Caracterización de fracturas abiertas de tibia / Characterization of Open Tibial Fractures

Introducción: Las fracturas diafisiarias de la tibia son las que con mayor frecuencia encuentran los cirujanos ortopédicos en su práctica habitual. La fractura expuesta de tibia es una urgencia quirúrgica que requiere desbridamiento, lavado, reducción y estabilización de los fragmentos óseos lo antes posible, e inicio de la administración de antibióticos profilácticos. Objetivo: Caracterizar los pacientes con fractura expuesta de tibia grado II y IIIA, tratados mediante estabilización con clavo acerrojado intramedular, identificando mecanismo de producción, número de intervenciones quirúrgicas por paciente, así como las principales complicaciones encontradas. Método: Estudio observacional, descriptivo, ambispectivo y de corte transversal en pacientes con fractura abierta de tibia, tratados quirúrgicamente con clavo acerrojado intramedular. Resultados: La edad de los pacientes osciló entre 21 y 69 años. Predominó el sexo masculino (65,4 porciento), la mayor causa traumática fueron los accidentes en la vía pública (37 pacientes); predominaron las fracturas del tercio medio abiertas grado IIIA con estadía hospitalaria menor de 10 días, y complicaciones en la tercera parte de los pacientes. Conclusiones: Se observó mayor incidencia en pacientes masculinos en edades comprendidas entre 18 y 29 años por accidentes del tránsito. La localización habitual fue el tercio medio y más de la mitad fueron clasificadas como grado IIIA de la tipología de Gustilo y Anderson(AU)

Introduction: Diaphyseal fractures of the tibia are those most frequently treated by orthopedic surgeons in their common practice. The exposed fracture of the tibia is a surgical emergency that requires debridement, lavage, reduction and stabilization of the bone fragments as soon as possible, and initiation of the administration of prophylactic antibiotics. Objective: To characterize patients with grade II and IIIA exposed tibial fracture, treated by stabilization with an intramedullary nail, identifying production mechanism, number of surgical interventions per patient, as well as the main complications found. Method: An observational, descriptive, ambispective and cross-sectional study in patients with an open fracture of the tibia treated surgically with an intramedullary locking nail. Results: The age of the patients ranged between 21 and 69 years. Male sex predominated (65.4 percent), the major traumatic cause was accidents on public roads (37 patients); Grade IIIA open middle third fractures predominated with hospital stays of less than 10 days, and complications in a third of the patients. Conclusions: High incidence was observed in male patients between the ages of 18 and 29 due to traffic accidents. The usual location was the middle third and more than half were classified as grade IIIA of Gustilo and Anderson typology(AU)

Osteosíntesis mínima invasiva percutánea con placa en fractura de tibia distal / Percutaneous Minimally Invasive Plate Osteosynthesis in Distal Tibial Fracture

Introducción: Las fracturas diafisarias de la tibia tienen una alta incidencia por año, incluidas las del tercio distal. Son las más frecuentes de los huesos largos y se observan sobre todo en adultos jóvenes. Se producen, generalmente, por traumatismos de alta energía como accidentes del tránsito y caídas de alturas. Objetivo: Presentar los resultados del tratamiento realizado a un paciente con fractura extrarticular del tercio distal de la tibia, mediante una técnica de osteosíntesis percutánea mínimamente invasiva. Presentación del caso: Paciente de 45 años, masculino, de piel blanca que sufrió accidente del tránsito, y fue atendido en el servicio de Ortopedia y Traumatología del Hospital General Docente Dr. Antonio Luaces Iraola, con trauma en pierna izquierda. Presentó dolor, inflamación e imposibilidad para caminar. A la exploración física se constató dolor, deformidad, crepitación, movilidad anormal, aumento de volumen e impotencia funcional absoluta. Se realizó radiografía, se corroboró diagnóstico y se decidió tratamiento quirúrgico con técnica mínima invasiva percutánea. Se siguieron los principios de la osteosíntesis biológica y se utilizó placa de segunda generación del sistema AO. Conclusiones: El tiempo quirúrgico fue de 45 minutos, la estadía hospitalaria fue de 48 horas. Se comenzó apoyo parcial a las ocho semanas, y total a las 15 semanas. Se logró la consolidación total de la fractura a las 16 semanas de operado, evaluado de excelente a través de la American Orthopaedic Foot and Ankle Society (AOFAS) score(AU)

Introduction: Diaphyseal fractures of the tibia have high incidence per year, including those of the distal third. They are the most common of the long bones and are seen mostly in young adults. They are generally caused by high-energy trauma such as traffic accidents and falls from heights. Objective: To present the results of the treatment on a patient with extra-articular fracture of the distal third of the tibia, using minimally invasive percutaneous osteosynthesis technique. Case report: A white 45-year-old male patient was injured in a traffic accident, and he was treated in the Orthopedics and Traumatology service at Dr. Antonio Luaces Iraola General Teaching Hospital, because of a trauma to his left leg. He had pain, swelling and inability to walk. Physical examination revealed pain, deformity, crepitus, abnormal mobility, increased volume, and absolute functional impotence. X-rays were performed. The diagnosis was confirmed, and surgical treatment was decided with a minimally invasive percutaneous technique. The principles of biological osteosynthesis were followed and a second generation plate of AO system was used. Conclusions: The surgical time was 45 minutes. The hospital stay was 48 hours. Partial support of the leg was started at eight weeks, and full support at 15 weeks. Full fracture healing was achieved 16 weeks after surgery, the procedure was evaluated as excellent according to the American Orthopedic Foot and Ankle Society (AOFAS) score(AU)

Fracturas avulsivas tibiales del ligamento cruzado posterior fijadas con tornillos: un estudio clínico y radiológico / Screw fixation of posterior cruciate ligament tibial avulsion fractures: a clinical and radiographic study

OBJETIVO: Realizar la evaluación clínica, imagenológica y funcional de pacientes con fracturas avulsivas tibiales del ligamento cruzado posterior (FTALCPs) fijadas con tornillos canulados con técnica abierta. MÉTODOS: Los pacientes con FTALCP operados entre 2010 y 2017 fueron revisados retrospectivamente. Criterios de inclusión: fracturas agudas, desplazadas, test de cajón posterior grado III, lesiones combinadas de rodilla, seguimiento > 12 meses. Se excluyeron pacientes > 65 años, con FTALCPs bilaterales, lesiones del ligamento cruzado posterior (LCP) intrasustancia, test de cajón posterior grados I-II, fracturas expuestas, lesiones neurovasculares, y seguimientos < 12 meses. Objetivo primario: medir la estabilidad clínica mediante test de cajón posterior y radiografía de estrés arrodillada comparativa. Objetivos secundarios: nvaluar la consolidación en radiografías, complicaciones y funcionalidad con las escalas de Lysholm y Tegner. Resultados Se incluyeron 20 pacientes, con edad media de 41 años (rango: 32 a 61 años). El seguimiento promedio fue de 33,9 meses (rango: 12 a 82 meses). La estabilidad clínica mejoró en 93% (cajón posterior postoperatorio grados 0 y I) de los pacientes. La radiografía de estrés arrodillada mostró una diferencia promedio de 2,6 mm (rango: 0,1 mm a 6,8 mm) de traslación posterior al comparar con el lado sano. Todas las fracturas consolidaron. Siete pacientes presentaron complicaciones. El puntaje promedio de la escala de Lysholm al final del seguimiento fue de 85,17. El promedio preoperatorio del puntaje en la escala de Tegner no varió significativamente en comparación con el postoperatorio. CONCLUSIONES: La fijación de fracturas avulsivas tibiales del LCP con tornillos canulados con técnica abierta es efectiva en restaurar la estabilidad posterior y lograr la consolidación ósea. La funcionalidad clínica a mediano plazo es buena, a pesar del alto número de complicaciones y lesiones concomitantes. NIVEL DE EVIDENCIA: tipo IV.

OBJECTIVE: To report mid-term clinical, radiographic, and functional outcomes following open reduction and fixation of posterior cruciate ligament tibial avulsion fractures (PCLTAFs) with cannulated screws. METHODS: This is a retrospective analysis of patients with PCLTAF operated on from August 2010 to April 2017. Patients with acute fractures, with more than 2 mm of displacement and grade III on the posterior drawer test, combined or not to knee injuries, were included. Patients older than 65 years of age, with bilateral avulsion fractures, intrasubstance posterior cruciate ligament (PCL) lesions, stable grade-I to -II on the posterior drawer test, concomitant neurovascular injuries, mid-substance tears, open fractures, and less than 12 months of follow-up were excluded. Primary outcomes: the clinical stability was assessed using the posterior drawer test and a single comparative knee stress radiograph. Secondary outcomes: radiographic consolidation, complications, Lysholm score, and Tegner activity score. RESULTS: In total, 20 patients with a mean age of 41 years (range: 32 to 61 years) were included. The mean follow-up was of 33.9 months (range: 12 to 82 months). Clinical stability (grade 0 or I on the posterior drawer test) was observed in 93% of the patients. The mean difference in contralateral posterior displacement was of 2.6 mm (range: 0.1 mm to 6.8 mm) on a single comparative knee stress radiograph. All fractures presented radiological consolidation. Seven patients developed complications. The mean Lysholm score at the last follow-up visit was of 85.17. The postoperative Tegner activity scores did no vary significantly compared to the preinjury scores. CONCLUSIONS: Cannulated screw fixation of a displaced PCLTAF through a posterior approach restores clinical and radiographic stability and has excellent union rates. The mid-term functional outcomes are good despite the high rates of combined knee lesions and postoperative complications. LEVEL OF EVIDENCE: IV.

Fractura de Toddler. Reporte de un caso y revisión de la literatura / Toddler's fracture, case report and review of literature

Resumen: Introducción: La sospecha del diagnóstico de una fractura de Toddler a menudo es complicada debido a una historia poco clara, a la falta de hallazgos específicos en la clínica y a la ausencia de cambios evidentes en las radiografías iniciales. Presentamos el caso de una infante de tres años y siete meses de edad con el antecedente de caída desde su propia altura con mecanismo de rotación del miembro pélvico izquierdo. La finalidad de este escrito es describir la etiología, patología, diagnóstico y el manejo terapéutico en este tipo de fracturas. Discusión: La historia clínica, la exploración física y el uso de estudios de imagenología ayudan a identificar las fracturas de Toddler, patología que debe ser conocida por médicos especialistas para su manejo ideal.

Abstract: Introduction: The suspected diagnosis of a Toddler's fracture can often be complicated by an unclear history, the lack of specific clinical findings and the absence of obvious changes in the initial radiographs. We present the case of an infant of 3 years and 7 months old with a history of falling from her own height with a rotation mechanism of the left pelvic limb. The purpose of this paper is to describe the etiopathology, diagnosis and therapeutic management of these fractures. Discussion: The clinical history, physical examination and the use of imaging studies help identify Toddler's fractures, pathology that must be known to medical specialists for an ideal treatment.

External Fixation Using Femoral Less Invasive Stabilization System Plate in Tibial Proximal Metaphyseal Fracture

BACKGROUND: The locking plates are often used for internal fixation of closed tibial fractures. The use of a locking plate as an external fixator is still controversial, particularly for closed fractures. The purpose of this study is to evaluate the results of external fixation using the femoral less invasive stabilization system (LISS) plate in proximal metaphyseal fractures of the tibia. METHODS: We prospectively evaluated 35 patients (26 males and 9 females) with a mean age of 42 years (range, 21 to 62 years) who presented with fresh tibial proximal metaphyseal fractures. According to the AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification, the fractures were identified as type 41-A2 in 18 cases and type 41-A3 in 17 cases, including 25 closed fractures and 10 open fractures. The femoral LISS plate was used to fix these fractures, which was placed on the anteromedial aspect of the tibia as an external fixator. The mean follow-up period was 18 months (range, 13 to 22 months). RESULTS: All fractures healed in a mean time of 14 weeks (range, 10 to 20 weeks). There was no case of nonunion, deep infection, and loosening of screws and plates. One month after the appearance of cortical bridging on biplanar radiographs, the locking plate was removed within 3 minutes in the clinic without any difficulty. According to the Hospital for Special Surgery (HSS) knee scoring system and American Orthopaedic Foot & Ankle Society (AOFAS) ankle scoring system, the mean HSS score was 91 (range, 85 to 100) and 98 (range, 93 to 100), and the mean AOFAS score was 94 (range, 90 to 100) and 98 (range, 95 to 100) at 4 weeks postoperatively and final follow-up, respectively. CONCLUSIONS: For proximal metaphyseal fracture of the tibia, external fixation using the femoral LISS plate is a safe and reliable technique with minimal complications and excellent outcomes. Its advantages include ease of performing the surgery, use of a less invasive technique, and convenience of plate removal after fracture healing.

Tomographic imaging of fragmented cortical bone heteroimplant and methylmethacrylate in segmental bone defect of rabbit tibia

PURPOSE: To evaluate the performance of composites consisting of fragmented cortical bone heteroimplant in association with methylmethacrylate preserved in 98% glycerin, in segmental bone defect of rabbit tibia medial metaphysis. METHODS: In this study were used twelve adult New Zealand rabbits, divided into three groups of four animals each: G30 (30 days), G60 (60 days) and G90 (90 days). The bone defects previously created in the tibia were filled with composites and both were evaluated by cone-beam computed tomography, immediately after surgery and after 30, 60, and 90 days. RESULTS: The composites fulfilled and remained in the sites of bone defects in all cases and were not registered signals of infection, migration or rejection. CONCLUSIONS: The implanted composites promoted the bone defects repair without signals of infection and/or rejection. The composites are one more option for bone defects repair.

Locking Plate in Proximal Tibial Fracture: A Correlation between the Coronal Alignment of Tibia and Joint Screw Angle

PURPOSE: The purpose of this study is to evaluate the relationship between the angle formed between the proximal most screw through the locking compression plate-proximal lateral tibia (LCP PLT) and the joint line, and to evaluate if this angle can be used intraoperatively as an assessment tool to determine normal alignment of the tibia in the coronal plane. MATERIALS AND METHODS: There are two parts to this study: in the first part, LCP PLT was applied to 30 cadaveric adult tibia. The angle between the joint line and the proximal most screw was measured and termed as the 'joint screw angle' (JSA). In the second part, 56 proximal tibial fractures treated with LCP PLT were retrospectively studied. Two angles were measured on the radiographs, the medial proximal tibial angle (MPTA) and the JSA. Their relationship was analyzed statistically. RESULTS: The average JSA was 1.16 degrees in the anatomical study. Statistical analysis of the clinical study showed that the normal MPTA had a direct correlation with an acceptable JSA. CONCLUSION: We therefore conclude that the JSA can be used intraoperatively to assess the achievement of a normal coronal axis.

Surgical Management of Ipsilateral Fracture of the Femur and Tibia in Adults (the Floating Knee): Postoperative Clinical, Radiological, and Functional Outcomes

BACKGROUND: This study evaluated the outcomes of surgical management of ipsilateral femoral and tibial fractures in adults. METHODS: Fifteen patients (13 men, 2 women; mean age, 34.8 years; range, 18 to 65 years) were enrolled in this study. The fractures types were classified according to the classification by Fraser et al. as follows: type I (5), type IIa (3), IIb (4), IIc (3). Femur fractures were treated using locked intramedullary nails, plate-screws, or dynamic condylar screws, and tibia fractures were treated with an external fixator (in open fractures), or plate-screws, and locked intramedullary nailing. The mean follow-up duration was 2.2 years (range, 1.3 to 4 years). RESULTS: The extent of bony union according to the Karlstrom criteria was as follows: excellent, 8; good, 4; acceptable, 2; poor, 1. CONCLUSIONS: The associated injuries and type of fracture (open, intra-articular, comminution) are prognostic factors in a floating knee. The best management of the associated injuries for good final outcome involves intramedullary nailing of both the fractures and postoperative rehabilitation.

Effects of low intensity pulsed ultrasound on healing of denervated Tibial fracture in the rabbit

Low intensity pulsed ultrasound [LIPUS] has been shown in healing of fractures. This study investigates the effect of LIPUS as a fracture-healing adjunct on the denervated tibial fractures in rabbit model. Twenty four male Dutch rabbits were randomly divided into four groups including two control and two ultrasound-treated [US-treated] groups. A standardized mid-tibial osteotomy was performed in the right tibia. Ipsilateral sciatic nerve was cut two centimeter above the right knee. After three days, the rabbits of US-treated groups received the therapeutic dose [100 mW/cm[]] of ultrasound for 15 minutes per day until the 6th and 8th week and the control groups did not receive any treatment. The rabbits were sacrificed at weeks 6th and 8th post surgery and the external fixator and tibia were carefully removed. Radiographs were taken by lateral and anteroposterior views. Mechanical testing of rabbit's tibiae was used. The specimens were taken from callus of fracture for histomorphometric study of trabecula in the fractured area. Immunohistochemical staining for ki67 was used to evaluate cellular proliferation. Radiographs showed the callus was visible indicating the ossification of the callus tissue without any significant difference between US- treated and control groups. Biomechanical, histomorphic and immunohistochemical evaluations had no significant difference between control and US-treated groups after 6 and 8 weeks postoperation. These finding suggest that ultrasound therapy with features which applied in this study had no significant effect on denervated tibial fracture repair in rabbits

Combined arthroscopic and radiologic management of tibial plateau fractures

Tibial plateau fractures are complex lesions capable of causing severe consequences if not appropriately treated. They are often the result of a high-energy trauma and, not rarely, are associated with significant soft-tissue and intra-articular injuries. Different therapeutic options can be managed in the treatment of these lesions. Minimally invasive surgery offers several advantages compared to other surgical techniques and allows, with less additional soft tissue damages, good reduction and stable fixation of the fracture. The use of arthroscopic and radiologic assistance for treatment of tibial plateau fractures seems reasonable because the fracture and its subsequent reduction can be directly visualized without arthrotomy or meniscal detachment, thereby lessening postoperative morbidity, pain, and stiffness. Associated ligamentous and meniscal injuries may also be better addressed arthroscopically. The purpose of this study is to evaluate the functional and radiographic results and the value of the combined arthroscopic and radiologic treatment of tibial plateau fractures as a minimally invasive method to achieve good congruity. Between January 2005 and December 2008 this study was performed with the combined arthroscopic and radiologic assisted treatment in 19 patients with tibial plateau fractures. We reviewed clinical records and radiographic findings of 18 out of the 19 patients with a minimal follow-up of at least 12 months [range 12 months-3 years]. There were 13 men and 5 women, mean age at injury 36 years old [range 15-61]. One patient refused to participate in the study. In this study we assessed the results of the combined arthroscopic and radiologic assisted reduction and internal fixation of tibial plateau fractures percutaneous with osteosynthesis in 18 patients affected by Schatzker type I, II and III fractures except in two cases plate and screws were applied also arthroscopically without arthrotomy. The indications for operative fixation included any lateral plateau fractures with a varus or valgus instability > 10 degrees, and an articular step off > 3 mm ora condylar widening > 5 mm. Initially, post-operative treatment started with 4 weeks of immobilization in plaster, followed by four weeks of physiotherapy without weight bearing using continuous passive and active motion. In the last cases this period of immobilization was shorter. Weight bearing was allowed after a mean time of 2 months. According to Kohl's and Rasmussen's grading system, 16 out of 18 patients scored as satisfactory result. We experienced no complications due to arthroscopy. All the fractures healed in 3 to 4 months There were no failure of fixation,infection, deep venous thrombosis, compartment syndrome, or arthrofibrosis and osteoarthritis According to the Rasmussen clinical scoring system [Table 1], 8 patients were assessed as excellent, 7 good, 2 fair and 1 poor. Combined arthroscopic and radiologic reduction and internal fixation provides an accurate assessment of, and allows definitive treatment for, intraarticular injuries associated with tibial plateau fractures. The technique allows less soft tissue stripping than with traditional arthrotomy, better visualization of the articular surface, early return to physical activities, and obviates the need for meniscal tear and partial menisectomy did. However, not all types of tibial plateau fractures are amenable to arthroscopic reduction and internal fixation. The split, split depression, and joint depression fracture types in young, active patients with good bone stock are ideally suited for arthroscopic reduction and internal fixation. Randomized, prospective trialsmay be needed to confirm the advantages of arthroscopic reduction and internal fixation in the treatment of tibial plateau fractures compared with conventional open reduction techniques

Arthroscopically-assisted internal fixation of tibial plateau fractures: adding an anti-settling screw

Intra-articular fractures of the proximal tibia can often be troublesome because of the early and late arthritic complications of damage of the articular surface, and intra-articular lesions. There are some potential benefits of arthroscopy in solving some of the pitfalls of these fractures. The purpose of this work is to study these benefits, and the benefits of adding an antiglide screw. Fifty patients with tibial plateau fractures were treated in Assiut University hospital. Of these patients only [16 patients] were included in this study. Fourteen were men, and two were women. The age ranged between 27-60 years [mean 43 years]. Inclusion in this study was limited to cases of split split depression, or local depression unicondylar fractures using Schatzker classification. Mean follow up was 15 months [6-24 months]. The post operative clinical evaluation depended on Rasmussen scoring system. The radiological evaluation was according to Honkonen and Jarvinen. Complete anatomical reduction of the fracture fragments was achieved in 14 knees [87.5%]. Up to 2 mm displacement or step off was accepted in two knees [12.5%]. Clinical assessment according to Rasmussen classification was: 10 knees [62.5%] excellent, 4 knees [25%] good, 2 knees [12.5%] fair, and none was poor. Radilogical results were: 13 knees [81.25%] grade one, 2 knees [12.5%] grade two, and one knee [6.25%] grade three. None of the cases was grade four at the final follow up radiograph. The use of arthroscopy allowed precise anatomic reduction of the articular surface in the knee. It is particularly helpful in type two and three injuries with central articular depression which often are difficult to assess on preoperative imaging studies. It is also helpful in assessing other intra-articular injuries as meniscal tears and/or ligamentous injuries and their management if possible. The antiglide screw may help in prevention of loss of reduction

Biological fixation of complex fractures of tibia and femur with the use of standard plates and specially designed plates

Tibial and femoral fractures of high velocity injuries are managed in our department following principles of internal fixator with high rate of union, good surgical outcome regarding alignment, reduction and function with specially constructed plate making the reconstructive interlocking system of little interest. The radiological follow up shows earlier union with callus formation. The technique is simple and percutaneous under x-ray control. In late follow up there is preservation of the anatomy and respect of subtrochantric region. The number of cases is increasing now almost over a period of time of 5 years including different types of femoral and tibial fractures fresh and old and as we gained more experience we had extended the indications of biological fixation to include cases with mal and non-union. This paper had been presented,discussed and accepted in: The annual international congress of the EOA in december 2003 Mena House, Cairo, Egypt. And the author was awarded

[Fractures of the tibial shaft [Report of 61 cases]]

Sixty one tibial pilon fractures have been collected at the department of orthopaedic and traumatologic surgery. The fracture of the tibial pilon represents 8% of the ankle traumatisms, it is the prerogative of the young person as the mean age of our patients was 36 years old with neat male predominance [71%]. The etiologic circumstances are dominated by the fall of a high place in 52%. The cutaneous lesions were present in 53% of cases. According to Vives classification, the complete complex fractures represent 46% of cases. The surgical treatment by internal osteosynthesis was practiced in 35 cases [57%], the osteosynthesis of the fibula fractures was systematic. The external fixator has been rise in 26 cases [22 Hoffman's type, 4 Ilizarov's type]. The functional results according to Lechevallier's criteria have been good in 30 cases [58%], medium in 11 cases [21%] and bad in 11 cases. We couldn't notice a correlation between functional results and radiological results; the latter's have been good in 20%, satisfactory in 46% and bad in 43%. The internal fixation proved its superiority in relationship with the external fixation

Percutaneous versus open bone grafting in the treatment of tibial fractures: a randomized prospective trial.

PURPOSE: To compare the results between percutaneous bone grafting and open bone grafting of tibial shaft fractures. METHOD: Thirty tibial fractured shafts with a delayed union or a high-energy tibial fractures which required early prophylaxis bone grafts were randomized to either percutaneous bone graft (n= 15) or open bone graft (n=15). One patient from the open bone graft group was lost to follow-up. Characteristics of the patients were similar in both groups. RESULTS: The mean length of follow-up was 2.5 years. Percutaneous bone graft technique was associated with significantly less blood loss (p<0.01) and shorter operative time (p<0.01). One patient in the percutaneous group had posterior tibial nerve palsy postoperatively, which recovered completely after 6 weeks. There were no differences in rate of union, healing time of the successful cases, postoperative pain and hospital stay. CONCLUSION: The percutaneous technique has effective results similar to the open technique in promoting union of tibial fractures. It should be considered as a useful alternative to the open bone graft technique.