Tratamiento mínimamente invasivo/percutáneo de fracturas de pilón tibial con asistencia artroscópica en Hospital Regional de Talca / Minimally invasive/percutaneous treatment of tibial pilon fractures with arthroscopic assistance at the Regional Hospital

Tibial pilon fractures are a complex injury to treat due to the great involvement of soft and bone tissues. The classic surgical treatment is based on open reduction with internal fixation (ORIF), adding morbidity to the soft tissues, increasing the risk of complications. This has motivated the development of minimally invasive and/or percutaneous techniques to reduce complications, and with the advent of arthroscopy, achieve anatomical reductions. METHODS: A retrospective observational study of twelve patients with tibial pilon fractures who were treated in our center with minimally invasive and/ or percutaneous osteosynthesis with arthroscopic support was carried out between January 2019 and June 2021. Fractures were characterized using the AO/OTA classification for tibial pilon. Age, sex, fracture mechanism, exposure and initial management in the emergency department (cast immobilization or external fixation), definitive treatment, complications and clinical and functional evaluation twelve months after definitive osteosynthesis. For this last point, plantar flexion, dorsiflexion and the AOFAS and FAOS Score were measured. RESULTS: The operated patients were 12, 8 were men (67%) and 4 were women (33%). The average age was 49 (17-68) years. The definitive treatment was carried out after an average of 8 days (5-12 days). Surgical treatment schemes were as follows: percutaneous osteosynthesis with medial anatomical plate and arthroscopic support (OPAA), minimally invasive osteosynthesis with cannulated screws and arthroscopic support (OMIAA) and osteosynthesis with external circular guide and arthroscopic support (OTCAA). In the AOFAS Score, three patients had excellent results (≥ 90 points), 6 patients had good results (≥ 80 points) and 3 patients had acceptable results (≥ 70 points). In the FAOS Score, eight patients had over 80% (good results) and 4 patients had over 60% (accep - table results). DISCUSSION: Historically, tibial pilon fractures have been considered non-reconstructable and with poor long-term results. Initially this paradigm changed with the principles of Rüedi for the reconstruction of the tibial pilon and improve the results. ORIF has been widely used until today, it allows achieving an anatomical joint reduction, it allows to give stability and length to the fibula, graft contribution and sta - bilization with the medial plate. Today this concept is changing again, since the emphasis is on the care of the soft tissues to allow a better recovery of the patient and reduce the complications of the classic approach, it is in this context that the appearance of minimally invasive and/or percutaneous techniques with arthroscopic assistance has allowed us to have excellent functional and clinical results with less da - mage to the soft tissues. CONCLUSION: The proper management and care of the soft tissues in a high-energy fracture of the tibial pilon is essential to obtain favorable clinical results and thus achieve restoration of ankle function. Percutaneous and minimally invasive management has optimized management of the tibial pilon, redu - cing the rates of complications, amputation, and pri - mary arthrodesis.

In Vivo Biological Effects of Marine Biosilica on a Tibial Bone Defect in Rats

Abstract Research on biomaterials of natural origin has gained prominence in the literature. Above all, marine sponges, due to their architecture and structural components, present a promising potential for the engineering of bone tissue. In vitro studies demonstrate that a biosilica of marine sponges has osteogenic potential. However, in vivo works are needed to elucidate the interaction of biosilica (BS) and bone tissue. The objective of the study was to evaluate the morphological and chemical characteristics of BS compared to Bioglass (BG) by scanning electron microscopy (SEM) and X-ray dispersive energy (EDX) spectroscopy. In addition, to evaluate the biological effects of BS, through an experimental model of tibial bone defect using histopathological, histomorphometric, immunohistochemical (IHC) and mechanical tests. SEM and EDX demonstrated the successful extraction of BS. Histopathological analysis demonstrated that Control Group (GC) had greater formation of newly formed bone tissue compared to BG and BS, yet BG bone neoformation was greater than BS. However, BS showed material degradation and granulation tissue formation, with absence of inflammatory process and formation of fibrotic capsule. The results of histomorphometry corroborate with those of histopathology, where it is worth emphasizing the positive influence of BS in osteoblastic activity. IHQ demonstrated positive VEGF and TGF-β immunoexpression for GC, BS and BG. In the mechanical test no significant differences were found. The present results demonstrate the potential of BS in bone repair, further studies are needed other forms of presentation of BS are needed.

Principios quirúrgicos en fracturas de platillos tibiales con compromiso de columna posterior / Surgical principles in posterior column tibial plateau fractures

Las fracturas de platillos tibiales son lesiones complejas que incluyen una variedad de patrones morfológicos cada vez mejor caracterizados en la literatura. Históricamente, los esquemas de clasificación se han basado en evaluar los rasgos de fractura en el plano frontal y las técnicas quirúrgicas en lograr la fijación de esos fragmentos, sin tomar en consideración el compromiso óseo que ocurre en la región posterior de los platillos tibiales. Con el advenimiento de la clasificación columnar basada en tomografía computada, se han logrado desarrollar estrategias de fijación optimizada, dando cada vez más relevancia a la columna posterior. Este artículo realiza una revisión extensa de la literatura, otorgando los fundamentos quirúrgicos que explican la importancia del tratamiento específico de la columna posterolateral y posteromedial, con el fin de restablecer la biomecánica normal de la rodilla y el razonamiento quirúrgico de las diversas vías de abordaje específicas para una reducción y osteosíntesis satisfactoria de esos fragmentos.

Tibial plateau fractures are complex injuries which include a variety of morphological patterns that have been increasingly better characterized in the literature. Historically, classifications have focused on description of fracture patterns in the frontal plane, while surgical techniques have focused on reduction of these fragments not considering the osseous defects that occur on the posterior region of the tibial plateau. With new CT scan column based classifications, strategies to optimize fixation have been developed, giving relevance to the posterior column. This article is an exhaustive review of the literature, providing the surgical foundations that explain the importance of specific treatment of the posterolateral and posteromedial column, aiming to restore normal knee biomechanics. Furthermore, this article provides the diverse specific surgical approaches rationale for a satisfactory open reduction and internal fixation of these fragments.

Effects of melatonin on tibia bone defects in rats / Efectos de la melatonina sobre defectos óseos en la tibia de ratas

The aim of this study was to evaluate the effects of melatonin healing in a tibial bone defect model in rats by means of histopathological and immunohistochemistry analysis. Twenty one male Wistar albino rats were used in this study. In each animal, bone defects (6 mm length ) were created in the tibias. The animals were divided into three groups. In group 1 control group (rats which tibial defects). Group 2 melatonin (10 mg/kg) + 14 days in the tibial defect group) was administered intraperitoneally to rats. Group 3 melatonin (10 mg/kg) + 28 days in the tibial defect group) was administered intraperitoneally to rats. Histopathological analysis of samples was performed to evaluate the process of osteoblastic activity, matrix formation, trabecular bone formation and myeloid tissue in bone defects. Immunohistochemical and immunoblot analysis demonstrated non-collagenous proteins (osteopontin and osteonectin) differences in tibial bone defects. The expression of osteopontin on tibia was increased by 14 days melatonin treatment. The expression of osteonectin on tibia was dramatically increased by 14 days melatonin treatment.

El objetivo fue evaluar por medio de análisis histopatológico e inmunohistoquímico los efectos cicatrizantes de la melatonina en un modelo de defecto óseo tibial en ratas. Se utilizaron 21 ratas albinas Wistar macho. En cada animal, se crearon defectos óseos en las tibias de 6 mm de longitud. Los animales se dividieron en tres grupos. El Grupo 1 correspondió al grupo control (defectos tibiales sin tratamiento). Al Grupo 2 se administró melatonina por vía intraperitoneal (10 mg/kg) 14 días posteriores al defecto tibial. Al Grupo 3 se administró melatonina por vía intraperitoneal (10 mg/kg) 28 días posteriores al defecto tibial. Se realizó un análisis histopatológico para evaluar los procesos de actividad osteoblástica, formación de matriz, formación de hueso trabecular y tejido mieloide en los defectos óseos. Los análisis inmunohistoquímicos y de inmunotransferencia mostraron diferencias de proteínas no colágenas (osteopontina y osteonectina). La expresión de osteopontina en defectos óseos tibiales se incrementó en el Grupo 2. La expresión de osteonectina en la tibia se incrementó fuertemente bajo el tratamiento con melatonina por 14 días.

Long Backbone Fracture Caused by Blunt Force: 99 Cases Analysis / 法医学杂志

OBJECTIVE@#To investigate the main point of long backbone fracture caused by blunt force in forensic clinical identification and to provide a reference for the inspection and appraisal practices of such injury.@*METHODS@#Ninety-nine cases of adult long backbone fractures were collected from January 2006 to December 2013 in Gutian County of Fujian Province. According to the terms of fracture location, mode of injury, type, the data were summarized.@*RESULTS@#In the 99 cases, there were 36 cases caused by hitting, kicking, and falling and 63 cases caused by vehicle collision. The majority of the former was ulna, and those of the latter were tibia and fibula. The types of fracture were transverse one, short oblique one, long oblique one, and spiral one.@*CONCLUSION@#Different types of long backbone fracture, not only causing stress load of fractures as well as structural differences related to each segment.

Intra- and interobserver agreement on the Oestern and Tscherne classification of soft tissue injury in periarticular lower-limb closed fractures / Concordancia intra e interobservador de la clasificación de Oestern y Tscherne para lesiones de tejidos blandos en fracturas cerradas periarticulares del miembro inferior

Background: The soft tissues injury in periarticular fractures of the lower extremities determines the proper time to perform bone fixation. Objective: The aim of this study was to determine the intra and interobserver agreement in the Tscherne classification. Methods: This is a descriptive, prospective study for patients admitted to the Pablo Tobón Uribe Hospital (PTUH) with tibial plateau or tibial pilon fractures. We performed a standardize evaluation using video photography at the time of admission and 24, 48, and 72 h after admission. Fifteen five reviewers who had various levels of training produced a total of 1,200 observations. The intra- and interobserver agreement was assessed using a weighted kappa for multiple raters and more than two categories. Results: Twenty patients were admitted with tibial plateau and tibial pilon fractures. The intraobserver agreement for all 15 raters was kappa 0.81 (95% CI 0.79-0.83), and the interobserver agreement for all 15 raters was kappa 0.65 (95% CI 0.55-0.73). The interobserver agreement at 24 h was kappa 0.67 (95% CI 0.46-0.86). Conclusions: Classifying the severity of soft tissue injury is critical in planning the surgical management of fractures of the lower extremities. Based on our results, we can reasonably argue that the Tscherne classification produced an adequate level of agreement and could be used to standardize and to guide the treatment, and to conduct research studies.

Antecedentes: La lesión de los tejidos blandos en fracturas periarticulares del miembro inferior determina el momento adecuado para realizar la fijación ósea. Objetivo: El propósito de este estudio fue determinar la concordancia intra e interobservador para la clasificación de Tscherne. Métodos: Estudio descriptivo, prospectivo en pacientes ingresados al Hospital Pablo Tobón Uribe con fracturas de platillos tibiales o pilón tibial. Se realizó una evaluación estandarizada utilizando videos y fotografías al momento del ingreso y 24, 48 y 72 h después. Quince evaluadores que tenían diferentes niveles de entrenamiento produjeron 1200 observaciones. La concordancia intre e interobservador fue evaluada utilizando kappa ponderado para múltiples evaluadores y más de dos categorías. Resultados: Veinte pacientes fueron admitidos con fracturas de los platillos o del pilón tibial. La concordancia intraobservador para los 15 evaluadores fue kappa 0.81 (95% IC 0.79-0.83), y la concordancia interobservador para los 15 evaluadores fue kappa 0.65 (95% IC 0.55-0.73). La concordancia interobservador a las 24 h del ingreso fue kappa 0.67 (95% IC 0.46-0.86). Conclusión: Clasificar la gravedad de la lesión de los tejidos blandos es un paso fundamental en la planeación del manejo quirúrgico de las fracturas periarticulares del miembro inferior, con base en nuestros resultados podemos afirmar razonablemente que la clasificación de Oestern y Tscherne tiene un nivel de concordancia adecuado y podría utilizarse de forma sistemática para estandarizar la evaluación entre los ortopedistas para orientar el tratamiento y también con fines investigativos.

The use of vancomycin-loaded poly-l-lactic acid and poly-ethylene oxide microspheres for bone repair: an in vivo study

OBJECTIVE: The aim of this study was to investigate bone repair after the implantation of vancomycin-loaded poly-L-lactic acid/poly-ethylene oxide microspheres compared with vancomycin-unloaded poly-L-lactic acid/poly-ethylene oxide microspheres. METHODS: Poly-L-lactic acid/poly-ethylene oxide microspheres were implanted in rat tibiae and evaluated for periods of 2, 4, 8, and 12 days and 4, 8, 16, and 32 weeks. The groups implanted with vancomycin-loaded and vancomycin-unloaded microspheres were compared. Histopathologic (semi-quantitative) and histomorphometric analyses were performed to evaluate the bone formation process. RESULTS: During the first period (second day), fibrin and hemorrhaging areas were observed to be replaced by granulation tissue around the microspheres. Woven bone formation with progressive maturation was observed. All of the histopathological findings, evaluated by a semi-quantitative assay and a quantitative analysis (percentage of bone formation), were similar between the two groups. CONCLUSION: Vancomycin-loaded poly-L-lactic acid/poly-ethylene oxide microspheres are a good bone substitute candidate for bone repair. Local antibiotic therapy using vancomycin-loaded poly-L-lactic acid/poly-ethylene oxide microspheres should be considered after the microbiological evaluation of its efficacy.

Minimally Invasive Plate Osteosynthesis for Open Fractures of the Proximal Tibia

BACKGROUND: Relatively few studies have addressed plate osteosynthesis for open proximal tibial fractures by now. The purpose of this study was to assess the results of minimally invasive plate osteosynthesis (MIPO) for open fractures of the proximal tibia. METHODS: Thirty-four patients with an open proximal tibial fracture were treated by MIPO. Thirty of these, who followed for over 1 year, constituted the subject of this retrospective study. According to the AO Foundation and Orthopaedic Trauma Association (AO-OTA) classification, there were 3 patients of type 41-C, 6 of type 42-A, 8 of type 42-B, and 13 of type 42-C. In terms of the Gustilo and Anderson's open fracture grading system, 11 patients were of grade I, 6 were of grade II, and 13 were of grade III (III-A, 6; III-B, 6; III-C, 1). After thorough debridement and wound cleansing, when necessary, a soft tissue flap was placed. Primary MIPO (simultaneous plate fixation with soft tissue procedures) was performed in 18 patients, and staged MIPO (temporary external fixation followed by soft tissue procedures and subsequent conversion to plate fixation after soft tissue healing) was performed in 12 patients. Results were assessed according to the achievement and time to union, complications (including infections), and function of the knee joint using Knee Society scores. Statistical analysis was performed to identify factors influencing results. RESULTS: Primary union was achieved by 24 of the 30 study subjects. Early bone grafting was performed in 6 cases with a massive initial bone defect expected to result in non-union. No patient had malalignment greater than 10degrees. The mean Knee Society score was 88.7 at final follow-up visits, 23 patients achieved an excellent result, and 7 a good result. There were 3 superficial and 5 deep infections, but none required early implant removal. Functional results were similar for primary and staged MIPO (p = 0.113). Fracture pattern (p = 0.089) and open fracture grade (p = 0.079) were not found to influence the results. CONCLUSIONS: If soft tissue coverage is adequately performed, MIPO could be regarded as an acceptable method for the treatment of open proximal tibial fracture.

Effects of ionizing radiation on bone neoformation: histometric study in Wistar rats tibiae / Efeitos da radiação ionizante na neoformação óssea: estudo histométrico em tíbias de ratos

PURPOSE: Comparing the ionizing radiation effects on bone neoformation of rats tibiae previously submitted to radiotherapy with a single dosage of 30Gy with the contralateral tibiae that have received secondary radiation. METHODS: In thirty male Wistar rats, 30 days before surgical procedure when round defects would be created on the bone, the right tibia was irradiated with 30Gy and the left tibia received a calculated secondary radiation dose of 7Gy. Sacrifices were performed after 4, 7, 14, 21, 56 and 84 postoperative days and both tibiae were removed for histological processing. RESULTS: The left tibiae that received the dose of 7Gy has shown more bone neoformation from 14th postoperative days, giving evidences of less damage to cellular population responsible by bone neoformation. On the other hand, the dose of 30Gyon right tibiae did not exhibit significant differences among the periods, suggesting damage of long-lasting or even permanent duration. CONCLUSION: Tibiae submitted to radiation dose of 30Gy have shown more damage to bone cells than tibiae that received secondary radiation dose of 7Gy, especially observed on 14th, 56th and 84th postoperative days.

OBJETIVO: Comparar os efeitos da radiação ionizante na reparação óssea em tíbias de ratos, submetidas à radioterapia prévia com doses 30Gy, com as tíbias contralaterais que receberam radiação secundária. MÉTODOS: No total, 30 ratos Wistar machos foram submetidos à cirurgia para realização de defeitos circulares em ambas as tíbias de cada rato, com radioterapia prévia de 30 dias, sendo que a tíbia direita recebeu a dose de 30Gy e tíbia esquerda a dose de radiação secundária calculada em 7Gy. Os sacrifícios ocorreram em 4, 7, 14, 21, 56 e 84 dias da realização do defeito ósseo e as tíbias foram removidas para processamento histológico. RESULTADOS: O grupo de 7Gy apresentou maior neoformação a partir do período de 14 dias, indicando pouco dano aos elementos celulares responsáveis pela reparação óssea, enquanto que o grupo de 30Gy não apresentou diferenças significantes entre os períodos, sugerindo um dano de efeito prolongado ou até mesmo permanente. CONCLUSÃO: As tíbias irradiadas com 30Gy apresentaram maior dano às células ósseas do que as tíbias que receberam radiação secundária de 7Gy, principalmente observadas nos períodos de 14, 56 e 84 dias.

Estudo transversal das fraturas diafisárias da tíbia tratadas cirurgicamente no Hospital Independência de Porto Alegre / Transversal study of diaphysial fractures of the tibia treated surgically in the Independência Hospital in Porto Alegre

Introdução: As fraturas da tíbia são comuns. Muitas necessitam tratamento conservador. O trabalho tem como objetivo verificar o perfil epidemiológico das fraturas de tíbia tratadas cirurgicamente. Metodologia: Estudo descritivo transversal através da avaliação epidemiológica em prontuários de 50 pacientes operados no Hospital Independência no período de 5 anos. Resultados: Dos 50 pacientes, 39 (78%) eram do sexo masculino e 11(22%), do feminino. Quanto à idade, observamos que há mais fraturas em pacientes entre 26 e 36 anos (30%). A idade média dos pacientes foi de 37,4 anos, com um desvio-padrão de 14,8 anos. Não houve diferença significativa quando analisamos a idade média entre os sexos. Podemos constatar também que os pacientes operados por fratura de tíbia eram em sua maioria solteiros (52%). Em relação à cor do paciente, observamos que houve prevalência em pacientes da cor negra (50%). Conclusão: As fraturas de tíbia, tratadas cirurgicamente no Hospital Independência entre 2001 e 2005, foram mais frequentes em pacientes jovens e com trauma de alta energia.

Introduction: Tibia fractures are common and often require conservative treatment. This work was designed to determine the epidemiological profile of the fractures of the tibia treated surgically. Methods: A descriptive, transversal study carried out through the epidemiological evaluation of the medical records of 50 patients operated in a 5-year period. Results: Of the 50 patients, 39 (78%) were males and 11 (22%) were females. As for age, it was found that there were more fractures in the 26-36 years bracket (30%). Patient mean age was 37.4 years with a standard deviation of 14.8 years. There was no significant gender difference as the mean age was analyzed. Most of the patients (52%) were single. Also, there was a prevalence of black patients (50%). Conclusion: The tibia fractures treated surgically in the Independência Hospital from 2001 to 2005 were more frequent in patients who were young and had highenergy trauma.

Significance of fracture gap in open tibial fracture

The healing pattern of medial and lateral cortical gap in open transverse or short oblique tibial fractures were retrospectively reviewed in 2 groups; In group A, 16 patients were treated by Judet external fixator in rigid mode. In group B, 6 patients were treated in biocompressive mode, which allowed predominantly longitudinal axial motion. The characteristic healing pattern in group A was gap healing without or with minimal periosteal callus. The healing time and time for consolidation per 1mm gap were significantly longer in medial cortices than lateral ones (p< 0.036, p< 0.024 respectively). In group B, the fractures were healed with periosteal callus. There was no difference in the healing time and the time for consolidation per 1mm gap between the two cortices. The consolidation time per 1mm gap in the medial cortices was significantly longer in group A than group B (p< 0.020). The longitudinal axial motion in open transverse tibial fractures seems to shorten the healing time effectively in the medial cortex.