Fractura triplanar de tibia distal: Reporte de un caso y revisión de la literatura / Triplanar fracture of proximal tibia: A case report and literature review

Las fracturas triplanares de tibia distal, son fracturas complejas caracterizadas por afectación multiplanar, clasificándose como Salter Harris tipo IV, en el periodo de cierre fisiario. Son poco frecuentes, representando el 5-15% de las fracturas pediátricas. El mecanismo de lesión que ocurre con mayor frecuencia, consiste en supinación y rotación externa. La tomografía computarizada es actualmente el Gold Standard para el diagnóstico de este tipo de fractura, nos permite evaluar todos los planos, siendo la radiografía simple insuficiente para el diagnóstico ya que puede pasar desapercibida. Paciente de 14 años de edad con fractura triplanar en 2 partes de tibia distal, con resolución quirúrgica. Nuestro caso es un ejemplo de una fractura triplanar de tibia distal, la cual es de baja frecuencia, difícil diagnostico e interpretación. Presentamos imágenes preoperatorias, intraoperatorias y postoperatorias del manejo de esta lesión, obteniendo resultados satisfactorios clínicos, funcionales y en estudios de imágenes. Es indispensable lograr una reducción anatómica de la superficie articular para lograr una evolución satisfactoria. Se recomienda una tomografía computarizada para diagnosticar y manejar esta lesión de manera adecuada. El seguimiento postoperatorio es crucial para el manejo de este paciente, ya que se espera una discrepancia en la longitud de las extremidades y/o deformidad(AU)

Triplane fractures of the distal tibia are complex fractures characterized by multiplane effects. They are classified in the Salter-Harris system as type IV in the period of physeal closure. These fractures are rare and represent 5-15% of pediatric fractures. The most common mechanism of injury is supination and external rotation. Computed tomography is currently the Gold Standard for the diagnosis of this type of fracture since it allows us to evaluate all planes, while plain radiography is insufficient because the fracture can go unnoticed. The objective is to report the clinical case of a 14-year-old patient with triplanar fracture in 2 parts of the distal tibia with surgical resolution. This case is an example of a triplanar fracture of the distal tibia, which is of low frequency, and difficult to diagnose and interpret. Preoperative, intraoperative and postoperative images of the management of this lesion are presented, obtaining satisfactory clinical, functional and imaging study results. It is essential to achieve an anatomical reduction of the joint surface to achieve a satisfactory evolution. A CT scan is recommended to properly diagnose and manage this injury. Postoperative follow-up is crucial for the management of this patient, as a limb length discrepancy and/or deformity is expected(AU)

Outcomes of the Carlson Approach in the Treatment of Posterior Tibial Plateau Fractures / Resultados da abordagem de Carlson para o tratamento de fraturas no platô tibial posterior

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.

Establishment and evaluation of rabbit model of closed tibial fracture / 中国骨伤

OBJECTIVE@#To explore the effect of a modified three-point bending fracture device for establishing a rabbit model of closed tibial fracture.@*METHODS@#The model of closed tibial fracture was established in 40 6-month-old male New Zealand white rabbits with a body weight of 2.5 to 3.0 kg, and the model was verified at 6 weeks after operation. Five rabbits underwent pre modeling without temporary external fixation before modeling, and then were fractured with a modified three-point bending fracture device;35 rabbits underwent formal modeling. Before modeling, needles were inserted, and splints were fixed externally, and then the fracture was performed with a modified three-point bending fracture device. The fracture model and healing process were evaluated by imaging and histopathology at 2 hours, 4 weeks, and 6 weeks after operation.@*RESULTS@#Two hours after modeling, the prefabricated module showed oblique fracture in varying degrees and the broken end shifted significantly;Except for 1 comminuted fracture, 2 curved butterfly fractures and 2 without obvious fracture line, the rest were simple transverse and oblique fractures without obvious displacement in formal modeling group. According to the judgment criteria, the success rate of the model was 85.71%. Four weeks after modeling, the fixed needle and splint of the experimental rabbits were in good position, the fracture alignment was good, the fracture line was blurred, many continuous callus growths could be seen around the fracture end, and the callus density was high. Six weeks after modeling, many thick new bone trabeculae at the fracture, marginal osteoblasts attached, and a small number of macrophages were seen under the microscope. The intramembrane osteogenesis area was in the preparation bone stage, the medullary cavity at the fracture had been partially reopened, the callus was in the absorption plastic stage, and many osteoclasts were visible. The X-ray showed that the fracture line almost disappeared, part of the medullary cavity had been opened, the external callus was reduced around, the callus was in the plastic stage, and the bone cortex was continuous. It suggests that the fracture model showed secondary healing.@*CONCLUSION@#The improved three-point bending fracture device can establish a stable rabbit model of closed tibial fracture, and the operation is simple, which meets the requirements of closed fracture model in basic research related to fracture healing.

Development and clinical application of a new reduction device for the treatment of tibial plateau fracture under arthroscopic monitoring / 中国骨伤

OBJECTIVE@#To develop a reduction device for the arthroscopy-assisted treatment of tibial plateau fracture and explore its clinical efficacy.@*METHODS@#From May 2018 to September 2019, 21 patients with tibial plateau fracture were treated, including 17 males and 4 females. Their ages ranged from 18 to 55 years old with an average of (38.6±8.7) years old. There were 5 cases of Schatzker typeⅡand 16 cases of Schatzker type Ⅲ. The self-designed reductor combined with arthroscope was used for auxiliary reduction and fixation(minimally invasive percutaneous plate osteosynthesis). The efficacy was analyzed by observing the operation time, blood loss, fracture healing time and knee function(HSS and IKDC scoring criteria).@*RESULTS@#All the 21 patients were followed up for 8 to 24 with an average of(14.0±3.1) months. The operative time ranged from 70 to 95 min with an average of(81.7±7.6)min, incision length ranged from 4 to 7 cm with an average of(5.3±0.9) cm, intraoperative blood loss ranged from 20 to 50 ml with an average of(35.3±5.2) ml, postoperative weight-bearing time ranged from 30 to 50 d with an average of(35.1±9.2) d, fracture healing time ranged from 65 to 90 d with an average of(75.0±4.4) d, and complications were 0 cases, respectively. The fracture was well healed and no screw plate fracture was observed. The knee function scores of HSS and IKDC 18 months after operation were significantly higher than those before operation(P<0.05).@*CONCLUSION@#The custom-made reduction tool for the arthroscopic management of tibial plateau fracture is reasonable in design and simple in operation. The specific reduction tool could effectively reduce the fracture, and shorten the fixation time with minimally invasive procedure.

Treatment analysis of complex Schatzker type Ⅳ tibial plateau fractures / 中国骨伤

OBJECTIVE@#To explore treatment strategy for complex Schatzker Ⅳ tibial plateau fracture.@*METHODS@#Forty-one patients with complex Schatzker type Ⅳ tibial plateau fractures were treated from January 2016 to January 2021, including 28 males and 13 females, aged from 19 to 65 years old with an average of (35.3±19.8) years old. Individualized treatment plan was developed according to preoperative imaging characteristics, medial surgical approach was mainly combined with other auxiliary incisions. Posteromedial inverted L approach was used in 18 patients, posteromedial approach and anterolateral extended approach in 19 patients, and posteromedial approach with anterolateral and lateral condylar osteotomy in 4 patients. Articular surface and facture healing were observed, range of knee joint motion was measured at 12 months after opertaion, and function of knee joint was evaluated by Lysholm scoring system.@*RESULTS@#Forty-one patients were followed up for 12 to 26 months with an average of (13.3±6.8) months. Twenty-nine patients and 10 patients were obtained complete fracture healing at 6 and 12 months after operation respectively, and fracture healing time was 4 to 13 months with an average of (5.0±3.7) months. Two patients occurred posterior medial internal fixation failure and varus deformity of knee joint, and the fracture healed and varus deformity was corrected after the second operation. Range of knee joint motion was (118±29) °, and Lysholm score was(83.0±16.0) points.@*CONCLUSION@#Individualized treatment should be reasonably selected for complex Schatzker Ⅳ tibial plateau fractures, the characteristics of lateral plateau fractures are an important reference for selecting surgical approaches, the effective fixation of posteromedial bone blocks should be pay full attention, and the overall treatment results are satisfied.

Effectiveness of arthroscopic binding fixation using suture through single bone tunnel for posterior cruciate ligament tibial insertion fracture in adults / 中国修复重建外科杂志

OBJECTIVE@#To explore the effectiveness of arthroscopic binding fixation using suture through single bone tunnel for posterior cruciate ligament (PCL) tibial insertion fractures in adults.@*METHODS@#Between October 2019 and October 2021, 16 patients with PCL tibial insertion fractures were treated with arthroscopic binding fixation using suture through single bone tunnel. There were 11 males and 5 females with an average age of 41.1 years (range, 26-58 years). The fractures were caused by traffic accident in 12 cases and sports in 4 cases. The time from injury to operation ranged from 2 to 10 days with an average of 6.0 days. The fractures were classified as Meyers-McKeever type Ⅱ in 4 cases and type Ⅲ in 9 cases, and Zaricznyi type Ⅳ in 3 cases. There were 2 cases of grade Ⅰ, 7 cases of grade Ⅱ, and 7 cases of grade Ⅲ in the posterior drawer test. There were 3 cases combined with lateral collateral ligament injury and 2 cases with meniscus injury. The visual analogue scale (VAS) score, Lysholm score, International Knee Documentation Committee (IKDC) score, and knee range of motion were used to evaluate knee joint function. The posterior drawer test and knee stability tester (Kneelax 3) were used to evaluate knee joint stability. The X-ray films were used to evaluate fracture reduction and healing.@*RESULTS@#All incisions healed by first intention after operation. There was no incision infection, popliteal neurovascular injury, or deep venous thrombosis of lower limbs. All patients were followed up 6-12 months, with an average of 10 months. X-ray films at 6 months after operation showed the fractures obtained bone union. There were 11 cases of grade 0, 4 cases of gradeⅠ, and 1 case of grade Ⅱin posterior drawer test, showing significant difference when compared with preoperative results ( Z=23.167, P<0.001). The VAS score, Lysholm score, IKDC score, knee range of motion, and the results of Kneelax3 examination all significantly improved when compared with preoperative results ( P<0.05).@*CONCLUSION@#For adult patients with PCL tibial insertion fractures, the arthroscopic binding fixation using suture through single bone tunnel has the advantages of minimal trauma, good fracture reduction, reliable fixation, and fewer complications. The patient's knee joint function recovers well.

A comparative study of absorbable screw fixation and absorbable screw combined with suture anchor fixation in treatment of avulsion fracture of posterior cruciate ligament at tibial insertion of knee joint / 中国修复重建外科杂志

OBJECTIVE@#To compare the effectiveness of open reduction of posterior cruciate ligament (PCL) avulsion fracture at tibial insertion of knee joint with absorbable screws fixation and absorbable screw combined with suture anchor fixation.@*METHODS@#The clinical data of 26 patients with PCL avulsion fracture at tibial insertion who met the selection criteria between March 2015 and October 2021 were retrospectively analyzed. Among them, 14 patients were fixed with simple absorbable screw (group A), and 12 patients were fixed with absorbable screw combined with suture anchors (group B). All patients were confirmed by X-ray film, CT, or MRI preoperatively, and got positive results in preoperative posterior drawer tests. There was no significant difference in gender, age, side of affected limb, time from injury to operation, comorbidities, and preoperative Meyers & McKeever classification, Lysholm score, and International Knee Documentation Committee (IKDC) score between the two groups ( P>0.05). The operation time and postoperative complications were recorded and compared between the two groups. At last follow-up, Lysholm score and IKDC score were used to evaluate the improvement of knee function.@*RESULTS@#There was no significant difference in operation time between the two groups ( P>0.05). All incisions healed by first intention, and no complication such as vascular and nerve injury or venous thrombosis occurred. All 26 patients were followed up 9-89 months, with an average of 55.3 months. The follow-up time of group A and group B was (55.7±23.2) and (56.8±29.3) months, respectively, with no significant difference ( t=-0.106, P=0.916). Radiographs showed bone healing in both groups at 3 months after operation, and no complication such as infection and traumatic arthritis occurred. At last follow-up, the posterior drawer test was negative in both groups, and the Lysholm score and IKDC score significantly improved when compared with the pre-operative values ( P<0.05). However, there was no significant difference in the improvement value between the two groups ( P>0.05).@*CONCLUSION@#For PCL avulsion fracture at tibial insertion of the knee joint, the open reduction and absorbable screw combined with suture anchor fixation can achieve reliable fracture reduction and fixation, which is conducive to the early rehabilitation and functional exercise, and the postoperative functional recovery of the knee joint is satisfactory.

Osteotomy of non-core weight-bearing area of the lateral tibial plateau, reduction, and internal fixation in treatment of tibial plateau fractures involving posterolateral column collapse / 中国修复重建外科杂志

OBJECTIVE@#To investigate the effectiveness of osteotomy of non-core weight-bearing area of the lateral tibial plateau, reduction, and internal fixation in the treatment of tibial plateau fractures involving posterolateral column collapse.@*METHODS@#A clinical data of 23 patients with tibial plateau fractures involving posterolateral column collapse, who had undergone osteotomy of non-core weight-bearing area of the lateral tibial plateau, reduction, and internal fixation between January 2015 and June 2021, was retrospectively analyzed. There were 14 males and 9 females with an average age of 42.6 years ranging from 26 to 62 years. The causes of injury included traffic accident in 16 cases, falling from height in 5 cases, and other injuries in 2 cases. According to Schatzker classification, there were 15 cases of type Ⅴ and 8 cases of type Ⅵ. The time from injury to operation was 4-8 days with an average of 5.9 days. The operation time, intraoperative blood loss, fracture healing time, and complications were recorded. The depth of articular surface collapse of posterolateral column and posterior inclination angle (PSA) of the tibial plateau were compared before operation and at 2 days and 6 months after operation; fracture reduction of tibial plateau fracture was evaluated by Rasmussen anatomic score. The recovery of knee function was evaluated by Hospital for Special Surgery (HSS) score at 2 days and 6 months after operation.@*RESULTS@#All 23 patients were completed the operation successfully. The operation time was 120-195 minutes, with an average of 152.8 minutes; the intraoperative blood loss was 50-175 mL, with an average of 109.5 mL. All patients were followed up 12-24 months, with an average of 16.7 months. One patient had superficial wound infection after operation, and the incision healed after dressing change; primary healing of incision of other patients was obtained. The fracture healing time was 12-18 weeks, with an average of 13.7 weeks. No failure of internal fixation, varus and valgus deformity of the knee joint, and instability of the knee joint was found at last follow-up. One patient developed joint stiffness and the range of motion of the knee joint was 10°-100°; the range of motion of the knee joint of other patients was 0°-125°. At 2 days and 6 months after operation, the depth of articular surface collapse of posterolateral column, PSA, and Rasmussen anatomic scores significantly improved when compared with those before operation ( P<0.05). There was no significant difference between the two postoperative time points ( P>0.05). The HSS score at 6 months after operation was significantly higher than that at 2 days after operation ( P<0.05).@*CONCLUSION@#For tibial plateau fractures involving posterolateral column collapse, reduction and internal fixation through osteotomy of non-core weight-bearing area of the lateral tibial plateau has the advantages of fully expose the posterolateral column fragment, good articular surface reduction, sufficient bone grafting, and fewer postoperative complications. It is beneficial to restore knee joint function and can be widely used in clinic.

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.

Fracturas del platillo tibial con hundimiento articular. Comparación entre reconstrucción con injertos óseos y sustitutos sintéticos. Revisión bibliográfica sistematizada / Depressed tibial-plateau fractures, a comparison between bone graft reconstruction and synthetic substitutes. Systematic bibliographic review / Fraturas do platô tibial com afundamento da articulação: comparação entre reconstrução com enxerto ósseo e substitutos sintéticos

Objetivo: comparar si existe diferencia en resultados clínicos, radiológicos y funcionales con el uso de diferentes tipos de injertos óseos o sustitutos sintéticos, así como tiempo quirúrgico y consolidación para el tratamiento de fracturas de platillo tibial con hundimiento articular en pacientes mayores de 18 años. Material y método: se realizó una búsqueda sistematizada en bases de datos de literatura médica, PubMed, Lilacs, Scielo, Cochrane y portal Timbó. Se utilizaron términos "tibial plateau fracture", "bone grafting", "bone substitutes". Se incluyeron estudios comparativos en seres humanos, pacientes mayores de 18 años, fracturas de platillo tibial que asociaron hundimiento articular, en los cuales se realizó aporte de injerto óseo o material sintético. Artículos en español, inglés, portugués. Publicaciones enero 1980 y diciembre 2021. Se obtuvieron 10 artículos. Resultados: los tipos de injertos y sustitutos óseos encontrados fueron 10. Las muestras en sumatoria total 524 pacientes. La edad promedio fue 49 años. El promedio de seguimiento fue de 12 meses. Se dividieron los estudios en tres grupos: comparación entre injerto autólogo (IOA) e injerto alogénico, IOA con sustitutos sintéticos, y los que comparan sustitutos sintéticos entre sí. El aloinjerto y los sustitutos sintéticos demostraron no ser inferiores en resultados clínicos, funcionales e imagenológicos, mejorando los tiempos intraoperatorios y disminuyendo complicaciones en el sitio donante con respecto al IOA. Conclusiones: el IOA continúa siendo el gold standard a pesar de sus posibles complicaciones vinculadas al sitio donante. El aloinjerto y los sustitutos sintéticos representan una opción válida para tratar estas lesiones.

Objective: to find out whether there are clinical, radiological and functional differences when using different types of bone grafts or synthetic substitutes, as well as surgical times and consolidation to treat depressed tibial-plateau fractures in patients older than 18 years old. Method: a systematized search was conducted in medical literature, PubMed, Lilacs, Scielo, Cochrane and Timbó portal databases using the following terms: "tibial plateau fracture", "bone grafting", "bone substitutes". The study included comparative studies in human patients older than 18 years old with depressed tibial-plateau fractures who were treated with bone grafts or synthetic materials. Publications in Spanish, English and Portuguese, between January, 1980 and December, 2021 were included in the search, what resulted in 10 articles found. Results: there were 10 kinds of bone grafts and bone substitutes found. Samples added up to 524 patients. Average age was 49 years old. Average follow up was 12 months. Studies were divided into 3 groups: comparison between autologous bone grafts and allogenic bone grafts, comparison between autologous grafts and synthetic substitutes and studies comparing synthetic substitutes with one another. Allogenic grafts and synthetic grafts proved at least equivalent in terms of clinical, functional and imaging studies results, improving intraoperative times and reducing complications in donor site when compared to autologous grafts. Conclusions: autologous grafts continue to be the gold standard despite possible complications associated to the donor site, and allogenic grafts and synthetic substitutes constitute a valid option to treat these lesions.

Objetivo: comparar os resultados clínicos, radiológicos e funcionais com o uso de diferentes tipos de enxertos ósseos ou substitutos sintéticos, bem como tempo cirúrgico e consolidação para o tratamento de fraturas do platô tibial com colapso articular em pacientes com mais de 18 anos. Material e método: foi realizada busca sistemática nas bases de dados da literatura médica, PubMed, Lilacs, SciELO, Cochrane e portal Timbó. Utilizaram-se os termos "tibial plateau fracture", "bone grafting", "bone substitutes". Foram incluídos estudos comparativos incluindo seres humanos maiores de 18 anos e fraturas do platô tibial associadas a colapso articular, nas quais foi realizado enxerto ósseo ou sintético, publicados entre janeiro de 1980 e dezembro de 2021 em espanhol, inglês e português. Foram obtidos 10 artigos. Resultados: foram identificados 10 tipos de enxertos e substitutos ósseos. 524 pacientes com idade média de 49 anos foram estudados. O seguimento médio foi de 12 meses. Os estudos foram divididos em 3 grupos: comparação entre enxerto autólogo (IOA) e enxerto alogênico, IOA com substitutos sintéticos e substitutos sintéticos entre si. O aloenxerto e os substitutos sintéticos mostraram-se não inferiores nos resultados clínicos, funcionais e de imagem, melhorando os tempos intraoperatórios e reduzindo as complicações da área doadora em relação à IOA. Conclusões: o IOA continua a ser o padrão ouro apesar de suas possíveis complicações relacionadas ao local doador; tanto o aloenxerto como os substitutos sintéticos representam uma opção válida para tratar essas lesões.

Compresión-distracción en el tratamiento de pseudoartrosis de tibia distal utilizando el aparato de Ilizarov: reporte de casos / Compression-distraction in the treatment of distal tibial no union using the Ilizarov apparatus: case report / Compressão-distração no tratamento da pseudoartrose distal da tibia com Ilizarov: relato de caso

El método de Ilizarov, con sus diferentes variantes y mediante la utilización de su aparato, desarrollado en la década del 50, continúa vigente, sobre todo en el tratamiento de las complicaciones de fracturas, principalmente aquellas vinculadas a la infección y a las dificultades de la consolidación. Reportamos 2 pacientes adultos con diagnóstico de pseudoartrosis hipertrófica, rígida, con deformidad, sin infección activa y sin dismetría, tratados mediante el método de distracción y compresión realizado con el aparato de Ilizarov. En ambos casos se logró la alineación y consolidación del miembro con escasas complicaciones.

The Ilizarov method, with its different variants and using its apparatus, developed in the 1950s, is still valid, especially in the treatment of fracture complications, mainly those linked to infection and consolidation difficulties. We report 2 adult patients with a diagnosis of hypertrophic, rigid nonunion, with deformity, without active infection and without dysmetria, treated by the distraction and compression method performed with the Ilizarov device. In both cases, the alignment and consolidation of the limb was achieved with few complications.

O método de Ilizarov, com suas diferentes variantes e pelo uso de seu aparato, desenvolvido na década de 1950, ainda é válido, principalmente no tratamento de complicações de fraturas, principalmente aquelas ligadas à infecção e dificuldades de consolidação. Relatamos 2 pacientes adultos com diagnóstico de pseudoartrose hipertrófica, rígida, com deformidade, sem infecção ativa e sem dismetria, tratados pelo método de distração e compressão realizado com o dispositivo de Ilizarov. Em ambos os casos, o alinhamento e a consolidação do membro foram alcançados com poucas complicações.

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.

Enclavado endomedular suprarrotuliano vs. infrarrotuliano en el tratamiento de fracturas diafisarias y distales de tibia: análisis comparativo y técnica quirúrgica / Suprapatellar vs. infrapatellar intramedullary nailing for the treatment of distal and diaphyseal tibial fractures: Comparative analysis and surgical technique

Introducción: Las fracturas diafisarias y distales de tibia son lesiones frecuentes en personas jóvenes que sufren un trauma de alta energía y en ancianos por un trauma de baja energía. El objetivo de este estudio fue comparar el tiempo quirúrgico, el uso de radioscopia, la evaluación funcional y el dolor en el tratamiento de fracturas diafisarias y distales de tibia mediante una técnica suprarrotuliana y una infrarrotuliana. Materiales y métodos: Se realizó un estudio retrospectivo entre marzo de 2018 y octubre de 2019. La información de los pacientes se obtuvo de la historia clínica electrónica. Se incluyó a pacientes con fracturas diafisarias y distales de tibia. Se estudiaron y compararon los tiempos de radioscopia y de cirugía. El dolor posoperatorio se evaluó mediante la escala analógica visual y la función, con el puntaje de Lysholm. Resultados:Ochenta pacientes cumplían con los criterios de inclusión. Sus datos sociodemográficos fueron pareados en dos grupos similares. Treinta y seis pacientes fueron tratados con la técnica infrarrotuliana y 44, con la técnica suprarrotuliana. Se obtuvieron diferencias estadísticamente significativas en el tiempo de cirugía, el tiempo de radioscopia y en el puntaje de la escala analógica visual para dolor al año. Conclusiones: Los resultados mostraron un menor tiempo de cirugía y de radioscopia, y mejores resultados en la escala analógica visual para dolor con la técnica suprarrotuliana para el tratamiento de las fracturas mediodiafisarias y distales de tibia. Nivel de Evidencia: III

Introduction: Fractures of the medial and distal tibial segment often occur in young patients with high-energy trauma and older patients with low-energy trauma. The objective of this study is to compare the time of surgery, time of use of fluoroscopy, functional outcomes, and postoperative pain in patients treated with the suprapatellar vs. infrapatellar technique for tibial nailing. materials and methods: We carried out a retrospective study between March 2018 and October 2019. All the data was collected from the electronic clinical record (ECR). We included patients with diaphyseal and distal tibial fractures. The variables analyzed were: fluoroscopy and surgery time, pain evaluation, and functional outcomes of the patients using the Lysholm score. Results: 80 patients met all the inclusion criteria. Sociodemographic data were divided into 2 similar groups. The suprapatellar approach was used in 44 patients and the infrapatellar in 36 of them. A statistical difference was obtained in the analysis for the time of surgery, use of fluoroscopy, and pain evaluation in favor of the suprapatellar technique. Conclusions: The results of our study showed shorter surgery and fluoroscopy times with the use of the suprapatellar technique compared with the infrapatellar technique. The suprapatellar technique also yielded better pain results in the visual analog scale. Level of Evidence: III

Enclavado endomedular en fracturas de tibia. ¿Existe una relación entre el punto de entrada para la inserción del clavo y su alineación final? / Intramedullary nailing of tibial fractures. Is there a relationship between the entry point and its final alignment?

Introducción: Las fracturas de tibia representan aproximadamente el 2% de las fracturas del adulto. El enclavado endomedular es hoy el procedimiento de elección para tratar fracturas diafisarias de tibia; sin embargo, esta técnica no está exenta de complicaciones, la desalineación en el plano coronal es una de las más frecuentes y temidas por los cirujanos. El objetivo de este estudio fue investigar la relación entre el punto de entrada del clavo y la desalineación en el plano coronal después de la cirugía. Materiales y Métodos: Se realizó un estudio retrospectivo, descriptivo, observacional, entre enero de 2015 y enero de 2019, de pacientes con fracturas diafisarias de tibia, tratadas con clavo endomedular. Se obtuvieron radiografías en el posquirúrgico inmediato y luego cada dos meses, se tuvo en cuenta la radiografía del octavo mes, en la que se observaban signos francos de consolidación ósea, para valorar la alineación tibial. Resultados:Cuando el punto de entrada del clavo fue central, hubo apenas un 0,021 de posibilidades (o 2,1%) de alguna desalineación significativa en el posquirúrgico inmediato y luego de 8 meses. En cambio, cuando fue medial, las posibilidades de una tendencia al valgo fueron >0,85 (u 85%) ya al tomar la primera imagen, i.e., poscirugía; y cuando fue lateral, esta posibilidad se modifica y profundiza según el tiempo transcurrido hasta la imagen lograda en el paciente. Conclusión: Se observó una relación marcada y continua entre el punto de entrada del clavo endomedular y la alineación de la tibia después de la consolidación ósea. Nivel de Evidencia: IV

Introduction: Tibial fractures represent approximately 2% of adult fractures. Today, intramedullary nailing is the procedure of choice to treat diaphyseal fractures of the tibia; however, this technique is not exempt from complications, misalignment in the coronal plane is one of the most frequent and feared by surgeons. The aim of this study was to investigate the relationship between nail entry point and misalignment in the coronal plane after surgery. Materials and Methods: We carried out a retrospective, descriptive, observational study between January 2015 and January 2019 of patients with diaphyseal fractures of the tibia, treated with intramedullary nailing. Radiographs were obtained in the immediate postoperative period and then every two months. The eighth-month radiograph, in which clear signs of bone consolidation could be observed, was taken into account to assess tibial alignment. Results: When the nail entry point was central, there was only a 0.021 chance (or 2.1%) of any significant misalignment in the immediate postoperative period and after 8 months. In contrast, when it was medial, the chances of a valgus tendency were >0.85 (or 85%) already at the first image, i.e., post-surgery; and when it was lateral, this possibility was modified and deepenedaccording to the time elapsed until the image achieved in the patient. Conclusion: A marked and continuous relationship wasobserved between the entry point of the intramedullary nail and the alignment of the tibia after bone consolidation..Level of Evidence: IV

Abordaje intergemelar posteromediano del platillo tibial. Descripción de la técnica quirúrgica / Posteromedial intergastrocnemius approach to the tibial plateau. Description of the surgical technique

Introducción: Se han publicado múltiples abordajes para el tratamiento de las fracturas que involucran las columnas posteriores de los platillos tibiales. Presentamos un abordaje anatómico intergemelar para tratar todas las fracturas con compromiso del componente posterior. Este procedimiento permite el acceso con visualización completa de toda la región posterior facilitando la reducción y colocación del material de osteosíntesis necesario para lograr la configuración más estable. Se describe el abordaje intergemelar posteromediano de acceso al platillo tibial descrito por nuestro equipo. Conclusiones:Consideramos que esta vía de abordaje representa una opción por tener en cuenta al tratar fracturas que afecten ambas columnas posteriores, alguna de ellas de manera aislada o la inserción tibial del ligamento cruzado posterior. Si bien las estructuras neurovasculares requieren atención constante durante el acto quirúrgico, la visión directa de ellas y su protección meticulosa, realizada por cirujanos experimentados, reduce al mínimo el riesgo de lesión y su manipulación no es una contraindicación para la elección de esta vía. Nivel de Evidencia: IV

Introduction: There are multiple approaches described in the literature for the treatment of fractures that involve the posterior columns of the tibial plateau. We present an anatomical intergastrocnemius approach for the treatment of all fractures involving the posterior component. It allows access with complete visualization of the entire posterior region, facilitating the reduction and placement of the osteosynthesis material necessary to achieve the most stable configuration. surgical technique: We describe the posteromedial intergastrocnemius approach to access the tibial plateau performed by our team. Conclusion: We consider that this approach represents an option to consider when treating fractures that affect both posterior columns, some of them in isolation, or the tibial insertion of the PCL. Although the neurovascular structures require constant attention during the surgical procedure, their direct vision and their meticulous protection, performed by experienced surgeons, minimizes the risk of injury, and their manipulation is not a contraindication for using this approach. Level of Evidence: IV

Tratamiento artroscópico de las fracturas de la eminencia intercondílea / Arthroscopic treatment of intercondylar eminence fractures

Introducción: las fracturas de la eminencia intercondílea son fracturas por avulsión del ligamento cruzado anterior (LCA). Las opciones terapéuticas en las fracturas desplazadas consisten en un abordaje artroscópico y fijación de las fracturas. Actualmente se debate sobre la técnica quirúrgica y el material de fijación. El objetivo de nuestra revisión bibliográfica es analizar los diferentes métodos de fijación artroscópica disponibles en la actualidad para el tratamiento de las fracturas de la eminencia intercondílea. Materiales y métodos: se realizó una revisión sistemática de la bibliografía con el formato PRISMA. Se incluyeron fracturas de la eminencia intercondílea en adultos tratados mediante artroscopía. Resultados: se analizaron dieciséis artículos, con un total de quinientas cincuenta y una fracturas. El método de fijación más utilizado fue la sutura (31%), cerclaje (25%), anclas (22%), fijación con Kw (8%), Endobutton® (6.3%), tornillos (4.5%) y alambre (3%). Conclusión: ningún método de fijación demostró superioridad en cuanto a porcentajes de estabilidad, consolidación y tiempo de inmovilización. Nivel de Evidencia: II

Introduction: fractures of the intercondylar eminence are avulsion fractures of the anterior cruciate ligament (ACL). Treatment options for displaced fractures consist of an arthroscopic approach and fracture fixation. There is currently debate about the surgical technique and the fixation material. The aim of our literature review is to analyze the different methods of arthroscopic fixation currently available in the treatment of fractures of the intercondylar eminence.Materials and methods: a systematic review of the bibliography was carried out using the PRISMA format. The inclusion criteria were fractures of the intercondylar eminence in adults treated by arthroscopy.Results: sixteen articles were analyzed, with a total of 551 fractures. The most affected knee was the right with 66% of cases. The most used fixation method was suture (31%), cerclage (25%), anchors (22%), Kw fixation (8%), Endobutton® (6.3%), screws (4.5%) and wire (3%).Conclusions: no fixation method showed the superiority in terms of percentages of stability, consolidation, and immobilization time. Level of Evidence: III

Avulsión de la tuberosidad tibial anterior combinada con desinserción del tendón rotuliano en paciente con fisis abierta. Resolución quirúrgica. Reporte de un caso / Anterior tibial tuberosity avulsion combined extensor mechanism injuries in open physis patient. Surgical resolution. Case report

Introducción: La avulsión de la tuberosidad anterior de la tibia representa <1% de las lesiones fisarias en la población pediátrica, mientras que las rupturas del tendón patelar son aun más infrecuentes. A su vez, la combinación de ambas es una lesión rara con escasos reportes en la bibliografía. Caso: se reporta el caso de un paciente de quince años con fisis abiertas, con una lesión combinada del aparato extensor. Se detalla su resolución quirúrgica y manejo postoperatorio sobre la base de la bibliografía actual. Discusión: existe escasa información precisa sobre la incidencia, diagnóstico y pronóstico de esta lesión. En trabajos recientes se describe un aumento en su incidencia y se propone una nueva clasificación que permita un mejor manejo de esta grave lesión en forma temprana. Conclusión: Las lesiones combinadas del aparato extensor están en aumento en la población esqueléticamente inmadura por la mayor participación en deportes competitivos a edades cada vez más tempranas. Actualmente no existe consenso en su diagnóstico. Se propone la resonancia nuclear magnética como método de elección por detectar lesiones asociadas y permitir planificar la estrategia quirúrgica.

Introduction: Avulsion of the anterior tuberosity of the tibia represents <1% of physeal injuries in the pediatric population, while patellar tendon ruptures are even more infrequent. In turn, the combination of both is a rare lesion with few reports in the bibliography. Case: the case of a 15-year-old patient with open physis, with a combined lesion of the extensor mechanism is reported. Its surgical resolution and postoperative management are detailed based on the current bibliography. Discussion: there is little precise information on the incidence, diagnosis and prognosis of this lesion. Recent works describe an increase in its incidence and propose a new classification that allows better management of this serious injury early. Conclusion: combined extensor mechanism injuries are increasing in the skeletally immature population due to greater participation in competitive sports at increasingly younger ages. Currently there is no consensus on its diagnosis. Magnetic resonance imaging is proposed as the method of choice because it detects associated lesions and allows planning the surgical strategy

Study on the Fixation Effect of Plate in the Middle Tibial Fracture Based on Finite Element Analysis / 中国医疗器械杂志

In this study, tibial shaft fracture has been treated with implants as numerically to investigate the stress behavior and the effect of plate material, position and length under pressure load. Plates of stainless steel, titanium alloy(Ti6Al4V), or CF-PEEK(CF50) were used to fix the tibial shaft comminuted fracture in different location and different working length. The maximum stress, the maximum micromotion of fracture and the stress shielding of cortex bone were analyzed. CF50 is more ideal biomechanical fixation material than traditional metal material for the treatment of tibial shaft comminuted fractures. In the treatment of tibial shaft comminuted fracture, lateral position and with relatively long working length of the plate have the advantages in micromotion, stress and stress shielding rate of the fracture end.

Analysis of the efficacy of a modified posteromedial approach for Klammer III posterior Pilon fractures / 中华创伤杂志(英文版)

PURPOSE@#To analyze the curative effect and technical points of a modified posteromedial approach in the treatment of Klammer III posterior Pilon fracture.@*METHODS@#A retrospective analysis of patients with Klammer III posterior Pilon fractures were conducted in our department from January 2018 to December 2019. Before the surgery, the patients were fully relieved of swelling and pain, and a comprehensive examination was carried out. The posteromedial approach exposed the posterior and medial fracture block of the distal tibia. According to the fracture of external malleolus, it is determined whether to combine a lateral incision and protect tendons and vascular nerves by a retractor, and then perform a fracture reduction and internal fixation. Postoperatively, the patients were treated with analgesia, detumescence, anticoagulation and rehabilitation exercise. The American orthopaedic foot and ankle society (AOFAS) score and visual analogue score were recorded at regular follow-up after surgery. A t-test was used for the comparison of the preoperative and final AOFAS score.@*RESULTS@#There were 7 male and 13 female (n = 20) included in the study, aged 22 to 88 years (average age 54.2 years). The injury mechanisms were falling from a height (n = 7), traffic accident (n = 6), walking injury (n = 2) and heavy injury (n = 5). The postoperative follow-up duration was 12-24 months (mean 16.95 months). The AOFAS score of the 20 patients before and after surgery were compared. The preoperative AOFAS score was 38.90 ± 3.91, and the final AOFAS score was 80.55 ± 4.20, (p < 0.001). The mean final visual analogue scores at rest, active and weight-bearing walking were 0.30, 0.85 and 1.70, respectively. One patient reported poor postoperative wound healing and required a return to hospital for debridement and anti-infection treatment.@*CONCLUSION@#In the treatment of Klammer III posterior Pilon fractures, the modified posteromedial approach can fully expose the fracture block and the collapsed articular surface of the medial malleolus, achieve good reduction and internal fixation with limited injury of the tendon and vascular nerves, and have a better prognosis.

Dual split and dislocation----a variant of Schatzker type-I tibial plateau fracture: A case report / 中华创伤杂志(英文版)

Schatzkter type-I tibial plateau fracture is a split fracture of the lateral tibial plateau in sagittal plane, consequent to valgus impaction caused by low velocity of trauma. However, a deep understanding of the different columns of the tibial plateau and patho-mechanisms of the injury led to the unmasking of atypical fractures around the tibial plateau. We have encountered 2 cases with unusual fracture pattern of the lateral tibial condyle caused by road traffic accidents. The fracture pattern and severity of injury deviate from the original description of Schatzker type 1; in view of dual plane split, there is rotation of the posterolateral column fragment along its sagittal plane plus grade-III medial collateral ligament injury. The patients were initially treated with knee spanning external fixator and after a latency of 5 days, definitive fracture specific fixation was done, combined with repair of grade-III medial collateral ligament injury. At the 6 months follow-up both the patients achieved satisfactory knee functions (knee society score case 1: 100 and case 2: 92) and returned to their jobs. The severity of fracture pattern and displacement as described should prompt for examination of associated ligament injury. Because of timely diagnosis, early and appropriate care promised an excellent function outcome even in such a severe nature of knee injury. To prompt the description of injury pattern we coined the name "dual split and dislocation" of lateral tibial plateau, as a complex injury variant of split fracture of lateral tibial plateau fracture.