Extra-articular proximal tibia fracture fixation with locked plating versus intramedullary nailing: A meta-analysis.

OBJECTIVES: This study compared outcomes of locked plating (LP) versus intramedullary nailing (IMN) techniques for treatment of extra-articular proximal-third tibia fractures. METHODS: Data Sources: PubMed, Ovid MEDLINE STUDY SELECTION: Studies were included if they compared LP and IMN fixation for proximal one third tibial shaft fractures without articular extension or with simple articular extension into the tibial plateau. Minimum 1 year of clinical and radiographic follow up was used. DATA EXTRACTION: Outcomes assessed included operative duration, postoperative knee range of motion (ROM), union outcomes (time to union, nonunion, malunion, delayed union), and incidence of postoperative complications (superficial and deep infection, secondary surgical intervention, compartment syndrome). DATA SYNTHESIS: Separate random-effects meta-analyses were conducted for each outcome. For categorical data, relative risks were used whereas the standardized mean difference was used for continuous variables, with corresponding 95 % confidence intervals. RESULTS: 7 studies were included reporting the outcomes of 319 patients treated with LP and 300 treated with IMN. IMN fixation had significantly shorter time to union (p = 0.049) and lower risk for superficial infection (p = 0.028). However, LP conferred a significantly lower risk for malunion (p = 0.017) and postoperative compartment syndrome (p = 0.018). CONCLUSION: IMN demonstrated significantly shorter time to union and lower risk of superficial infection when treating extra-articular proximal tibia fractures, while LP fixation demonstrated significantly lower risk for malunion and postoperative compartment syndrome. Although successful results can be achieved with good technique in LP and IMN fixation, a significant complication profile exists with these fractures regardless of construct choice. LEVEL OF EVIDENCE: Therapeutic Level III.

A Comprehensive Physiotherapeutic Intervention for Complex Proximal Tibia Fracture With Ilizarov Fixator and Foot Drop in 18-Year-Old Adult: A Case Report.

The susceptibility of the tibia to fractures arises from its exposed position, making it a commonly affected area. The proximal tibia exhibits a wide metaphyseal region that gradually narrows distally, forming a triangular shape. The extended tibia shaft articulates with the fibula, talus, and distal femur. We have discussed the case of an 18-year-old male who experienced a road traffic accident on January 7, 2023, involving a collision between his bike and four-wheeler, resulting in high-energy forces impacting his left lower limb. As a consequence, he lost mobility in the left lower limb. Upon examination, he was diagnosed with a compound grade 3C proximal tibia fracture treated with Ilizarov fixators, accompanied by a neurovascular deficit leading to a foot drop on the left side. Additionally, he had a previous operative case involving a femur shaft fracture on the left side, which was managed with in situ implants. It concluded that the rehabilitation approach was effective in pain reduction, improving range of motion, muscle strength, and reducing sensory impairment. Improved results on the lower extremity functional scale and the foot and ankle ability measures showed that the physiotherapy method had been successful in helping the patient regain independence in everyday activities. The success of rehabilitation and the recovery of patients are greatly influenced by post-operative physical therapy.

Non-vascularized Fibular Autograft and Locking Plate: A Solution to the Resistant Nonunion of a Tibial Metaphyseal Fracture.

The union of tibial fractures often raises concerns. In one such case, a 62-year-old female patient presented in our Emergency Room (ER) with a comminuted tibial metaphyseal fracture resulting from a traffic accident. The patient underwent three surgical procedures in the following two years. The first intervention was open reduction internal fixation (ORIF) with a plate and screws. The second intervention, which took place three months after the first surgery, addressed the union delay through implant removal and closed reduction and internal fixation (CRIF) with an antegrade intramedullary tibial nail. The third intervention addressed the implant failure and oligotrophic nonunion through the removal of the broken tibial nail and ORIF using a proximal tibia locking plate and screws, augmented with fibular shaft and reamed iliac crest autografts. We conducted frequent follow-ups with the patient and performed multiple X-rays to confirm and monitor the fracture union. At the last follow-up, two years after the last surgical intervention, imagistic investigations showed that the patient presented with fracture union, she could support her full body weight on the operated leg, and was able to walk and carry out normal daily activities. As such, we concluded that the surgical method chosen (ORIF with proximal tibia locking plate and screws, augmented with a fibula shaft strut and reamed iliac crest autograft) was a viable option to treat an aseptic oligotrophic nonunion in a high-energy comminuted tibia fracture.

Fixation of Proximal Tibial Fractures with Intramedullary Nail and Immediate Weightbearing: A Beneficial Alternative.

Newer intramedullary (IM) nails have become another option in the fixation of proximal tibia fractures. There is limited data on the successful use of these implants in intra-articular and extra-articular fractures of the proximal tibia, and no studies assessing the ability of these implants to maintain alignment with early weight bearing. Our objective was to determine whether immediate weight bearing after IM fixation, with or without supplemental plate or screw fixation, of proximal third tibial fractures (OTA/AO 41A-C) results in a change in alignment prior to union. 35 patients with 39 proximal tibia fractures from 2015 to 2020, all treated with IM nailing with or without supplemental plate or screw fixation, all made weight-bearing as tolerated following surgery, were included. The main outcomes were change in medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA) from initial post-operative films to final follow up. 12 fractures were OTA/AO 41 type A, 14 were type B, and 13 were type C. Mean initial MPTA was 87.0 +/-2.53 degrees, while mean initial PPTA was 79.6 +/- 3.50 degrees. The mean change in MPTA was 0.048 +/- 2.8 degrees (P=0.92), and mean change in PPTA was 0.264 +/- 3.67 degrees. 92.3% of fractures had normal final coronal plane alignment, with MPTA between 85.0 and 90.0 degrees. 89.7% of fractures had normal final sagittal plane alignment, with PPTA between 77.0 and 84.0 degrees. No patients required reoperation for malalignment. In OTA/AO type 41 fractures, immediate weight bearing after IM nail fixation, with or without supplemental plate or screw fixation when indicated, leads to minimal change in final coronal or sagittal alignment, and was well tolerated in most patients. [authors blinded for review].

Staged treatment of bicondylar tibial plateau fractures: influence of frame configuration and quality of reduction on outcomes.

PURPOSE: Despite evolving treatment, the surgical management of high-energy tibial plateau fractures (TPF) remains challenging, associating high rates of complications. In recent decades, staged management has emerged as an encouraging option. The main goal of our study was to evaluate the influence of bridging external fixation (EF) frame configuration and the resultant quality of reduction (QOR) on outcomes after staged-treatment of bicondylar TPF. METHODS: A retrospective review was conducted of patients with bicondylar TPF treated at our level-I trauma center using a staged-treatment protocol from January 2010 to January 2020. Data on baseline characteristics, injuries, treatments, and clinical/radiological results were collected. The QOR was evaluated on CT images after EF and on plain films after ORIF. RESULTS: Sixty-eight patients were eligible for analysis. By our criteria, QOR was good in 57.4% and 70.6% after EF and ORIF, respectively. A squared EF configuration was associated with superior EF QOR (p = 0.032), while better EF QOR was linked to improved ORIF QOR (p = 0.016). No relationship between ORIF delay and ORIF QOR was identified. Postoperative complications were documented in 19 patients. Average ROM at one-year follow-up was 114.9 ± 12.6°, and non-influenced by anterior femoral pin placement. CONCLUSIONS: Staged management of bicondylar TPF resulted in a reasonable rate of complications. A direct relationship between QORs obtained with EF and after ORIF was found. Squared frames were associated with faster and better reductions, regardless of the surgeon's background. Considering our results, we advocate for the wider use of squared EF configurations in these patients.

Risk for total knee arthroplasty after tibial plateau fractures: a systematic review.

PURPOSE: Tibial plateau fractures (TPFs) may lead to posttraumatic osteoarthritis and increase the risk for total knee arthroplasty (TKA). The aim of this systematic review was to analyse the conversion rate to TKA after TPF treatment. METHODS: A systematic search for studies reviewing the conversion rate to TKA after TPF treatment was conducted. The studies were screened and assessed by two independent observers. The conversion rate was analysed overall and for selected subgroups, including different follow-up times, treatment methods, and study sizes. RESULTS: A total of forty-two eligible studies including 52,577 patients were included in this systematic review. The overall conversion rate of treated TPF to TKA in all studies was 5.1%. Thirty-eight of the forty-two included studies indicated a conversion rate under 10%. Four studies reported a higher percentage, namely, 10.8%, 10.9%, 15.5%, and 21.9%. Risk factors for TKA following TPF treatment were female sex, age, and low surgeon and hospital volume. The conversion rate to TKA is particularly high in the first 5 years after fracture. CONCLUSION: Based on the studies, it can be assumed that the conversion rate to TKA is approximately 5%. The risk for TKA is manageable in clinical practice. PROSPERO REGISTRATION NUMBER: CRD42023385311. LEVEL OF EVIDENCE: IV.

The Rare Occurrence of Giant Cell Tumor of the Proximal Tibia With Pathological Fracture in an Elderly Male: A Case Report.

Giant cell tumor of the bone (GCTB) is a benign bone tumor that can occasionally progress to malignancy, usually in chronic cases. It is a common benign and aggressive bone tumor that affects patients aged between 20 and 45 years. The most common location is the knee joint. It manifests as a painless or occasionally painful swelling over the affected area. A case of giant cell tumor (GCT) of the proximal tibia in a 72-year-old male is reported here, which was difficult to diagnose as it is rarely found in the geriatric age group. The patient came with a chief complaint of pain and swelling over his left knee for two months with a history of trauma to the knee a couple of times. On clinical examination, the patient had grade 3 tenderness and swelling on the anterolateral aspect of the knee extending toward the proximal tibia. The swelling was well-defined, smooth, firm, and uniform in consistency with dimensions of 15 cm × 12 cm. The swelling was moveable sideways, and the movement of the knee suggested that it was not attached to the underlying bone. As per the age and history of the rapid-growing lesion, we suspected malignancy, but clinical findings were pointing toward benign tumor. X-ray of the affected knee was done, which revealed a soft tissue mass with the involvement of the bone. Magnetic resonance imaging (MRI) of the knee revealed a soft tissue mass with the cortical breach. An open biopsy was done for the confirmation of the diagnosis, which was later reported and confirmed as a giant cell tumor of the proximal tibia. As bone tumor is associated with a cortical breach and pathological fracture, it was classified under Campanacci grade 3, for which an en bloc resection and open reduction and internal fixation with plate osteosynthesis with bone cementing and bone grafting were done followed by knee bending physiotherapy and gradual weight-bearing. Finally, the knee function was improved with pain relief.

Evaluation of effects of small-incision approach treatment on proximal tibia fracture by deep learning algorithm-based magnetic resonance imaging.

In this study, magnetic resonance imaging (MRI) based on a deep learning algorithm was used to evaluate the clinical effect of the small-incision approach in treating proximal tibial fractures. Super-resolution reconstruction (SRR) algorithm was used to reconstruct MRI images for analysis and comparison. The research objects were 40 patients with proximal tibial fractures. According to the random number method, patients were divided into a small-incision approach group (22 cases) and an ordinary approach group (18 cases). The peak signal-to-noise ratio (PSNR) and the structural similarity index (SSIM) of the MRI images before and after the reconstruction of the two groups were analyzed. The operative time, intraoperative blood loss, complete weight-bearing time, complete healing time, knee range of motion, and knee function of the two treatments were compared. The results showed that after SRR, the PSNR and SSIM of MRI images were 35.28 and 0.826 dB, respectively, so the MRI image display effect was better. The operation time in the small-incision approach group was 84.93 min, which was significantly shorter than that in the common approach group, and the intraoperative blood loss was 219.95 mL, which was significantly shorter than that in the common approach group (P < 0.05). The complete weight-bearing time and complete healing time in the small-incision approach group were 14.75 and 16.79 weeks, respectively, which were significantly shorter than those in the ordinary approach group (P < 0.05). The half-year knee range of motion and 1-year knee range of motion in the small-incision approach group were 118.27° and 128.72°, respectively, which were significantly higher than those in the conventional approach group (P < 0.05). After 6 months of treatment, the rate of good treatment was 86.36% in the small-incision approach group and 77.78% in the ordinary approach group. After 1 year of treatment, the rate of excellent and good treatment was 90.91% in the small-incision approach group and 83.33% in the ordinary approach group. The rate of good treatment for half a year and 1 year in the small incision group was significantly higher than that in the common approach group (P < 0.05). In conclusion, MRI image based on deep learning algorithm has a high resolution, good display effect, and high application value. The small-incision approach can be applied to the treatment of proximal tibial fractures, which showed good therapeutic effects and a high positive clinical application value.

Comparison of suprapatellar intramedullary nailing versus minimal invasive locked plating for proximal tibia fractures.

PURPOSE: To compare the radiological alignment, union time, union rate, and complication rate between suprapatellar intramedullary nails and minimally invasive locking plate fixation in the treatment of proximal tibial fractures. MATERIALS AND METHODS: We retrospectively analyzed 103 patients who underwent plate fixation (n = 50) or suprapatellar intramedullary nailing (n = 53) for proximal tibial fractures involving the meta-diaphyseal junction between November 2015 and October 2020 at our institution. The union rate, union time, radiologic alignments, and complications, such as malalignment, nonunion, and deep infection, were investigated. RESULTS: The demographic data did not differ between the plate and suprapatellar intramedullary nail groups. The alignment of the coronal plane was 0.24 ± 3.19 in the plate group and - 0.49 ± 2.22 in the intramedullary nail group (p = 0.196). Sagittal plane alignment was - 0.29 ± 4.97 in the plate group and 0.24 ± 4.12 in the intramedullary nail group (p = 0.571), and coronal malalignment (p = 0.196), sagittal malalignment (p = 0.57), deep infection (p = 0.264), nonunion (p = 0.695), union time (p = 0.329), and final union rate (p = 0.699) were not significantly different between groups. CONCLUSION: Compared with the minimally invasive locking compression plate group, the suprapatellar intramedullary nail group yielded comparable results in terms of radiological alignment and complications. Considering that proximal tibial fractures are associated with high-energy trauma and severe soft tissue damage, we believe that a suprapatellar intramedullary nail may be a good alternative. LEVEL OF EVIDENCE: Level III.

Bridge Plating Versus Hybrid External Fixation in the Management of Proximal Tibia Metaphyseal Fractures.

BACKGROUND: Due to the surge in high-speed road traffic accidents during the past few years, extra-articular proximal tibia fractures have also risen in number. For the treatment of such fractures, various options are available like conservative treatment with casting, surgical treatment with plate osteosynthesis, or a hybrid external fixator. Exposure of the bone surface and extensive soft tissue dissection is needed in bridge plating, posing a risk of bleeding, infection, and soft-tissue healing issues, and the blood supply of the fractured area is also hampered as the periosteum is also destroyed. To avoid these complications, a hybrid external fixator can be used but it has its own risks of malunion, non-union, and pin-tract infections; another drawback is patient compliance. In this study, we compare the clinical and functional outcomes of two treatment modalities, i.e., bridge plating and hybrid external fixator, in the treatment of proximal tibia metaphyseal fractures. MATERIALS AND METHODS: This prospective randomized study was conducted from February 2021 to June 2022 on 46 adult patients diagnosed with proximal tibia metaphyseal fracture and willing to participate. An odd number of patients were treated with a bridge plate and even with a hybrid external fixator. RESULTS: A total of 46 patients were included in the study, sustaining proximal tibia metaphyseal fracture, out of which 23 patients underwent hybrid external fixation with an outcome of 69.43 ± 8.11 according to the Knee Society Score (KSS) and 23 for bridge plating which showed better results as their score at final follow-up was 75.00 ± 8.22. CONCLUSION: According to our study, we found that bridge plating is a better treatment modality than the hybrid external fixator as the former showed better postoperative knee range of motion and functional outcome and led to a smaller number of complications. But the clinical outcome would also be influenced by the type of fracture, degree of comminution, type of injury, i.e., open or closed, and quality of bone.

Anterolateral or Posteromedial Plate-Assisted Intramedullary Nailing for Fixation of Proximal Third Tibia Fractures: A Biomechanical Study / 医用生物力学

Objective To study the stability of plate-assisted intramedullary nailing for fixing proximal third tibiafractures, compare and observe biomechanical characteristics of anterolateral or posteromedial plate-assisted intramedullary nailing after fixation of proximal third tibia fractures. Methods Eight artificial tibia of 4th-generation sawbones were divided into two groups based on location of the assisted plate, namely, anterolateral plate group and posteromedial plate group, with 4 specimens in each group. Each two locking bolts were fixed to theintramedullary nail proximally and distally, and each three bicortical screws were fixed to the plate proximally and distally. The specimens were osteotomized with a 10-mm defect which located 0. 5 cm to the proximal locking bolt of intramedullary nail or 5-6 cm distally to the knee joint line, in order to simulate an AO/ OTA 41-A2 type proximal third tibia fracture after fixation of intramedullary nail. After osteotomy was finished, axial compression test, three point bending test, cyclic loading and overstress test were conducted by mechanical testing machine. The results of axial stiffness and three-point stiffness between two groups were compared and analyzed. Results Axial compression test showed that the average axial stiffness in posteromedial plate group was lower than that in anterolateral plate group, but no significantly statistical differences were found between the two groups. Three point bending test showed that the average bending stiffness in posteromedial plate group was significantly higher than that in anterolateral plate group when stimulating either varus stress (plate located at pressure side of the fracture, t = 3. 679, P<0. 05) or valgus stress (plate located at tension side of the fracture, t = 8. 975, P<0. 05). Conclusions Plate-assisted intramedullary nailing for fixation of proximal third tibia fractures can minimize the angulation malalignment, improve the stability of nailed proximal tibial fragment and allow the early weight bearing. Both anterolateral and posteromedial plate-assisted intramedullary nail can provide satisfactory axial stability for proximal third tibia fractures, while posteromedial plate-assisted intramedullary nail shows better bending stability than anterolateral plate in countering varus or valgus stress deformity. This study provides an essential basis for clinical decision making about plate-assisted intramedullary nailing for fixing proximal third tibia fractures.

Systematic Review of Current Approaches to Tibia Plateau: Best Clinical Evidence.

If not treated adequately, tibia plateau fractures result in premature osteoarthritis and lifelong disability. The advent of newer implants and techniques to improve outcomes has necessitated the development of different surgical approaches. A Medline and EMBASE search (June 2020) was conducted to identify publications during the last 10 years that focused on surgical approaches for proximal tibia fractures/ tibia plateau management. A total of 2107123 and 2715399 articles were found related to fractures in this area with 133 and 103 review articles looking at the approach on MEDLINE and EMBASE, respectively. This article reviews the continued development of the surgical approaches to aid understanding for surgeons and identify areas for future research to help improve outcomes. Although the anterolateral approach is the most commonly applied surgical technique, having the knowledge of newer approaches (medial, posteromedial, posterolateral, or direct posterior) in the armamentarium is necessary to treat the vast array of fracture patterns. There has been a shift amongst trauma surgeons of using a combination of approaches for complex tibia plateau fractures.

Biomechanical design of a new percutaneous locked plate for comminuted proximal tibia fractures.

Comminuted proximal tibia fractures are an ongoing surgical challenge. This "proof of concept" study is the first step in designing a new percutaneous plate for this injury under toe-touch weight-bearing as prescribed after surgery. Finite element simulations generated design curves for overall stiffness, bone and implant stress, and interfragmentary motion using 3 fixations (no, 1, or 2 "kickstand" (KS) screws across the fracture gap) over a range of plate elastic moduli (EP = 5 to 200 GPa). Combining well-established optimization criteria to enhance callus formation (i.e. 0.2 mm ≤ axial interfragmentary motion ≤ 1 mm; shear / axial interfragmentary motion ratio < 1.6), lessen stress shielding (i.e. bone stress under the proposed plate > bone stress under a traditional titanium or steel plate), and reduce steel screw breakage (i.e. screw max stress < ultimate tensile stress of steel) resulted in plate design recommendations: 172.6 ≤ EP < 200 GPa (no KS screw), 79.8 ≤ EP < 100 GPa (1 KS screw), and 4.9 ≤ EP < 100 GPa (2 KS screws). A prototype plate could be made from materials currently used or proposed for orthopaedics, such as polymers, fiber-reinforced polymers, fiber metal laminates, metal foams, or shape memory alloys.

Total knee arthroplasty, following application of Taylor Spatial Frames to treat knee osteoarthritis with severe tibia extraarticular deformity due to fracture malunion: A case report.

Obtaining alignment during end-stage knee osteoarthritis with extraarticular deformities has always been challenging. Therefore, we report a case of total knee arthroplasty, following the application of Taylor Spatial Frame to treat knee osteoarthritis with severe tibia extraarticular deformity due to a proximal tibia fracture injury for more than 50 years ago. First, proximal tibial opening wedge osteotomy was conducted below the patellar tendon insertion from the anterior to the posterior direction to correct the deformity in multiple planes gradually. Then, osteotomy was done to restore both the varus and recurvatum deformities. Finally, Taylor Spatial Frame was used as a virtual hinge, with gradual adjustments to correct the deformity. Afterward, patient-specific instrumentation-assisted total knee arthroplasty was conducted after correcting the extraarticular deformity. During the two-year follow-up, no superficial and deep infection occurred, and his Oxford Knee Score had improved from 32 to 19 out of 48 at the time of the latest follow-up. Moreover, the patient walked using a one-hand clutch without protective limping. Hence, patient-specific instrumentation-assisted total knee arthroplasty, following proximal tibial osteotomy with Taylor Spatial Frame, should be considered a treatment option for patients with knee osteoarthritis having severe proximal tibia extraarticular deformity.

Proximal tibia fracture dislocations: Management and outcomes of a severe and under-recognized injury.

INTRODUCTION: Proximal tibia fracture dislocations (PTFDs) are a subset of plateau fractures with little in the literature since description by Hohl (1967) and classification by Moore (1981). We sought to evaluate reliability in diagnosis of fracture-dislocations by traumatologists and to compare their outcomes with bicondylar tibial plateau fractures (BTPFs). METHODS: This was a retrospective cohort study at 14 level 1 trauma centers throughout North America. In all, 4771 proximal tibia fractures were reviewed by all sites and 278 possible PTFDs were identified using the Moore classification. These were reviewed by an adjudication board of three traumatologists to obtain consensus. Outcomes included inter-rater reliability of PTFD diagnosis, wound complications, malunion, range of motion (ROM), and knee pain limiting function. These were compared to BTPF data from a previous study. RESULTS: Of 278 submitted cases, 187 were deemed PTFDs representing 4% of all proximal tibia fractures reviewed and 67% of those submitted. Inter-rater agreement by the adjudication board was good (83%). Sixty-one PTFDs (33%) were unicondylar. Eleven (6%) had ligamentous repair and 72 (39%) had meniscal repair. Two required vascular repair. Infection was more common among PTFDs than BTPFs (14% vs 9%, p = 0.038). Malunion occurred in 25% of PTFDs. ROM was worse among PTFDs, although likely not clinically significant. Knee pain limited function at final follow-up in 24% of both cohorts. CONCLUSIONS: PTFDs represent 4% of proximal tibia fractures. They are often unicondylar and may go unrecognized. Malunion is common, and PTFD outcomes may be worse than bicondylar fractures.

Association between open tibia fractures and acute compartment syndrome: A retrospective cohort study.

BACKGROUND: Studies on the association of open tibia fractures and acute compartment syndrome (ACS) show confusing results, with some papers highlighting a positive association, and others failing to do so. The aim of this study was to determine if an open tibia fracture is at increased risk of ACS occurrence, when compared to a closed fracture. HYPOTHESIS: Skin injury in the setting of an open tibia fracture does not prevent from ACS occurrence, because the energy transmitted to the limb during trauma may lead to soft tissue lesions, including skin lacerations and ACS. PATIENTS AND METHODS: In total, 711 consecutive adult patients (mean age 44.6 years; 65.8% males) sustaining 725 tibia fractures between 01.01.2005 and 31.12.2009 were included in this retrospective study. The outcome measure was ACS. The following variables were assessed: soft tissue condition, age, sex, low- vs. high-energy injury, type of fracture, associated contiguous skeletal injury. A logistic regression model was used and adjustment was performed for age and sex. RESULTS: ACS occurred in 10.4% of proximal intra-articular fractures, 10.4% of extra-articular fractures and 3.3% of distal intra-articular fractures, and in 8.7% of closed fractures, 7.8% of open Gustilo 1 fractures and 13.3% of open Gustilo 2 and 3 fractures. Open lesions were not associated with ACS when tibia fractures were considered as a whole. When stratifying by types of fractures, open Gustilo 2 and 3 lesions were associated with ACS in proximal intra-articular fractures (p=0.048). There was no association with closed or any type of open lesions for extra-articular fractures. There were not enough ACS cases among distal intra-articular fractures to draw conclusions. DISCUSSION: As ACS may occur with any type of open tibia fractures, clinicians should not be wrongly reassured by an open fracture, assuming that the wound would relieve the pressure inside the muscle compartments. There is a weak association between open Gustilo 2 and 3 lesions and ACS in proximal intra-articular fractures only. These findings are important for surgeons treating these injuries, especially by intubated, sedated or obtunded patients. LEVEL OF EVIDENCE: III; retrospective diagnostic study.

Report of Missed Non-Hodgkin's Lymphoma Presenting as Pathological Tibial Fracture.

Pathological fractures usually occur in patients with known malignancies, though pathological fracture may be the first sign of cancer. Malignant pathological fractures most commonly represent metastatic lung, breast, kidney, thyroid, or prostate cancer and typically occur in the spine, pelvis, femur, and humerus. We present the case of a 71-year-old female with an atraumatic tibial fracture in which further imaging was not pursued. Five months later, she was diagnosed with non-Hodgkin's lymphoma. Pathological proximal tibial fracture is an exceedingly rare presentation of lymphoma; however, diagnostic delay could likely have been avoided if a thorough workup had been pursued. Our case highlights the importance of careful examination of all patients presenting with a low-energy fracture, particularly when constitutional symptoms suggestive of cancer are present. All patients with pathological fractures should receive a thorough physical examination that includes lymph node palpation.

Management of Necrotizing Fasciitis with Proximal Tibia Fracture.

INTRODUCTION: Necrotizing fasciitis is a rare disease of soft tissue infection with a high mortality. It is characterized by rapidly spreading inflammation and necrosis of fascial planes. It usually follows an injury, though the cause may be a small abrasion or an insect bite or surgical incisions. It is commonly caused by bacteria such as Group A streptococcus. It may be accompanied by septic shock. It causes rapid death unless it is diagnosed quickly and managed aggressively. Prompt surgical debridement must be done to reduce mortality. Rapid diagnosis, antibiotic therapy, fluid resuscitation, and surgical debridement of the infection are all needed in the management of this fatal disease. However, when necrotizing fasciitis is associated with an underlying fracture the treatment becomes even challenging and limb-threatening. CASE REPORT: A 48-year-male patient of South Asian descent came to Emergency Room with history of road traffic accident and sustained injury to the right (RT) leg. He was admitted with pain, swelling and blisters of the RT leg and suspected to have necrotizing fasciitis with proximal tibia fracture of the RT leg. He was treated with thorough surgical debridement, broad-spectrum antibiotics, free flap, and Masquelet's technique with limb reconstruction system (LRS). At 18 months of follow-up the fracture healed, LRS was removed, pin tracts healed and patient was able to walk without any support. CONCLUSION: Necrotizing fasciitis is rare, rapidly progressive disease with a high mortality rate which requires prompt diagnosis, early surgical debridement, broad-spectrum antibiotics, careful fluid, and electrolyte management. These patients require a combined multidisciplinary approach for their management.

Stress fracture of proximal tibia after proximal fibula osteotomy: A case report.

INTRODUCTION: Proximal fibula osteotomy (PFO) is a new method for treating medial compartment osteoarthritis of the knee, which is based on the theory of differential settlement (nonuniform settlement). This procedure has been widely recognized for its advantages of relative simplicity, low rate of postoperative complications, and low postoperative costs. Stress fracture of the proximal tibia after PFO has not been previously reported. CASE PRESENTATION: We report a 62-year-old woman with chronic rheumatoid arthritis (RA) underwent left PFO for chronic knee pain, who developed a stress fracture of the proximal tibia more than 1 year after PFO. CLINICAL DISCUSSION: In the early stage of proximal tibia stress fracture, due to the concealment of radiography manifestations, doctors from another hospital performed total knee arthroplasty (TKA) for the patient. They ignored the treatment of stress fracture of the proximal tibia, and the stress fracture was further aggravated after surgery. Six months later, the patient underwent open reduction and internal fixation with a plate and screw in the left proximal tibia fracture at our hospital. The patient was followed up at the hospital three months after open reduction, and the proximal tibia stress fracture began to heal. CONCLUSION: RA is usually not confined to the medial compartment and its pathogenesis is different from that of osteoarthritis. Therefore, PFO is not an appropriate procedure for this type of patient.

Outcome after polyaxial locking plate osteosynthesis in proximal tibia fractures: a prospective clinical trial.

BACKGROUND: The aim of this study was to evaluate the clinical and/or radiologic outcome using different polyaxial locking plates for the treatment of proximal tibia fractures, the Non-Contact-Briding plate (NCB-PT®) by Zimmer or the Variable Angle Locking Compression Plate (VA-LCP®) by Synthes. METHODS: This study enrolled 28 patients with proximal tibia fractures (AO/ OTA 41 B-C) and indication for locking plate osteosynthesis. All patients were treated with a polyaxial locking plate system. Depending on the fracture morphology, patients were either treated with a NCB-PT® or VA-LCP®. The implant was chosen according to the surgeon's experience and preference, in case of a higher degree of comminution the tendency was observed to use the NCB-PT® plate. After a time interval of 12 months postoperative we conducted clinical (e.g. range of motion, the Rasmussen score) and radiological (e.g. primary/secondary loss of reduction) follow-ups. RESULTS: Patients provided with the NCB-PT® (9 patients) showed longer operation time, use of longer implants, longer interval from injury to surgery and lower clinical scores after the 12 months follow-up compared with the VA-LCP® group (19 patients). Interestingly, the results showed no significant differences regarding the clinical and radiologic outcome. CONCLUSIONS: The small number of patients as well as the heterogeneity of fractures constitute a limitation of this study. Nevertheless, the differentiated use of implants is associated with comparable clinical and radiological outcomes. This trial emphasizes the need for further prospective randomised trials with higher patient numbers. TRIAL REGISTRATION: Retrospectively registered 21.12.2020. Registration number NCT04680247 .