Application of Nice knot technique in wound closure of Gustilo type ⅢA and ⅢB open tibial fractures / 中国修复重建外科杂志

OBJECTIVE@#To explore the effectiveness of Nice knot technique for wound closure in Gustilo type ⅢA and ⅢB open tibial fractures.@*METHODS@#A retrospective study was performed on 22 patients with Gustilo type ⅢA and ⅢB open tibial fractures, who underwent wound closure using the Nice knot technique and were admitted between June 2021 and June 2022. There were 15 males and 7 females. The age ranged from 18 to 67 years, with an average of 41.9 years. The causes of injury included traffic accident in 11 cases, falling from height in 7 cases, and heavy object injuries in 4 cases. Fractures were located on the left side in 9 cases and on the right side in 13 cases. And 9 cases were type ⅢA fractures and 13 were type ⅢB fractures according to Gustilo classification. All patients had extensive soft tissue injuries, and no vascular or neurological damage was observed. The time from injury to debridement was 3-8 hours (mean, 6.5 hours). The sizes of wounds before operation and at 2 weeks after operation were measured and wound healing rate at 2 weeks after operation were calculated. The wound healing time and wound healing grading were recorded. The Vancouver Scar Scale (VSS) score was used to assess the wound scar after wound healed and the excellent and good rate was calculated.@*RESULTS@#The wound area was 21.0-180.0 cm 2 (mean, 57.82 cm 2) before operation, and it was 1.2-27.0 cm 2 (mean, 6.57 cm 2) at 2 weeks after operation. The wound healing rate at 2 weeks after operation was 76%-98% (mean, 88.6%). After operation, 2 cases needed to adjust Nice knot due to skin cutting and 1 case occurred soft tissue infection on the wound. The other patient's wounds healed. The average wound healing time was 27.8 days (range, 18-44 days). And the wound healing were grade A in 13 cases and grade B in 9 cases. VSS score was 2-9, with an average of 4.1; 10 cases were rated as excellent, 10 as good, and 2 as poor, with an excellent and good rate of 90.9%. All patients were followed up 9-24 months (mean, 14.6 months). During follow-up, no deep infection or osteomyelitis occurred. Two cases experienced fracture non-union, and were treated with compression fixation and bone grafting. The fractures of the other patients all healed, with a healing time of 85-190 days (mean, 148.2 days).@*CONCLUSION@#Nice knot technique can be used in wound closure of Gustilo type ⅢA and ⅢB open tibial fractures effectively, which is easy to operate.

Fatores associados à maior permanência hospitalar na fratura do planalto (platô) tibial / To evaluate associated factors and epidemiology related to increased length of stay and costs in patients with tibial plateau fractures

Introdução: As fraturas de platô tibial são consideradas lesões intraarticulares comuns do joelho. Objetivo: Avaliar os fatores associados e a relação ao aumento do tempo de internação e custos nesses pacientes. Métodos: Estudo qualitativo descritivo de tabelas de frequência e cruzadas de 108 pacientes vítimas de trauma ortopédico. Foram avaliadas as médias de idade; gênero; trauma de alta energia; tempo de internação; e tempo médio da interferência. Resultados: O perfil epidemiológico foi idade média de 41,2 anos; homens (70,4%); vítimas de trauma de alta energia (53,70%); tempo de internação; e tempo mediano. Os fatores que interferiram para aumento dessas 2 últimas variáveis foram: mecanismos de lesão de alta energia (8 dias); tratamento provisório (10 dias); tratamento cirúrgico definitivo (8 dias); prolongamento justificado dos dias (8 dias), complicações na internação (11 dias); lesão de partes moles (10 dias); infecção da ferida (12 dias) e internamento na UTI (26 dias). Conclusão: Os fatores que apresentaram diferença significativa em relação ao aumento de dias de internamento hospitalar foram: mecanismo de lesão de alta energia, realização de tratamento provisório, fraturas complexas (tipo IV, V, VI), tipo de tratamento cirúrgico definitivo, complicações na internação - principalmente lesão de partes moles, infecção e internamento em UTI.

Introduction: Tibial plateau fractures are considered common intraarticular knee injuries. Objective: To evaluate the associated factors and their relationship to increased length of stay and costs in these patients. Methods: Descriptive qualitative study of frequency and cross tables of 108 patients who were victims of orthopedic trauma. Were evaluated mean age; gender; high-energy trauma; hospitalization time; and median time of the interference. Results: The epidemiological profile was a mean age of 41.2 years; men (70.4%); high-energy trauma victims (53.70%); hospitalization time; and median time. The factors that interfered with the increase in these last 2 variables were: high-energy injury mechanisms (8 days); interim treatment (10 days); definitive surgical treatment (8 days); justified extension of days (8 days), hospitalization complications (11 days); soft tissue injury (10 days); wound infection (12 days) and ICU stay (26 day\s). Conclusion: The factors that showed a significant difference in relation to the increase in hospitalization days were: mechanism of high-energy injury, provisional treatment, complex fractures (type IV, V, VI), type of definitive surgical treatment, complications in hospitalization - mainly soft tissue injury, infection and ICU admission.

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.

3D-printing-assisted surgery versus conventional surgery for treatment of Schatzker VI tibial plateau fractures: a multi-center clinical study / 中华创伤骨科杂志

Objective:To compare 3D-printing-assisted surgery and conventional surgery in the treatment of Schazker type Ⅵ tibial plateau fractures.Methods:A retrospective study was conducted to analyze the clinical data of 50 patients with type Ⅵ tibial plateau fracture who had been treated from January 2019 to December 2021 at the 5 Departments of Orthopedics in The First Affiliated Hospital of Nanchang University, The First People's Hospital of Jiujiang, Pingkuang General Hospital, Ganzhou People's Hospital, and Nanchang Hongdu Hospital of Traditional Chinese Medicine. The patients were divided into 2 groups according to their different treatment methods. In the 3D printing group of 25 cases treated by 3D-printing-assisted surgery, there were 14 males and 11 females, with an age of (42.5±9.1) years; in the conventional group of 25 cases treated by conventional surgery, there were 13 males and 12 females with an age of (42.2±9.3) years. The 2 groups were compared in terms of operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, fracture healing time, postoperative complications, the Rasmussen radiological scores and the American Hospital for Special Surgery (HSS) knee function scores at 6 and 12 months after operation.Results:There was no significant difference in the preoperative general data between the 2 groups, indicating comparability ( P>0.05). The operation time [(125.4±10.6) min], intraoperative blood loss [(206.2±16.3) mL], intraoperative fluoroscopy frequency [(9.2±2.7) times] and fracture healing time [(3.0±0.7) months] in the 3D printing group were all significantly less than those in the conventional group [(168.2±14.1) min, (303.2±20.4) mL, (15.5±3.5) times and (4.1±0.8) months] while the Rasmussen radiological scores (17.6±1.2 and 17.9±0.6) and HSS knee scores (90.8±6.4 and 91.5±5.6) at 6 and 12 months after operation in the 3D printing group were all significantly higher than those in the conventional group (16.2±2.6 and 16.7±2.2; 84.5±9.2 and 87.6±8.0) (all P<0.05). In the 3D printing group, there were 1 case of wound infection and 1 case of wound dehiscence after operation. In the conventional group, there were 2 cases of wound skin necrosis, 3 cases of wound dehiscence, 1 case of traumatic arthritis, 2 cases of wound infection, and 1 case of screw loosening. The incidence of complications in the 3D printing group (8.0%, 2/28) was significantly lower than that in the conventional group (36.0%, 9/25) ( P<0.05). Conclusion:In the treatment of Schatzker type VI tibial plateau fractures, compared with conventional surgery, 3D-printing-assisted surgery can lead to better curative outcomes, because it is conducive to lowering surgical difficulty, reducing postoperative complications, and promoting fracture union and functional recovery of the knee.

Treatment of open tibial fractures in children with composite pin-rod external fixation / 中华创伤骨科杂志

Objective:To explore the clinical efficacy of composite pin-rod external fixation in the treatment of open tibial fractures in children.Methods:The clinical data were retrospectively analyzed of the 21 pediatric patients with open tibial fracture who had been treated at Department of Pediatric Orthopeadics, Tianjin University by composite pin-rod external fixation from January 2019 to December 2021. There were 15 boys and 6 girls, and 9 left sides and 12 right sides. The age at the time of operation was (8.6±4.1) months. According to the Gustilo-Anderson classification, there were 3 cases of type Ⅰ, 12 cases of type Ⅱ, 3 cases of type ⅢA, 1 case of type ⅢB, and 2 cases of type ⅢC. Twenty cases had a concomitant fibular fracture, 3 cases multiple injuries, and 3 cases a segmental fracture. All the operations were performed at the emergency department. After debridement, the fractures were reduced and immobilized with a triangle external fixation of composite pin-rod system. In the patients whose conditions permitted, the wounds were closed at one stage, and no other external fixation was added after operation. Wound healing, fracture healing, frame time, knee and ankle functional results and complications were evaluated.Results:All patients were followed up for (20.7±15.8) months. Primary wound closure was achieved in 18 cases; the wound was covered by vacuum sealing drainage after debridement and reverse skin removal in the other 3 cases, of which 2 healed smoothly, and 1 was complicated with superficial infection of Gustilo type ⅢC treated eventually by an anterolateral thigh flap. Fractures healed satisfactorily in 20 cases, with a frame time of (4.5±1.7) months. At the last follow-up, there was no significant difference in the range of motion of the knee and ankle joints on the affected side compared with the uninjured side ( P>0.05). According to the Johner-Wruhs evaluation criteria, the functional recovery was excellent in 16 cases and good in 4 cases. Fracture nonunion happened in one child after skin flap operation, but fracture occurred again after reoperation for fracture, yielding a poor Johner-Wruhs evaluation. Needle tract infection was found in 9 cases but responded to therapy with no other complications. Conclusions:In the treatment of open tibial fractures in children, the composite pin-rod external fixation may lead to satisfactory clinical outcomes. It is easy in operation, provides stable fixation, and allows early rehabilitation after surgery. It can be used as a terminal treatment for wounds that can be closed at one stage.

Metallic screw fixation versus absorbable screw fixation after open reduction in treatment of distal tibial epiphyseal fractures in adolescents / 中华创伤骨科杂志

Objective:To compare the efficacy between metallic screw fixation and absorbable screw fixation after open reduction in the treatment of adolescent distal tibial epiphyseal fractures.Methods:A retrospective study was conducted to analyze the data of 82 patients with closed distal tibial epiphyseal fracture who had been admitted to Department of Pediatric Orthopedics, Shengjing Hospital Affiliated to China Medical University from January 2013 to December 2020. There were 61 males and 21 females (aged from 8 to 15 years), and 39 left sides and 43 right sides. The Salter-Harris classification: type Ⅱ in 25 cases, type Ⅲ in 8 cases, and type Ⅳ in 49 cases. They were divided into 2 groups according to different internal fixation methods. Group A (42 cases) was subjected to open reduction and metallic screw fixation and group B (40 cases) to open reduction and absorbable screw fixation. Preoperative data, operation time, total treatment cost and complications during follow-up were recorded and compared between the 2 groups. In both groups at the last follow-up, anteroposterior and lateral ankle radiographs were taken for radiographic evaluation of the injury to the distal tibial epiphysis and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used to assess the ankle function.Results:The 2 groups were comparable because there were no significant differences in all their preoperative demographic data ( P>0.05). Group A was followed up for 18.0(16.0, 21.3) months while group B for 16.0(13.0, 20.0) months. The treatment cost for group A [27, 000 (25, 000, 33, 000) Yuan] was significantly higher than that for group B [23, 000 (19, 000, 27, 000) Yuan] ( P<0.05). The operation time was (112.4±34.3) min for group A and (101.0±41.1) min for group B, showing no significant difference ( P>0.05). The lateral distal tibial angle was 89.5 (88.0, 91.0)° on the affected side and 89.7°±1.8° on the unaffected sides in group A; it was 90.0 (88.3, 90.8)° on the affected side and 89.5°±1.8° on the unaffected side in group B. The anterior distal tibial angle was 81.9°±1.8° on the affected side and 81.8°±1.5° on the unaffected side in group A; it was 82.0 (81.0, 83.0)° on the affected side and 82.1°±2.2° on the unaffected side in group B. There was no significant difference in the above comparisons at the last follow-up in radiographic evaluation of the distal ankle joint between the affected and the unaffected sides in either group or between groups( P>0.05). There was a significant difference between the 2 groups in the rate of superficial skin infection [11.9% (5/42) versus 0% (0/40)] ( P<0.05), but there was no significant difference in the incidence of premature physeal closure between the 2 groups [11.9% (5/42) versus 5.0% (2/40)] ( P>0.05). The last follow-up revealed no significant difference in the AOFAS ankle-hindfoot score between group A [(90.6±4.9) points] and group B [(92.1±4.6) points] ( P>0.05). Conclusions:In the treatment of adolescent distal tibial epiphyseal fractures, compared with metallic screw fixation, absorbable screw fixation may lead to comparable efficacy in fixation, functional recovery and imaging evaluation, but no increased risk of premature physeal closure. Moreover, it spares the need for secondary surgical removal, and reduces operation time and treatment cost.

Short-term effectiveness of ultrasound-guided Kirschner wire provocation technique in treatment of Salter-Harris types Ⅰ and Ⅱ periosteal entrapment of distal tibial epiphyseal fractures in children and adolescents / 中国修复重建外科杂志

OBJECTIVE@#To investigate the short-term effectiveness of ultrasound-guided closed reduction by Kirschner wire provocation technique in the treatment of Salter-Harris types Ⅰ and Ⅱ periosteal entrapment of distal tibial epiphyseal fractures in children and adolescents.@*METHODS@#Between May 2019 and May 2022, 41 patients with Salter Harris types Ⅰ and Ⅱ distal tibial epiphyseal fractures were admitted, all of whom had periosteal entrapment on preoperative MRI, and 38 cases (92.7%) were confirmed to have periosteal entrapment by intraoperative ultrasound. There were 24 males and 14 females, the age ranged from 6.8 to 15.7 years, with an average of 10.7 years; and there were 20 cases of Salter Harris type Ⅰ and 18 cases of type Ⅱ. The time from injury to operation was 22-76 hours, with an average of 28.4 hours. The preoperative imaging examination showed excellent alignment in 4 cases, good in 20 cases, and poor in 14 cases. The ultrasound guided Kirschner wire provocation technique for closed reduction and percutaneous Kirschner wire internal fixation were performed. The operation time, intraoperative fluoroscopy frequency, fracture healing time, and complications were recorded. Anteroposterior and lateral X-ray films of the affected ankle joint were taken before operation, at 3 months after operation, and at last follow-up to observe the healing of the fracture, and anteroposterior X-ray films of the whole length of both lower limbs were taken to evaluate the alignment of the force lines of the affected limbs. The range of motion (ROM), visual analogue scale (VAS) score, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were used to evaluate ankle function. The mechanical lateral distal tibia angle (mLDTA) and the anatomic anterior distal tibia angle (aADTA) were measured.@*RESULTS@#The operation time ranged from 17 to 52 minutes, with an average of 22.6 minutes, and the intraoperative fluoroscopy frequency ranged from 3 to 11 times, with an average of 4.2 times. X-ray examination during operation and at 2 days after operation showed that anatomical reduction was achieved. All patients were followed up 10-24 months, with an average of 16.4 months. All fractures healed in 6.1-7.2 weeks, with an average of 6.3 weeks; no fracture displacement occurred, and the patients recovered to their pre-injury level of motion at 6 months after operation. Needle tail irritation occurred in 2 cases at 4 weeks after operation, and they recovered after symptomatic treatment. During the follow-up, there was no serious complication such as incision deep infection, bone nonunion, delayed union, and malunion. At last follow-up, the patients' alignment were all excellent, and the difference was significant when compared with preoperative one ( Z=-7.471, P<0.001). The VAS score, AOFAS ankle-hindfoot score, dorsiflexion-plantar flexion ROM, varus-valgus ROM, mLDTA, and aADTA significantly improved at 3 months after operation and last follow-up when compared with preoperative ones ( P<0.05).@*CONCLUSION@#Ultrasound-guided closed reduction by Kirschner wire provocation technique for treating Salter-Harris types Ⅰ and Ⅱ periosteal entrapment of distal tibial epiphyseal fractures in children and adolescents is minimally invasive and safe.

Suplementación efectiva de vitamina D en pacientes con fractura tibial / Effective vitamin D supplementation in patients with tibial fracture

OBJETIVOS Determinar la prevalencia de déficit de vitamina D, así como evaluar la seguridad y efectividad de un nuevo método de carga con colecalciferol en pacientes adultos con fractura de tibia. MATERIALES Y MÉTODOS Se reclutaron a 56 pacientes consecutivos con edades entre 18 y 65 años con fractura de tibia ingresados en nuestro hospital durante 1 año. Se determinó el nivel de 25-hidroxivitamina D ([25(OH)-D]) al ingreso y tras suplementación con 100.000 UI semanales de colecalciferol, durante 3 o 5 semanas, en casos de insuficiencia ([25(OH)-D] entre 20 ng/mL y 29,9 ng/mL) o deficiencia ([25(OH)-D] < 20 ng/mL), respectivamente. Se determinó la prevalencia de hipovitaminosis D, el porcentaje de normalización de [25(OH)-D], y los efectos adversos. RESULTADOS Se evaluaron 56 pacientes; 98,2% presentó hipovitaminosis D, y 28 (73,7%) y 10 (26,3%) presentaron déficit e insuficiencia, respectivamente. Tras la suplementación, 92,1% alcanzaron niveles [25(OH)-D] normales. Ningún paciente presentó efectos adversos. DISCUSIÓN La prevalencia de deficiencia de vitamina D en nuestra población fue mayor a la reportada en la literatura. Comprobamos que un esquema de suplementación en altas dosis de vitamina D es seguro, y más efectivo que los previamente recomendados. Este esquema de suplementación puede ser implementado en futuros estudios randomizados. CONCLUSIÓN La prevalencia de hipovitaminosis D en pacientes adultos chilenos con fractura de tibia fue alta (98,2%). El esquema de suplementación con vitamina D propuesto fue efectivo y seguro.

OBJETIVOS Determinar la prevalencia de déficit de vitamina D, así como evaluar la seguridad y efectividad de un nuevo método de carga con colecalciferol en pacientes adultos con fractura de tibia. MATERIALES Y MÉTODOS Se reclutaron a 56 pacientes consecutivos con edades entre 18 y 65 años con fractura de tibia ingresados en nuestro hospital durante 1 año. Se determinó el nivel de 25-hidroxivitamina D ([25(OH)-D]) al ingreso y tras suplementación con 100.000 UI semanales de colecalciferol, durante 3 o 5 semanas, en casos de insuficiencia ([25(OH)-D] entre 20 ng/mL y 29,9 ng/mL) o deficiencia ([25(OH)-D] < 20 ng/mL), respectivamente. Se determinó la prevalencia de hipovitaminosis D, el porcentaje de normalización de [25(OH)-D], y los efectos adversos. RESULTADOS Se evaluaron 56 pacientes; 98,2% presentó hipovitaminosis D, y 28 (73,7%) y 10 (26,3%) presentaron déficit e insuficiencia, respectivamente. Tras la suplementación, 92,1% alcanzaron niveles [25(OH)-D] normales. Ningún paciente presentó efectos adversos. DISCUSIÓN La prevalencia de deficiencia de vitamina D en nuestra población fue mayor a la reportada en la literatura. Comprobamos que un esquema de suplementación en altas dosis de vitamina D es seguro, y más efectivo que los previamente recomendados. Este esquema de suplementación puede ser implementado en futuros estudios randomizados. CONCLUSIÓN La prevalencia de hipovitaminosis D en pacientes adultos chilenos con fractura de tibia fue alta (98,2%). El esquema de suplementación con vitamina D propuesto fue efectivo y seguro.

Impacto del diámetro del clavo endomedular en la consolidación de fracturas diafisarias de tibia. Análisis retrospectivo sobre 96 pacientes / Impact of the nail diameter on consolidation of tibial diaphyseal fractures. Retrospective analysis of 96 patients

Resumen: Introducción: el estándar de oro de tratamiento para la mayoría de las fracturas diafisarias de tibia está representado por el clavo endomedular (CEM). El objetivo de este estudio fue analizar la importancia del diámetro del CEM sobre la consolidación de fracturas diafisarias de tibia. Material y métodos: se realizó un estudio retrospectivo en pacientes con fracturas cerradas de tibia 42 OTA/AO, tratados con un CEM fresado y acerrojado, entre Enero de 2014 y Diciembre de 2020. Las variables analizadas fueron género, edad, comorbilidades, cantidad de cerrojos utilizados, relación clavo/canal (diferencia entre el diámetro del canal medular y clavo), el índice clavo/canal (razón entre diámetro del clavo y el canal medular), en relación con la tasa de consolidación y falla (retardo de consolidación y seudoartrosis). Resultados: la serie final se conformó por 96 pacientes y la tasa de consolidación fue de 91.7% (n = 88). Se observó un diámetro de clavo significativamente mayor en los pacientes que consolidaron respecto a los que fallaron (p = 0.0014), incrementando la posibilidad de consolidación 5.30 (p = 0.04) veces, por cada milímetro que el clavo aumentó su diámetro. Se observó un incremento de probabilidad de consolidación de 13.56 (p = 0.018) veces utilizando un clavo > 10 mm de diámetro. El índice clavo/canal ≥ 0.80 aumentó la posibilidad de consolidación 23.33 veces (p = 0.005). Conclusión: nuestros hallazgos sugieren que los CEM fresados y acerrojados en fracturas diafisarias de tibia deben colocarse del mayor diámetro posible (> 10 mm y con un índice clavo/canal ≥ 0.80) para favorecer la consolidación.

Abstract: Introduction: the gold standard for tibial diaphyseal fracture treatment is represented by the intramedullary nail (IMN). This study aimed to assess the relevance of nail diameter in bone healing of tibial diaphyseal fractures. Material and methods: a retrospective study was conducted analyzing patients with closed 42 OTA/AO tibial fractures, treated with a reamed and locked IMN between January 2014 and December 2020. The variables assessed were gender, age, comorbidities, number of bolts used, canal/nail index (difference between the diameter of the medullary canal and nail), nail/canal ratio (ratio between nail diameter and medullary canal), related to consolidation and failure rates (delay - and non-union). Results: 96 patients were included. The consolidation rate was 91.7% (n = 88). Patients with consolidation had a significantly larger nail diameter than those who failed (p = 0.0014), increasing the chance of consolidation 5.30 (p = 0.04) times for each millimeter that the nail increased its diameter. Using a nail > 10 mm increased the chance of consolidation 13.56 times (p = 0.018). A nail/canal ratio ≥ 0.80 increased the chance of consolidation 23.33 times (p = 0.005). Conclusion: our findings suggested that reamed and locked IMN in tibial diaphyseal fractures should be implanted with the largest possible diameter (> 10 mm and with a nail-to-canal ratio ≥ 0.80) to promote bone healing.

Ilizarov Ring External Fixation for Complex Tibial Plateau Fractures / Fixação externa do anel de Ilizarov para fraturas complexas do platô tibial

Abstract Objective To analyze the results of clinical, radiological, and functional outcomes of tibial plateau fracture (Schatzker Type V, VI) treated with Illizarov ring external fixator with or without minimum opening. Methods A total of 52 tibial plateau fractures of type V, VI were treated with Ilizarov ring external fixator with or without mininum internal fixation were studied. Functional outcome assessment was done using the American Knee Society (AKS) score with clinical, radiological union, and complications were analyzed. Results There were 37 (71.15%) male and 15 (28.84%) female patients, with a mean age of 39.07 ± 12.58 years old. Road traffic accidents (RTAs) were the major cause of fracture, accounting for 32 cases (61.53%) followed by fall injury, with 16 cases (30.76%), and direct impact, with 4 cases (7.69%). Twenty-one (40.38%) cases were type V and 31 (59.61%) cases were type VI fractures, and there were 24 (46.15%) cases of open fracture. The mean AKS score of Type V and Type VI fractures were 82.8 and 80.70, respectively, but this was statistically not significant at p<0.05. The mean AKS score of closed and open fractures were also statistically not significant at p<0.05. Conclusions For Schatzker Types V and VI complex tibial plateau fractures, Ilizarov external fixation is a safe, cost-effective and efficient treatment method that presents a satisfactory outcome.

Resumo Objetivo Analisar os resultados clínicos, radiológicos e funcionais da fratura do planalto tibial (Schatzker Tipo V, VI) tratada com fixador externo do anel Illizarov com ou sem abertura mínima. Métodos Um total de 52 fraturas do planalto tibial dos tipos V e VI foram tratadas com fixador externo do anel Ilizarov com ou sem fixação interna mínima. A avaliação do desfecho funcional foi feita utilizando-se o escore da American Knee Society (AKS, na sigla em inglês) com consolidação clínica, radiológica e complicações encontradas. Resultados Foram 37 (71,15%) pacientes do sexo masculino e 15 (28,84%) do sexo feminino, com idade média de 39,07 ± 12,58 anos. Acidentes de trânsito (ATs) foram a principal causa das fraturas, contabilizando 32 casos (61,53%), seguidos por lesão por queda, com 16 casos (30,76%), e impacto direto, com 4 casos (7,69%). Foram 21 (40,38%) casos de fraturas tipo V, 31 (59,61%) casos do tipo VI e 24 (46,15%) casos de fratura exposta. Os escores médios da AKS para as fraturas tipo V e VI foram de 82,8 e 80,70, respectivamente, mas não foi estatisticamente significativo em p <0,05. O escore médio da AKS para fraturas fechadas e abertas também não foi estatisticamente significativo em p <0,05. Conclusões Para a fratura do planalto tibial complexa dos tipos V e VI de Schatzker, a fixação externa de Ilizarov é um método de tratamento seguro, econômico e eficiente que resulta em resultados satisfatórios.

The postoperative cognitive dysfunction induced by central inflammation with possible involvement of the gut-brain axis

Abstract Background: Postoperative cognitive dysfunction is widely recognized as severe postoperative central nervous dysfunction and has a significant impact on the 'patient's physical and mental health. Methods: Postoperative models of tibial fracture in aged rats were established, including the control group, model group, CCL11 protein injection group, and saline injection group. Morris water maze test was used to detect the behavioral characteristics of rats. Enzyme-Linked Immunosorbent Assay was used or determine the content of CCL11 and CXCL10. Immunofluorescence staining was used to detect the distribution of CD14+CD163+macro-phages in colon tissues and CD11b+CCR3+microglia cells in hippocampal tissues. Western blot analyzed NOX1 and STAT3 expression in hippocampus tissues. Results: Water maze test results confirmed severe cognitive impairment in CCL11 rats. The content of CCL11 and CXCL10 in the CCL11 group was much higher than that of the model group. The distribution of macrophage and microglia cells in the CCL11 model group was greater than that in the model group and the saline group. The expression of NOX1 and STAT3 in the CCL11 group was higher compared with the model group. Conclusion: Abnormal macrophage function and excessive CCL11 secretion were observed in the rats with lower limb fractures after surgery. Postoperative central inflammation in rats with lower limb fracture induced postoperative cognitive dysfunction through the gut-brain axis molecular mechanism.

Isolated open tibial shaft fracture: a seven-hospital, prospective observational study in two Latin America countries / Fraturas expostas isoladas da diáfise da tíbia: estudo prospectivo observacional em sete hospitais de dois países da América Latina

ABSTRACT Introduction: open tibial fractures are challenging due to the frequent severe bone injury associated with poor soft tissue conditions. This is relevant in low- and middle-income countries, mainly related to delayed definitive fixation and lack of adequate training in soft tissue coverage procedures. Due to these factors, open tibial fracture is an important source of disability for Latin American countries. Herein we sought to provide an epidemiological overview of isolated open tibial shaft fracture across seven hospitals in southern cone of Latin America. The secondary goal was to assess the impact on quality of life based on return-to-work rate (RWR). Methods: patients with an isolated open tibial shaft fracture treated in seven different hospitals from Brazil and Argentina from November 2017 to March 2020 were included in the study. Clinical and radiographic results were evaluated throughout the 120-day follow-up period. Final evaluation compared RWR with the SF-12 questionnaire, bone healing, and gait status. Results: Seventy-two patients were treated, 57 followed for 120 days and 48 completed the SF-12 questionnaire. After 120 days, 70.6% had returned to work, 61.4% had experienced bone healing. Age, antibiotic therapy, type of definitive treatment, and infection significantly influenced the RWR. Gait status exhibited strong correlations with RWR and SF-12 physical component score. Conclusions: Isolated open tibial shaft fractures are potentially harmful to the patient's quality of life after 120 days of the initial management. RWR is significantly higher for younger patients, no history of infection, and those who could run in the gait status assessment.

RESUMO Introdução: o tratamento de fraturas expostas isoladas da diáfise da tíbia (FEIDT) apresenta desafios por frequentemente associar severa lesão óssea com condições ruins de tecido mole, fatores relevantes em países de média e baixa renda, especialmente devido a atrasos na implementação da fixação definitiva e falta de treinamento adequado no manejo de tecidos moles. Consequentemente, FEIDTs representam importante fonte de incapacitação na América Latina. Este estudo objetivou apresentar uma visão geral das FEIDTs em sete hospitais do cone sul da América Latina. O objetivo secundário foi avaliar o seu impacto na qualidade de vida baseado na taxa de retorno ao trabalho (TRT). Métodos: foram incluídos no estudo pacientes com FEIDT tratados em sete hospitais de Brasil e Argentina entre novembro de 2017 e março de 2020. Resultados clínicos e radiográficos foram analisados num período de 120 dias. Avaliação final comparou TRT com o questionário SF-12, consolidação óssea e condições de marcha. Resultados: setenta e dois pacientes foram tratados, 57 seguidos por 120 dias e 48 completaram o questionário SF-12. Após 120 dias, 70,6% havia retornado ao trabalho, 61,4% tinha fratura consolidada. Idade, antibioticoterapia, tipo de tratamento definitivo e infecção influenciaram significativamente na TRT. A condição de marcha apresentou forte correlação com TRT e o componente físico do SF-12. Conclusão: FEIDTs são potencialmente deletérias à qualidade de vida dos pacientes 120 dias após o tratamento inicial. TRT é significativamente maior para pacientes mais jovens, sem história de infecção e que conseguem correr na avaliação da condição de marcha..

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.

Treatment of Schatzker type Ⅳ tibial plateau fracture involving the postero-lateral condyle with a medial support plate and a row of screws / 中华创伤骨科杂志

Objective:To investigate the clinical efficacy of a medial support plate and a row of screws in the treatment of Schatzker type Ⅳ tibial plateau fracture involving the postero-lateral condyle.Methods:A retrospective analysis was performed of the data of 26 patients who had been admitted to Department of Orthopedic Trauma, Honghui Hospital Affiliated to Xi'an Jiaotong University for Schatzker type Ⅳ tibial plateau fracture involving the postero-lateral condyle from December 2015 to December 2020. There were 17 males and 9 females, aged from 19 to 51 years (average, 36.1 years). All their fracture lines involved the postero-lateral condyle and all fractures were fixated with a medial support plate and a row of screws via one medial and one lateral incisions. Recorded were the operation time, hospital stay, blood loss, incision length, fracture healing, complications, quality of knee joint reduction and knee joint function at the last follow-up.Results:The length of hospital stay ranged from 8 to 16 days, averaging 10.4 days. The 26 patients were followed up for 8 to 18 months, with an average of 14.3 months. All the fractures got united after 11 to 17 weeks (average, 13.7 weeks). During the follow-up, no reduction loss, internal fixation failure or surgical complications were observed. Rasmussen radiographic scores at the last follow-up ranged from 11 to 18 points, averaging 16.1 points. The range of motion of the knee joint ranged from 0° to 140°, averaging 120.8°. The Rasmussen scores of the knee function ranged from 14 to 28 points, averaging 24.4 points.Conclusion:In the treatment of Schatzker type Ⅳ tibial plateau fracture involving the postero-lateral condyle, the use of a medial support plate and a row of screws can achieve satisfactory clinical results.

Luxación femorotibial abierta con fractura de rótula y tibia

RESUMEN Introducción: Las luxaciones de rodilla son poco frecuentes, lo que hace que su combinación abierta, con fracturas de rótula y del tercio superior de la tibia, sea rara y grave. Constituye una entidad causada por traumas de alta energía y se asocia a otras lesiones. Objetivo: Presentar un caso raro y complejo de luxación femorotibial posterior abierta con fractura del polo inferior de la rótula y tercio superior de la tibia. Caso clínico: Paciente masculino de 37 años de edad, que ingresó en el servicio de ortopedia y traumatología, quien como consecuencia de un accidente de tránsito, presentó luxación femorotibial posterior con fractura abierta del polo inferior de la rótula y tercio superior de la tibia, grados III-B, en el inferior derecho. Fue intervenido quirúrgicamente de urgencia; se realizó amplio desbridamiento quirúrgico, reducción de la luxación, reparación primaria de las lesiones ligamentosas, patelectomía parcial, reparación del tendón rotuliano y fijación externa para la fractura del tercio superior de la tibia. El paciente evolucionó bien, sin infección de la herida quirúrgica y recuperación total a los 4 meses. Conclusiones: La combinación de luxación femorotibial posterior abierta, con fractura del polo inferior de la rótula y tercio superior de la tibia es rara y obedece a altas energías traumáticas, como los accidentes automovilísticos. La cirugía de urgencia y la profilaxis antimicrobiana, es el método eficaz para el tratamiento definitivo de esta lesión.

ABSTRACT Introduction: Knee dislocations are infrequent, which makes the combination with open fractures of the patella and the upper third of the tibia, rare and serious. It is an entity caused by high-energy trauma and is associated with other injuries. Objective: To present a rare and complex case of open posterior femorotibial dislocation with fracture of the lower pole of the patella and the upper third of the tibia. Clinical case: A 37-year-old male patient, who was admitted to the orthopedic and trauma service, who, as a consequence of a traffic accident, presented posterior femorotibial dislocation with an open fracture of the lower pole of the patella and upper third of the tibia. grades III-B, in the lower right. He underwent emergency surgery; extensive surgical debridement, dislocation reduction, primary repair of ligamentous injuries, partial patellectomy, patellar tendon repair, and external fixation were performed for the fracture of the upper third of the tibia. The patient evolved well, without infection of the surgical wound and full recovery at 4 months. Conclusions: The combination of open posterior femorotibial dislocation, with fracture of the lower pole of the patella and upper third of the tibia is rare and is due to high traumatic energies, such as motor vehicle accidents. Emergency surgery and antimicrobial prophylaxis is the effective method for the definitive treatment of this lesion.

Treatment of triplane fracture ankle fractures associated with ipsilateral tibial fractures using a novel approach / Fratura triplanar do tornozelo concomitante a fratura ipsilateral da tíbia. uma nova abordagem

ABSTRACT Objective: The aim of this study is to purpose a novel approach to the concomitant triplanar and tibial shaft fracture. Methods: Retrospective study between 2001 and 2019. We collected the patients' general information, clinical and radiographic data, and complications after the following three-step treatment: (1) fixation of the Salter-Harris II fracture of the triplane fracture, (2) fixation of the Salter-Harris II/IV fracture with cannulated screws, and (3) fixation of the tibial fracture with flexible titanium nails. Results: The study included seven patients (six males) with a mean age of 14 years and a mean follow-up of 6.4 years (minimum two years). Five triplane fractures had two fragments and two had three fragments. Five fractures were classified as Salter-Harris II and two as Salter-Harris IV. Three tibial fractures were long oblique, three were spiral, and one had a third fragment. Six fractures affected the middle third and one affected the distal third of the tibia. All triplane and tibial fractures consolidated without significant displacement. No physeal damage was identified. Conclusions: This study described the association of tibial fractures with triplane ankle fractures managed by our proposed treatment, which proved to be effective for this fracture association. Level of Evidence IV, Case Series.

RESUMO Objetivo: Propor uma nova abordagem para fraturas concomitantes da diáfise da tíbia e triplanares do tornozelo. Métodos: Estudo retrospectivo entre 2001 e 2019. Foram coletadas informações gerais: dados clínicos, radiográficos e complicações. As fraturas seguiram três passos no tratamento: (1) fixação do fragmento Salter-Harris tipo III da fratura triplanar; (2) fixação do fragmento Salter-Harris II/IV com parafuso canulado; e (3) fixação da fratura diafisária da tíbia com hastes flexíveis. Resultados: O estudo incluiu sete pacientes (seis homens) com idade média de 14 anos e seguimento médio de 6.4 anos (mínimo de dois anos). Cinco fraturas triplanares tinham dois fragmentos principais e duas tinham três fragmentos. Cinco fraturas na radiografia em perfil foram classificadas como Salter-Harris II e duas como Salter-Harris IV. Três fraturas diafisárias tibiais tinham traço obliquo longo, três traço espiral e uma fratura com terceiro fragmento. Seis fraturas eram do terço médio e uma fratura do terço distal da tíbia. Todas as fraturas triplanares e tibiais consolidaram sem desvio significativo e não tivemos nenhuma lesão fisária. Conclusão: O estudo descreveu a associação da fratura da tíbia com a fratura triplanar do tornozelo e nossa proposta de tratamento, que se mostrou uma boa opção no tratamento dessa fratura especial. Nível de Evidência IV, Série de casos.

Application of Wall Thickness Analysis in Estimating the Degree of Tibial Fracture Bone Healing / 医用生物力学

Objective To quantitatively judge the degree of tibial bone healing using the finite element wall thickness analysis method, so as to provide an intuitive diagnostic basis for clinical judgment of tibial union and delayed bone healing. Methods After three-dimensional (3D) modeling for the affected and healthy limb side of 48 patients, the maximum wall thickness (MWT) was calculated, and the ratio (B value) was used as a quantitative index of bone healing. When both BMWT2 and BMWT1 were greater than 0.9, bone healing could be judged. When BMWT2 was between 0.9 and 0.7, bone union was judged to be poor, and there was no significant increase in this value after regular reexamination. When BMWT3 was above 0.9 while both BMWT1 and BMWT2 were smaller than 0.7, it could be judged as internal fixation failure, which should be replaced during the second operation. The clinical diagnosis was revised twice, and the final clinical healing results were observed. Results Clinical diagnosis analysis and finite element wall thickness analysis were carried out in 48 patients during each review period, and 21 cases of delayed bone healing and 27 cases of bone nonunion were judged clinically. Among them, 2 cases were judged to be ineffective, and bone grafting intervention was adopted to replace the internal fixation, 12 cases were judged to be still effective, and all cases were finally healed by surgical intervention of bone grafting alone. By Bowker test, P=0.094 was obtained, indicating that the wall thickness analysis method was consistent with the clinical diagnosis. Conclusions The wall thickness analysis method can be used to quantitatively analyze the degree of bone healing at fracture end and realize the rapid calculation of bone healing degree. The case results in this study show that the finite element wall thickness analysis method is superior to the simple clinical diagnosis method, and has better differential diagnostic significance for early diagnosis of poor bone healing.

Clavo Intramedular de Sign en Rodilla Flotante: Una serie de casos / Sign Intramedullary Nail in 'Floating Knee". A Case Series Report.

INTRODUCCIÓN: El concepto de "rodilla flotante" describe fracturas ipsilaterales del fémur y la tibia, donde la rodilla está desconectada del resto de la extremidad. El mecanismo suele ser un trauma de alta energía. Las tasas de infección, no unión, malunión y rigidez de la rodilla, pérdida excesiva de sangre, embolia grasa, son relativamente altas; lo que lleva a un deterioro funcional y con frecuencia resultados no satisfactorios. La reducción definitiva inmediata y fijación de las fracturas por clavo intramedular disminuye la incidencia de complicaciones. MATERIALES Y MÉTODOS: Se realizó un estudio descriptivo, serie de casos de 7 pacientes tratados con el Clavo Intramedular de SIGN (Surgical Implant Generation Network); para establecer resultados funcionales, lesiones concomitantes, complicaciones y ventajas del clavo en nuestra práctica. RESULTADOS: La mayoría de pacientes fueron del sexo masculino, con una media de 26 años de edad. Todas las lesiones fueron producidas en accidentes de tráfico, el 50% de las fracturas fueron expuestas. Según la clasificacion de Blake & McBryde, 6 fueron de Tipo I y un caso tipo IIa. Los resultados funcionales se evaluaron según los criterios de Karlström&Olerud; excelentes y buenos resultados se obtuvieron en el 85% de los casos. Todas las fracturas consolidaron; se describe un caso de infección superficial y un paciente presentó acortamiento de miembro <3cms y limitación menor del rango de movilidad de la rodilla. CONCLUSIÓN: El CIM de SIGN resultó eficiente y versátil en el tratamiento de rodilla flotante en adultos. Con buenos resultados funcionales (85%) y baja incidencia de complicaciones.

BACKGROUND: "Floating knee" describes ipsilateral fractures of the femur and tibia, where the knee is disconnected from the rest of the limb. The mechanism is usually a high-energy trauma. Rates of infection, lack of union, stiffness of the knee, excessive blood loss, fat embolism, are relatively high; leading to functional impairment and often unsatisfactory results. Immediate definitive reduction and fixation of fractures by intramedullary nail reduces the incidence of complications. METHODS: A descriptive study was carried out, a case series report of 7 patientes treated by the SIGN Intramedullary Nail (IMN); to establish the functional results, concomitant injuries, complications and advantages of this nail, in our practice. RESULTS: The majority of the patients were male, with a mean age of 26 years. All injuries were caused in traffic accidents, 50% of the fractures were exposed fractures. According to the Blake & McBryde classification, 6 were Type I and one case Type IIa. Functional results were evaluated according to the Karlström and Olerud criteria; excellent and good results were obtained in 85% of cases. All of the fractures healed; one case of superficial infection was described, one patient presented limb shortening <3 cm and minor limitation of the knee motion range. CONCLUSION: The SIGN intramedullary nail, was efficient and versatile for the treatment of floating knee in adults. It had good functional results (85%) and low incidence of complications.

Modelo predictivo de la no unión de tibia / Tibia non union predictive model

OBJETIVOS: Estimar un modelo predictivo para la no-unión en pacientes que presentan fractura de tibia. MATERIALES Y MÉTODOS: Estudio de cohorte retrospectivo, en pacientes con fractura de tibia operadas entre 2012 y 2018, con un mínimo de 12 meses de seguimiento, excluyendo amputaciones traumáticas. Realizamos un modelo de regresión logística con 13 variables descritas en la literatura. Se descartaron las variables estadísticamente no significativas y las que no causaban efecto de confusión. Se evaluó la bondad de ajuste mediante el test de Hosmer-Lemeshow y la discriminación del modelo con la curva ROC. RESULTADOS: Se incluyeron 411 fracturas de tibia, las variables estadísticamente significativas fueron: exposición ósea OR » 2,57(IC:1,15­5,75, p » 0,022), diabetes OR » 3,29 (IC:1,37­7,91, p » 0,008) y uso de tutor externo OR » 1,77(IC:0,81­3,85), el que tuvo efecto de confusión. La bondad de ajuste demostró que los datos se ajustan adecuadamente al modelo (p » 0,35). La curva ROC demuestra un 70,91% de poder discriminatorio. Al evaluar aisladamente las fracturas expuestas, no hubo asociación estadísticamente significativa con ninguna variable. DISCUSIÓN: Al evaluar el modelo, obtuvimos una asociación estadísticamente significativa entre: no unión, exposición ósea, diabetes y uso de tutor externo, información concordante con la literatura. Al estudiar el subgrupo de fracturas expuestas, las demás variables son estadísticamente no significativas. Eso refleja que la exposición ósea es la variable que confiere mayor riesgo. El seguimiento adecuado de esos pacientes es fundamental dado este alto riesgo de evolucionar con no-unión. CONCLUSIÓN: En nuestra serie, la exposición ósea es el factor de riesgo más importante para presentar no unión de tibia.

OBJECTIVES: Estimate a predictive model for non-union in patients presenting with a tibial fracture. MATERIALS AND METHODS: Retrospective cohort study in patients with tibia fractures operated between 2012 and 2018, with a minimum follow-up of 12 months, excluding traumatic amputations. We performed a multivariate logistic regression model with 13 variables described in the literature. The variables that were statistically non-significant and those variables that do not cause confusion, were discarded. Goodness of fit was evaluated using the Hosmer-Lemeshow test and the discrimination of the model with the ROC curve. RESULTS: 411 tibial fractures were included, the statistically significant variables were: bone exposure OR » 2.57(CI:1.15­5.75, p » 0.022), diabetes OR » 3.29(CI:1.37­7.91, p » 0.008) and use of external fixation OR » 1.77(CI:0.81­3.85), being included in the model because of its confounding effect. Goodness of fit demonstrates that the data fit the model adequately(p » 0.35). The ROC curve demonstrates 70.91% discriminatory power. When evaluating the exposed fractures in isolation, there was no statistically significant association with any variable. DISCUSSION: When evaluating the model, we obtained a statistically significant association between non-union, bone exposure, diabetes and use of external fixation, being consistent with the literature. When studying the subset of exposed fractures, the other variables are statistically non-significant. This reflects that bone exposure is the variable that confers the greatest risk. Proper follow-up of these patients is essential given this high risk of evolving with non-union. CONCLUSION: In our series, bone exposure is the most important risk factor for presenting tibial non-union.

Comparison of hidden blood loss between minimally invasive percutaneous locking plate fixation and intramedullary nail fixation in the treatment of tibial shaft fracture / 中国骨伤

OBJECTIVE@#To analyze and compare the hidden blood loss of minimally invasive percutaneous plate osteosynthesis(MIPPO) combined with locking plate fixation and intramedullary nail fixation in the treatment of tibial shaft fracture.@*METHODS@#One hundred and ninety-one cases of tibial shaft fracture treated from January 2017 to January 2019 were analyzed retrospectively. The patients were all treated with closed reduction and divided into two groups:group A (110 cases) and group B (81 cases). In group A, 78 males and 32 females were treated with MIPPO combined with locking plate. The age ranged from 19 to 74 (45.32±11.79) years old. According to AO classification, 42cases were type 42-A, 45 were type 42-B and 23 were type 42-C fractures. Group B was treated with intramedullary nail, including 65 males and 16 females, aged 19 to 84 (45.44± 14.32) years old. According to AO classification, there were 39 cases of type 42-A, 29 cases of type 42-B and 13 cases of type 42-C. The operation time, intraoperative blood loss and hidden blood loss were observed and compared between the two groups.@*RESULTS@#On the first day, the hidden blood loss was (155.27±47.89) ml in group A and (160.43±131.42) ml in group B, the difference was statistically significant (0.05).@*CONCLUSION@#In the treatment of tibial shaft fracture with intramedullary nail, there is obvious hidden blood loss, which is much higher than expected.