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.

Anterolateral Minimally Invasive Plate Osteosynthesis of Distal Tibial Fractures Using an Anterolateral Locking Plate / 대한족부족관절학회지

PURPOSE: Anterolateral minimally invasive plate osteosynthesis (MIPO) was performed to treat patients with distal tibial fractures associated with open fractures or extensive soft tissue injuries, which is limited medial MIPO. The treatment results of the anterolateral MIPO technique were evaluated and analyzed.MATERIALS AND METHODS: Seventeen patients with distal tibial fractures associated with an open fracture or large bullae formation on the distal tibia medial side were treated with anterolateral MIPO using anterolateral locking plates. Within 24 hours of visiting the emergency room, external fixation was applied, and the medial side wound was managed. After damage control, the anterolateral locking plate was applied using an anterolateral MIPO technique. The union time, nonunion, or malunion were evaluated with regular postoperative radiographs. The ankle range of motion, operative time, blood loss, Iowa score, and wound complications were investigated.RESULTS: Radiological evidence of bony union was obtained in all cases. The mean time to union was 16.7 weeks (12~25 weeks). The mean operation time was 44.0 minutes. Regarding the ankle range of motion, the mean dorsiflexion was 15°, and the mean plantarflexion was 35°. Satisfactory results were obtained in 15 out of 17 cases; five results were classified as excellent, four were good, and six were fair. The mean blood loss was 125.2 mL. Two complications were recorded.CONCLUSION: In distal tibial fractures with severe medial soft tissue damage caused by high-energy trauma, the staged anterolateral MIPO technique using anterolateral locking plates is a useful alternative treatment to achieving optimal wound care, rapid union with biological fixation, and intra-articular reduction.

Outcome Analysis of Distal Tibial Fractures Managed by Open Reduction Internal Fixation using Plate Osteosynthesis

Introduction: Fracture of the distal tibia is one of the common fractures encountered by an orthopedic surgeon. Many studieshave been associated even as little as 1 mm incongruence of articular surface landed with worst outcome. Distal tibial fracturesare complicated by poor bone stock, soft tissue complication, poor vascularity leading to nonunion, gross comminution, andmalalignment.Aim: The aim of the study was to evaluate functional outcome analysis of distal tibial fractures managed by open reductioninternal fixation using plate osteosynthesis.Materials and Methods: This was a prospective study conducted at KAPV Medical College, Tiruchirappalli. A total of 20 patientswere treated with distal tibial plating. Fibular plating was done in eight of these patients. Patients were analyzed using Karlströmand Olerud scoring system, with follow-up of 3–18 months.Results: Ten patients had excellent functional results, six patients had good results, three patients had acceptable results,and 1 patient had a poor result. Quality and vascularity of bone seem to influence the outcome to a large extent.Conclusion: Based on our study, we conclude that distal tibial fractures managed with plate minimally invasive plateosteosynthesis technique allow early mobilization of the patients and provide a good functional outcome.

​Outcome Analysis of Distal Tibial Fractures Managed by Open Reduction Internal Fixation Using Plate Osteosynthesis

Introduction: Fracture of the distal tibia is one of the common fractures encountered by an orthopedic surgeon. Many studieshave been associated even as little as 1 mm incongruence of articular surface landed with worst outcome. Distal tibial fracturesare complicated by poor bone stock, soft tissue complication, and poor vascularity, leading to non-union, gross comminution,and malalignment.Aim: The aim of the study was to evaluate the functional outcome analysis of distal tibial fractures managed by open reductioninternal fixation using plate osteosynthesis.Materials and Methods: This a prospective study conducted at KAPV Medical College, Tiruchirappalli. 20 patients treatedwith distal tibial plating. Fibular plating was done in eight of these patients. Patients were analyzed using Karlström and Olerudscoring system, with follow-up of 3–18 months.Results: Ten patients had excellent functional results, six patients had good results, three patients had acceptable results, andone patient had a poor result. Quality and vascularity of bone seem to influence the outcome to a large extent.Conclusion: Based on our study, we conclude that distal tibial fractures managed with plate minimally invasive percutaneousplate osteosynthesis technique allow early mobilization of the patients and provide a good functional outcome.

Comparative Analysis of Minimally Invasive Plate Osteosynthesis and Intramedullary Nailing in the Treatment of the Distal Tibia Fractures

PURPOSE: This study compared the radiological and clinical results of minimally invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) of distal tibial fractures, which were classified as the simple intra-articular group and extra-articular group. MATERIALS AND METHODS: Fifty patients with distal tibial fractures, who could be followed-up more than 12 months, were evaluated. Group A consisted of 19 patients treated with MIPO and group B consisted of 31 patients treated with IMN. The results of each group were analyzed by radiological and clinical assessments. RESULTS: The mean operation times in groups A and B were 72.4 minutes and 65.7 minutes, respectively. The mean bone union times in groups A and B were 16.4 weeks and 15.7 weeks, respectively. The bone union rate in groups A and B were 100% and 93%, respectively. The ranges of ankle motion were similar in the two groups at the last follow-up. The mean American Orthopaedic Foot and Ankle Society score was similar: 90.1 in group A and 90.5 in group B. The radiological and clinical results were similar in the intra and extra-articular groups. In groups A and B, two cases of posterior angulation and five cases of valgus deformity of more than 5° were encountered. CONCLUSION: Both MIPO and IMN achieved satisfactory results in extra-articular AO type A and simple articular extension type C1 and C2 distal tibia fractures.

Management and complications of Distal Tibial fractures

Background: Management of distal tibal fractures is a great challenge. This type of fractures has high complication rate. Materials and methods: 86 fractures on 86 patients were studied during the period of 2015 to 2017 April. Intramedullary nailing, internal fixation, external fixation and conservative treatment were used. Treatment outcome was measured by occurrence of complications, radiographic analysis, evaluation of the American orthopaedic foot and ankle society (AOFAS) ankle score and measures of the ankle range of motion. Results: The average functional score was 79 points and complications occurred in 16 patients. Conclusion: Poor results were due to complications, fracture severity and use of external fixation. So we recommended external fixation must reserve for trauma with severe kin injury and other cases can be treated by traditional open reduction and internal fixation with early mobilisation

Minimally invasive percutaneous plate osteosynthesis treatment of distal tibial fractures / 中国医师进修杂志

Objective To explore the clinical application and efficacy of minimally invasive percutaneous plate osteosynthesis (MIPPO) treatment of distal tibial fractures.Method From March 2007 to February 2013,MIPPO technology locking compression plate for the treatment of 49 cases of distal tibial fractures,including 12 cases of open fractures,37 cases of closed fractures involving the articular surface 7 cases,38 cases of fracture reduction and limited open reduction of 11 cases.Results Forty-nine patients were followed up for 6-24 months,an average of 12 months,1 case of a finite complex open reduction and nonunion,and re-open reset grafting healing,2 cases of distal tibial fractures delayed healing.The mean healing time was 4.9 months,press the Johner-Wruhs score,excellent in 42 cases,good in 5 cases,and middle in 2 cases.Excellent rate of 95.9％ (47/49).Conclusion MIPPO technology locking compression plate fixation of distal tibial fracture trauma,can reduce the interference of the blood supply of the fracture,fracture healing rate and reduce the rate of infection,is the ideal treatment of distal tibial fractures.

Minimally Invasive Percutaneous Plate Osteosynthesis Using a Lateral Plate in Distal Tibial Fracture

PURPOSE: To evaluate the efficacy of minimally invasive percutaneous plate osteosynthesis (MIPPO) using a lateral plate (Zimmer, Periarticular Lateral Distal Tibial Plates, USA) in distal tibial fracture within 3 cm to plafond, associated with medial soft tissue damage. MATERIALS AND METHODS: From January 2005 to December 2007, 15 patients with distal tibial fracture treated by MIPPO technique using a lateral plate were analyzed. The duration of follow-up was more than 1 year. We evaluated union time by simple X-ray, clinical results by IOWA ankle rating system, and complication. RESULTS: The bone union was achieved in all cases at average 16.7 weeks. Evaluation of the ankle function test showed an average of 90.3 points, resulting in satisfactory. At the last follow-up, there was no non-union, angular deformity more than 5 degrees or infection. CONCLUSION: We concluded that MIPPO technique using a lateral plate is a efficient method for high functional recovery with good bone healing and low complication in distal tibial fracture within 3 cm to plafond, associated with medial soft tissue damage.

Staged Minimally Invasive Plate Osteosynthesis of Distal Tibial Fractures

PURPOSE: To assess the result of staged minimally invasive plate osteosynthesis (MIPO) for distal tibial fracture with an open wound or injured soft tissue. MATERIALS AND METHODS: In 20 patients (mean age, 47.8 year-old) with distal tibial fractures, there were 4 type A fractures and 16 type C fractures based on the AO classification system. Eight of the 20 patients had open fractures. MIPO was performed on average 23.9 days after bridging external fixation. At the final follow-up, we assessed the radiological results of bone union and alignment. Functional results were also evaluated by measuring the degrees of ankle motion and the American Orthopedic Foot & Ankle Society (AOFAS) scores. RESULTS: Seventeen of 20 cases (85%) achieved primary union at an average of 21.3 weeks. There were 3 cases of nonunion requiring a bone graft. The mean AOFAS score was 88.5 (range, 67~92) and the average range of ankle motion was 49.2degrees (plantarflexion: 37.4degrees, dorsiflexion: 11.8degrees). Complication included 2 cases of minor mal-alignment, 1 case of claw toe and 1 case of peroneal neuropathy. Patients over the age of 60 had lower functional results. Additional factors did not affect the final results. CONCLUSION: Staged MIPO may achieve satisfactory results in distal tibial fractures with soft tissue compromise, decreasing deep infections and soft tissue complications.

A Comparative Study of Interlocking IM Nailing and LCP Fixation through MIPPO Technique in the Treatment of Distal Metaphyseal Tibial Fracture / 대한족부족관절학회지

PURPOSE: To evaluate and compare the outcome between interlocking IM nailing and LCP fixation in the treatment of distal metaphyseal tibial fracture. MATERIALS AND METHODS: From January 2000 to December 2007, 17 patient were treated by interlocking IM nail and 13 patient were treated by LCP fixation for distal metaphyseal tibial fracture. RESULTS: According to AO classification, there were 2 type A1 fracture (12%), 6 type A2 fracture (36%), 3 type A3 fracture (18%), 4 type B1 fracture (24%), 1 type B3 fracture (6%), 1 type C1 fracture (6%) in interlocking IM nailing group and 1 type A2 fracture (7.7%), 2 type A3 fracture (15.4%), 3 type B1 fracture (23%), 3 type B2 fracture (23%), 3 type C1 fracture (23%), 1 type C2 fracture (7.7%) in LCP fixation group. The clinical functional outcome (according to AOFAS score) is 75.6 point in IM nailing group and 81.5 point in LCP fixation group. In IM nailing group, 65% of patient showed satisfactory result and In LCP fixation group, 77% of patient showed satisfactory result. CONCLUSION: There is no difference on clinical results between IM nailing and MIPPO (minimal invasive percutaneous plate osteosynthesis) group in the treatment of distal tibia fracture. But MIPPO group have higher subjective satisfactory score and less complication rate. The weakness of our study is a small case number and limited follow-up and we believe a better designed prospective study will be needed.

Mid-term Results of Distal Tibial Fractures Treated with Ilizarov External Fixator

PURPOSE: We analyed the mid-term results of distal tibial fractures treated with ilizarov external fixator and functional results according to delayed metaphyseal healing and fracture pattern. MATERIALS AND METHODS: We reviewed 23 distal tibial fractures treated with ilizarov external fixator followed for minimum two year (mean 53 months). There were 10 A fractures, 2 B fractures, and 11 C fractures according to the AO classification. Radiographically, we analyzed bony union time according to translation of diaphyseal-metaphyseal fracture line and assessed arthritic score. Functional results was assessed with AOFAS score and analyzed according to delayed healing and fracture pattern. RESULTS: Average union time was 21 weeks. Delayed healing of metaphyseal fracture line was associated translational displacement >3 mm (p=0.01). AOFAS scrore was averaged to 68 and there was no stastical significance between delayed metaphyseal healing and functional results (p=0.31). But, low AOFAS score and arthritis score was related to fracture type (p=0.02). In 11 C fractures, radiographic arthritic change were developed in 6 cases (55%). CONCLUSION: The main prognosis of distal tibial fractures depends on articular involvement and to shorten the external fixation time, metaphyseal fracture should be reduced within 3mm.

Mid-term Results of Distal Tibial Fractures Treated with Ilizarov External Fixator

PURPOSE: We analyed the mid-term results of distal tibial fractures treated with ilizarov external fixator and functional results according to delayed metaphyseal healing and fracture pattern. MATERIALS AND METHODS: We reviewed 23 distal tibial fractures treated with ilizarov external fixator followed for minimum two year (mean 53 months). There were 10 A fractures, 2 B fractures, and 11 C fractures according to the AO classification. Radiographically, we analyzed bony union time according to translation of diaphyseal-metaphyseal fracture line and assessed arthritic score. Functional results was assessed with AOFAS score and analyzed according to delayed healing and fracture pattern. RESULTS: Average union time was 21 weeks. Delayed healing of metaphyseal fracture line was associated translational displacement >3 mm (p=0.01). AOFAS scrore was averaged to 68 and there was no stastical significance between delayed metaphyseal healing and functional results (p=0.31). But, low AOFAS score and arthritis score was related to fracture type (p=0.02). In 11 C fractures, radiographic arthritic change were developed in 6 cases (55%). CONCLUSION: The main prognosis of distal tibial fractures depends on articular involvement and to shorten the external fixation time, metaphyseal fracture should be reduced within 3mm.

Internal Fixation with Two Lowprofile Plates in Fractures of the Distal Tibia

PURPOSE: To evaluate the functional results after internal fixation with two low profile plates in fractures of the distal tibia. MATERIALS AND METHODS: From March 1998 to October 2002, twelve patients with fractures of the distal tibia were treated with internal fixation using two low profile plates and followed for at least one year. Fractures according to AO/OTA classification were one Type A1, four Type A2, two Type C1, two Type C2 and three Type C3. We analyzed the functional results by the Olerud and Molander ankle scoring system and the postoperative complications. RESULTS: The average functional score was 81.2 points and the results were three excellent, six good, one fair and two poor. Bony union was achieved in all cases. There was 1 case of superficial wound infection as a complication. CONCLUSION: Internal fixation with two low profile plates in fractures of the distal tibia may minimize the incidence of soft tissue complications and provide good bony union and functional results. Therefore, we consider internal fixation with two low profile plates as a good alternative treatment of the distal tibial fracture.

Treatment of distal tibial fracture with unilateral half-pin external fixation / 中国微创外科杂志

Objective To explore the surgical result of unilateral half-pin external fixation in the treatment of distal tibial fracture. Methods For type A fracture, two pins were inserted into the proximal fragment of tibia fracture and another two pins into the distal fragment; for type B and C fracture, distal pins were inserted into the talus and calcaneus. The fracture reduction was performed by distraction of external fixators. A limited open reduction was required in some difficult cases to restore the joint surface, with bone grafting and small fragments fixed with wires or screws. Meanwhile, fracture of fibula was fixed with plate and screws. Results The duration of external fixation was 3.5~8 months (mean, 5 months) in 22 patients. Bone union was achieved in all patients, without serious deep infection, osteomyelitis, or non-union. The patients were followed for 10~32 months (mean, 20 months). Functional exercise was carried out for more than 6 months after the removal of the external fixator. According to the Tornetta’s evaluation standard, excellent results were obtained in 11 patients, good in 7 patients, fair in 3, and poor in 1. Conclusions Unilateral half-pin external fixation combined with limited open reduction and internal fixation is a simple and effective minimally invasive method for the treatment of distal tibial fracture.

Anterolateral Approach for the Distal Metaphyseal Fracture of the Tibia

PURPOSE: The purpose of this study is to evaluate the effectiveness of anterolateral approach of the ankle for the distal tibial fracture in aspect of preventing complication and acquiring union. MATERIALS AND METHODS: Authors reviewed 21 patients of distal metaphyseal fracture of the tibia treated by anterolateral approach and lateral plating method from February, 2000 to May, 2002. Mean follow-up period was 17 months (12~29 months). There were twelve type A, two type B, and four type C patients according to AO/OTA classification. We have analyzed the bone union rate and Ovadia`s functional scale. We also reviewed the complication rate, such as soft tissue problem and postoperative infection. RESULTS: In all cases union was achieved and mean time to union were 16 weeks. The functional result by Ovadia's scale were 17 excellent cases and 4 good cases in objective evaluation, and 19 excellent cases and 2 good cases in subjective evaluation. Wound infection occurred in one case, but the infection was controlled after plate removal and the union was acquired through cast immobilization. There was no other complication, such as soft tissue necrosis. CONCLUSION: The anterolateral approach is a safe and worthwhile method for distal tibia fracture while avoiding some of the complication associated with standard anteromedial approach and plating method.