incidence of postoperative incisional complications.

Risk factors for contralateral anterior cruciate ligament injury after primary anterior cruciate ligament reconstruction / 中国修复重建外科杂志

OBJECTIVE@#To investigate the risk factors of contralateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction.@*METHODS@#A retrospective review was conducted on the 716 patients with ACL injury who received primary ACL reconstruction surgery and met the selection criteria between January 2012 and September 2018. After a mean follow-up period of 7.6 years (range, 4-10 years), 65 patients (9.1%) experienced contralateral ACL injury (injured group) and 651 patients (90.9%) did not (uninjured group). There was no significant difference in age, body mass index, and preoperative Lachman test degree between groups ( P>0.05). However, the proportion of female in the injured group was significantly higher than that of male ( P<0.05), and the preoperative posterior tibial slope (PTS) was significantly higher than that of the uninjured group ( P<0.05). Using the outcome of contralateral ACL injury as the dependent variable, the clinical data of the patient was first used as the independent variable, and univariate COX regression was used to analyze the prognostic influencing factors. Then, the indicators with differences in univariate COX regression were used as the independent variable, and multivariate COX regression was used to analyze the independent risk factors affecting prognosis. Log-Rank (Mantel-Cox) test was used to test and analyze the occurrence time of contralateral ACL injury in patients of different genders; X-tile software was used to analyze the occurrence time of contralateral ACL injury in patients with different PTS using Log-Rank (Mantel-Cox) test and PTS cut-off values.@*RESULTS@#Univariate COX regression analysis showed that gender and PTS were influence factors for contralateral ACL injury ( P<0.05); further multivariate COX regression analysis showed that female and increased PTS were independent risk factors for contralateral ACL injury ( P<0.05). The Log-Rank (Mantel-Cox) test results showed that the contralateral ACL injury occurred in female at 8.853 (8.600, 9.106) years, which was significantly shorter than that in male [9.661 (9.503, 9.819) years] ( χ 2=20.323, P<0.001). Using X-tile software to analyze the cut-off value of PTS, it was found that the cut-off value of PTS for contralateral ACL injury was 10.92°. According to the Log-Rank (Mantel-Cox) test, it was found that the contralateral ACL injury occurred in 5.762 (4.981, 6.543) years in patients with PTS≥10.92°, which was significantly shorter than patients with PTS<10.92° [9.751 (9.650, 9.853) years]( χ 2 =302.479, P<0.001).@*CONCLUSION@#Female and PTS≥10.92° after primary ACL reconstruction are independent risk factors for contralateral ACL injury.

Conceptos actuales en osteotomías en doble nivel alrededor de la rodilla / Current concepts in double-level osteotomies around the knee

Con la osteotomía en un solo nivel, se puede lograr la corrección del eje de la extremidad en pacientes con deformidades combinadas femoral y tibial, pero de forma simultánea generará una alteración patológica de oblicuidad de la interlínea articular, lo que conducirá a elongación ligamentaria, inestabilidad, degeneración condral y, en última instancia, comprometerá su sobrevida y los resultados funcionales. En virtud del análisis de la literatura más reciente, podemos concluir que existe un número significativo de pacientes que requieren de un procedimiento combinado para lograr un objetivo biomecánico óptimo. La finalidad de una osteotomía en doble nivel alrededor de la rodilla consiste en restablecer la anatomía normal, descargar el compartimiento afectado, normalizar los ángulos mecánicos y la orientación de la interlínea articular. Los ejes fisiológicos pueden restablecerse a través de un análisis preoperatorio exhaustivo, respetando principios biomecánicos y fijación estable con placas bloqueadas. Es un procedimiento demandante y con indicaciones en evolución, que progresivamente se ha instaurado como una alternativa de tratamiento justificada en estudios clínicos y biomecánicos para el manejo de deformidades severas alrededor de la rodilla.

With single-level osteotomy, correction of the limb axis in patients with combined femoral and tibial deformities can be achieved. This correction, however, will generate a pathological alteration in the joint line oblicuity, leading to ligament elongation, instability, joint degeneration and, ultimately, it will compromise the longevity and functional results of the correction. By analyzing the most recent literature, we can conclude that there is a significant number of patients who require a combined procedure to achieve an optimal biomechanical goal. The purpose of a double-level osteotomy around the knee is to restore normal anatomy, unload the affected compartment, normalize the mechanical angles and the orientation of the joint line. Physiological axes can be reestablished by means of a thorough preoperative analysis, observing the biomechanical principles and stable fixation with locked plates. It is a demanding procedure with increasing indications, which has progressively been established in clinical and biomechanical studies as a justified treatment alternative for the management of severe deformities around the knee.

La fijación con tornillo de interferencia tibial cuadrante específico permite un constante desplazamiento de los injertos de tejido dentro de tuneles tibiales mal poscionados: análisis cuantitativo de ligamento cruzado anterior en porcinos / Quadrant specific tibial interference screw fixation allows constant displacement of soft tissue grafts inside misplaced tibial tunnels: a porcine anterior cruciate ligament quantitative assessment study

INTRODUCCIÓN El error técnico más común durante la reconstrucción del ligamento cruzado anterior (LCA) es la ubicación incorrecta del túnel. Es incierto si un túnel tibial mal ubicado puede corregirse en el intraoperatorio. OBJETIVO Medir el desplazamiento del injerto de tejido blando con tornillos de interferencia tibial.MATERIALES Y MÉTODOS Estudio experimental ex vivo en 28 rodillas porcinas. Se cosechó el tendón flexor de la extremidad posterior, que fue duplicado y dimensionado para que pasara a través de un túnel tibial mal posicionado. Las muestras se dividieron en 4 grupos según el cuadrante de entrada (anterior [A], posterior [P], medial [M], o lateral [L]) de un tornillo de interferencia tibial de 9 mm con relación al injerto. Se ubicó una regla milimétrica en la meseta tibial, la cual fue fotografiada con una cámara EOS T6 (Canon Inc., Ota, Tokio, Japón), y la imagen fue digitalizada, y puesta en escala a tamaño. La distancia y dirección de los desplazamientos del injerto se midieron con Adobe Photoshop CC 2019 (San José, CA, EEUU). Se analizaron las diferencias medias entre los grupos por análisis de la varianza (analysis of variance, ANOVA, en inglés) unidireccional. El análisis estadístico se realizó con el programa Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, EEUU), versión 25.0 (p ≤ 0,05)).RESULTADOS La distancias medias de los desplazamientos del injerto fueron similares en todos los grupos: A ­ 4,4 mm; P ­ 4,6 mm; M ­ 4,5 mm; y L ­ 4,3 mm, sin diferencias estadísticamente significativas (p = 0,894). Las direcciones medias de los desplazamientos del injerto también fueron similares entre los 4 grupos: A ­ 176° (desviación estándar [DE]: ± 15,4°); P ­ 165° (DE: ± 16,6°); M ­ 166° (DE: ± 12,1°); y L ­ 169° (DE: ± 10,6°). No se encontraron diferencias estadísticamente significativas (p = 0.42).CONCLUSIONES Independientemente del cuadrante de entrada, se observó un desplazamiento constante del injerto hacia el lado opuesto cuando el tornillo tibial alcanzaba la superficie articular. Relevancia clínica: el tornillo tibial mal posicionado puede corregirse en el intraoperatorio con fijación proximal en cuadrante específico, y debe alcanzar la superficie articular para generar un desplazamiento efectivo del injerto. Sin embargo, no podemos predecir la magnitud de error en todos los túneles mal brocados, que debe ser evaluada caso a caso.

BACKGROUND The most common technical error during anterior cruciate ligament (ACL) reconstruction is incorrect tunnel placement. It remains unclear if a misplaced tibial tunnel may be corrected intraoperatively. AIM To measure the displacement of soft-tissue grafts with tibial interference screws. MATERIALS AND METHODS Ex-vivo experimental study in 28 porcine knees. The flexor tendon of the posterior limb was harvested, doubled and sized to fit through a 9-mm misplaced tibial tunnel. The specimens were divided into 4 groups according to the quadrant of entry (anterior [A], posterior [P], medial [M], or lateral [L]) of a 9-mm tibial interference screw in relation to the graft. A millimetric ruler was placed at the tibial plateau, which was photographed with a an EOS T6 (Canon Inc., Ota, Tokio, Japan) camera, and the image was digitalized and scaled to size. The length and direction of the graft displacements were measured with Adobe Photoshop CC 2019 (San José, CA, US). The mean differences among the groups were analyzed through one-way analysis of variance (ANOVA). The statistical analysis was performed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, US) software, version 25.0 (p 0.05) RESULTS The mean lengths of the graft displacements were similar among the groups: A ­ 4.4 mm; P ­4.6 mm; M ­ 4.5 mm; and L ­ 4.3 mm, without statistically significant differences (p » 0.894). The mean directions of the graft displacements were also similar among the groups: A ­ 176° (standard deviation [SD]: 15.4°); P ­ 165° (SD: 16.6°); M ­ 166° (SD: 12.1°); and L ­ 169° (SD: 10.6°). No statistically significant differences were found (p » 0.42). CONCLUSIONS Regardless of the entry quadrant, constant graft displacement to the opposite side was observed when the tibial screw reached the articular surface. Clinical relevance: a misplaced tibial tunnel may be corrected intraoperatively with a quadrantspecific screw, which must reach the articular surface to produce an effective graft displacement. Nevertheless, we cannot predict the magnitude of this error in every poorly-drilled tibial tunnel; it should be assessed case by case.

Comparative study between intramedullary interlocking nailing and minimally invasive percutaneous plate osteosynthesis for distal tibia extra-articular fractures / 中华创伤杂志(英文版)

PURPOSE@#Treatment of distal tibia fractures poses significant challenge to orthopedic surgeon because of poor blood supply and paucity of soft tissue coverage. There is considerable controversy regarding the superior option of treatment for distal tibia fracture between the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique and intramedullary interlocking (IMIL) nailing for extra-articular distal tibia fractures. The aim of our study is to compare the functional outcome between the two treatment methods.@*METHODS@#This was the prospective comparative study of 100 patients with distal third tibia fractures divided into two groups. The first group of patients were treated with MIPPO technique while the second group of patients were managed by IMIL nailing. Patients were followed up in outpatient department to assess the functional outcomes, malunion, delayed union, nonunion, superficial and deep infection between the two groups. Statistical analyses were performed using the SPSS software (version 16.0).@*RESULTS@#Average malunion (degrees) in the MIPPO group was 5 (3-7) ± 1.41 vs. 10.22 (8-14) ± 2.04 in the IMIL group (p = 0.001). Similarly postoperative knee pain in the IMIL group was 10% vs. 2% in the MIPPO group (p = 0.001). In terms of superficial infection and nonunion, the results were 8% vs. 4% and 2% vs. 6% for the MIPPO and IMIL group, respectively (p = 0.001).@*CONCLUSION@#Both procedures have shown the reliable method of fixation for distal extra-articular tibia fractures preserving the soft tissue, bony vascularity and fracture hematoma that provide a favourable biological environment for fracture healing. Considering the results of the study, we have slightly more preference for the MIPPO technique.

Proximal tibiofibular stabilization by anatomical ligamentoplasty and diaphyseal osteotomy of the fibula / 中华创伤杂志(英文版)

Proximal tibiofibular instability is a rare condition for which treatment is poorly codified. A 21-year-old patient, a leisure sportswoman, presented a post-traumatic anterolateral instability of the proximal tibiofibular articulation without cartilage lesion. We propose an original surgical technique based on a review of the literature that combines an anatomical ligamentoplasty of the proximal tibiofibular joint and a proximal fibular diaphyseal osteotomy to reduce the distal tibiofibular mechanical stresses. This original technique allows a favorable evolution with recovery of professional and sports activities at 6 months.

Coronal curvature of tibial leads to malalignment of tibial prosthesis after total knee arthroplasty / 中国骨伤

OBJECTIVE@#To investigate the effect of tibial coronal curvature on the alignment of tibial prosthesis in patients undergoing total knee arthroplasty (TKA).@*METHODS@#From July 2019 to April 2021, 100 patients with knee osteoarthritis were treated with total knee arthroplasty. Before operation, the full-length films of lower limbs were taken and the tibial bowing angle(TBA) was measured. TBA more than 2° was tibial bending, which was divided into tibial bending group and non bending group. There were 40 cases in tibial bending group, 9 males and 31 females, aged 56 to 84 years old with an average of (69.22±7.10) years. There were 60 cases in the non bending group, 19 males and 41 females, aged from 51 to 87 years old with an average of (70.80±7.21) years. The preoperative tibial length (TL) and medial proximal tibial angle (MPTA) were measured and compared between the two groups. The full-length X-rays of the lower limbs were taken again 3 days to 1 week after operation. The medial angle of the tibial component coronal aligement angle (TCCA) and the outilier rate of force line of the tibial prosthesis were measured and compared between the two groups. Pearson method was used to analyze the correlation between TCCA and age, TCCA and height, TCCA and weight, TCCA and BMI, TCCA and TBA, TCCA and TL, TCCA and MPTA; Spearman method was used to analyze the correlation between TCCA and gender, TCCA and Kellgren-Lawrence(K-L) grade.@*RESULTS@#All 100 patients successfully completed the operation and obtained satisfactory full-length X-rays in standing position. There was no significant difference in TL, MPTA and TCCA between bending group and non bending group(P>0.05). The outilier rate of force line in tibial bending group was 22.5%, and that in non bending group was 6.67%, the difference was statistically significant(P<0.05). The correlation study found that TCCA was strongly correlated with TBA(r=-0.702, P<0.01), weakly correlated with MPTA(r=0.311, P<0.01), and had no correlation with other parameters(P>0.05).@*CONCLUSION@#In patients with knee osteoarthritis undergoing total knee arthroplasty, tibial bending will lead to poor force line of tibial prosthesis. During operation, attention should be paid to osteotomy of proximal tibial vertical tibial mechanical axis and correct installation of prosthesis to avoid poor alignment of prosthesis.

Rotational alignment of the tibial component in total knee arthroplasty:a narrative review / 中华外科杂志

Component malrotation is one of the major causes of failure in total knee arthroplasty.Based on previous researches,Insall line has excessive external rotation tendency.Although Akagi line is the most recognized anatomical axis at present,it still has a certain tendency of internal rotation.The tibial posterior condylar axis is not suitable for symmetrical component and yet the Curve-on-Curve technique is not suitable for anatomic component.In addition,reference to any fixed anatomical markers cannot ensure the rotation consistency of tibiofemoral component in extension position.Although range of motion technique is beneficial to tibiofemoral rotation synchronization,its clinical effect seems to be unstable.Nevertheless,Patients can obtain good postoperative results with all major techniques.Before the recognized "gold standard" is defined,orthopedic surgeons can determine the rotation alignment of tibial component according to their most accustomed surgical method.With a deeper understanding of knee anatomy,biomechanics and kinematics,digital assistive technology may be expected to become a breakthrough in the tibial rotational alignment.

Osteotomia valguizante de tibia aditiva medial: analisis de dos tipos de implante / Valgus tibial osteotomy. Two surgical alternatives

La osteotomía valguizante de tibia es un procedimiento comúnmente utilizado para la corrección del deseje en varo con el objetivo de restaurar el eje neutro. Existen dos alternativas quirúrgicas: osteotomía de apertura y de cierre. Los implantes utilizados para la osteotomía de apertura ofrecen ciertas ventajas y también desventajas. El objetivo de esta nota técnica es describir y comparar dos tipos de implante diseñados para las osteotomías valguizantes de tibia proximal: la placa Puddu y la placa TomoFix™. Nivel de Evidencia: V

The valgus tibial osteotomy is a procedure commonly used for the correction of the varus displacement with the objective of restoring the neutral axis. There are two surgical alternatives, opening and closing osteotomy. The implants used for opening osteotomy offer certain advantages and disadvantages. The objective of this technical note is to describe and compare two types of implants designed for valgus osteotomies of the proximal tibia: the Puddu plate and the TomoFix™ plate. Level of Evidence: V

Double plating technique for fixing tibial plateau leveling osteotomy and modified cranial closing wedge ostectomy of the tibia in a dog with cranial cruciate ligament disease and excessive plateau angle: case report / [Técnica de placa dupla para fixação concomitante da osteotomia de nivelamento do platô tibial e ostectomia modificada em cunha de fechamento cranial da tíbia em um cão com doença do ligamento cruzado cranial e ângulo de platô tibial excessivo: relato de caso]

Tibial plateau leveling osteotomy (TPLO) associated to cranial wedge closing ostectomy (CCWO) has been one of the best options to manage cranial cruciate ligament (CCL) disease and excessive tibial plateau angle (TPA) in large dogs, however, the complication rate is potentially high. It is believed that a more robust fixation is necessary to stabilize them and decrease the risk of implant failure. A 6-year-old male American Pit Bull, weighing 36kg, with 90-day history of right hind limb lameness, was diagnosed with CCL disease. Due to the excessive tibial plateau angle (42°), TPLO was associated with a modified CCWO using a double plating technique. A final TPA of 12° was accomplished, and a restricted level of exercises and physiotherapy were recommended. The patient was followed monthly until the fifth month postoperatively, when radiographic bone consolidation and no lameness were observed. By the date of this submission, 3 years after the procedure, the owner has reported no complications. The double plating technique for fixing TPLO and modified CCWO proved to be effective for the treatment of CrCL deficiency in a large dog with an excessive TPA.(AU)

A osteotomia de nivelamento do platô tibial (TPLO) associada à ostectomia modificada em cunha de fechamento cranial da tíbia (CCWO) tem sido uma das melhores opções para tratamento de cães grandes com doença do ligamento cruzado cranial (DLCCr) e ângulo excessivo do platô tibial, mas o índice de complicações é alto. Acredita-se haver necessidade de fixação mais robusta para reduzir as chances de falha nos implantes. Um cão macho, seis anos, da raça American Pit Bull, 36kg, com histórico de claudicação em membro pélvico direito há 90 dias, foi diagnosticado com DLCCr. Devido ao ângulo excessivo do platô tibial (42°), a osteotomia de nivelamento do platô tibial foi associada à ostectomia modificada em cunha de fechamento cranial da tíbia (CCWO) por meio da técnica de placa dupla. No pós-operatório imediato, identificou-se TPA de 12°; exercícios controlados e fisioterapia foram recomendados e a evolução do quadro foi analisada mensalmente até o quinto mês pós-cirurgia. Com 150 dias de evolução, não houve alterações de locomoção e havia ocorrido completa consolidação radiográfica das osteotomias. Até o momento da submissão deste artigo, três anos pós-procedimento, o tutor relata ausência de complicações, via contato telefônico. Portanto, a técnica modificada mostrou-se eficaz no tratamento da DLCCr.(AU)

Effect of different low-level intensity laser therapy (LLLT) irradiation protocols on the osseointegration of implants placed in grafted areas

Abstract Objective To evaluate the effect of different protocols of low-level intensity laser therapy (LLLT) irradiation on the osseointegration of implants placed in grafted areas. Methodology 84 rats were randomly allocated into six groups: DBB: defect filled with deproteinized bovine bone; HA/TCP: defect filled with biphasic ceramic of hydroxyapatite/β-tricalcium phosphate ; DBB-LI: defect filled with DBB and treated with LLLT after implant placement; HA/TCP-LI: defect filled with HA/TCP and treated with LLLT after implant placement; DBB-LIB: defect filled with DBB and treated with LLLT after graft procedure and implant placement; and HA/TCP-LIB: defect filled HA/TCP and treated with LLLT after graft procedure and implant placement. The bone defects were made in the tibia and they were grafted. After 60 days, the implants were placed. The rats were subsequently subjected to euthanasia 15 and 45 days after implant placement. The pattern of osseointegration and bone repair in the grafted area was evaluated by biomechanical, microtomographic, and histometric analyses. Furthermore, the expression of bone biomarker proteins was assessed. Results The LLLT groups presented higher removal torque, mineralized tissue volume, and a greater degree of osseointegration, especially when LLLT was performed only after implant placement, and these findings were associated with higher expression of BMP2 and alkaline phosphatase. Conclusion LLLT performed on implants placed in grafted areas enhances the osseointegration process.

Percutaneous application of allogeneic adipose-derived mesenchymal stem cell in dogs submitted to minimally invasive plate osteosynthesis of the tibia

ABSTRACT Purpose To evaluate clinical outcome following minimally invasive plate osteosynthesis (MIPO) associated with percutaneous transplantation of allogeneic adipose-derived mesenchymal stem cells (AD-MSC) at the tibial fracture site in dogs. Methods Thirty-six dogs presenting with nonarticular complete tibial fracture were included in this study. All fractures were treated by the same MIPO technique. The animals were divided in group 1 (n = 20) received a percutaneous application of 3 × 106 AD-MSC at the fracture site and group 2 (n = 16) did not receive any adjuvant treatment. Postoperative radiographic examinations were made at 15, 30, 60, 90 and 120 days. Results Fifty-eight percent of the patients were classified as skeletally immature. The median weight of the animals was 18.8 kg. The mean radiographic union time differed statistically between the AD-MSC group (28.5 days) and the control group (70.3 days). Sixty percent of dogs in group 1 and 56.25% of the group 2 were considered immature. Conclusions The use of allogeneic AD-MSC cell therapy and MIPO is a safe, viable and effective technique for promoting bone healing in nonarticular tibial fractures in dogs.

A castor oil plant (Ricinus communis)-derived implant improves the biomechanical properties of noncritical bone defects

ABSTRACT Purpose The biomechanical properties of the polyurethanes implant material derived from castor oil plant (Ricinus communis) were evaluated in a noncritical bone defect model in rat tibia. Methods After three weeks of the implant application, the tibias were tested by means of the biomechanical three-point flexion test and resistance, rigidity, energy at maximum load and maximum energy were evaluated. Nonparametric statistical analysis was performed. Results It was found that the group that received the implant behaved the same as the intact control group and also showed a significant increase in maximum load compared to the spontaneous repair group. Conclusions Our results indicate that the tibias with the implant material in a noncritical bone defect recover normal biomechanical parameters in less time than spontaneously.

Integration of heterologous bone matrix associated with polymethylmethacrylate in induced tibial bone defects. An experimental study in rabbits

ABSTRACT Purpose To analyze and compare the reactions at the interface between the composite, composed of fragmented heterologous mineralized bone matrix (MOMHF) and polymethylmethacrylate (PMMA), and the rabbit's tibias, through macroscopic evaluation and scanning electron microscopy (SEM) in different periods. Methods In this study, 12 New Zealand adult rabbits were used (E1: n = 3, E2: n = 3, E3: n = 3 and E4: n = 3). They had the right tibial defects filled with composite and were evaluated immediately after surgery and at 30, 60, 90, and 120 days. Results The composites were incorporated and integrated into the recipient beds in 100% of the cases, defined by the MOMHF osseointegration and the PMMA fibrointegration, with no sign of infection, migration, or rejection. Conclusions The behavior of the composites in the recipient beds demonstrates that these biomaterials have the potential to be used in bone defect repairs, offering, thus, better quality of life to the orthopedic patient.