Maintenance of joint reduction and allograft incorporation in treating tibial plateau fractures. Retrospective case series using cortico-cancellous, non-irradiated, bone allograft.

Background: Restoring joint congruence and maintaining reduction until healing is imperative in treating tibial plateau fractures (TPF). The main objective of this study was to evaluate the feasibility of augmentation with impacted bone allograft (IBA) to prevent loss of reduction in tibial plateau fractures during healing and to evaluate its incorporation. Methods: We retrospectively analyzed all patients with an acute, closed tibial plateau fracture (Schatzker II, III, IV) treated between 2010 and 2019 with open reduction and internal fixation (ORIF) and impacted bone allograft (IBA), with a minimum follow-up of 24 months. We evaluated the postoperative radiographs by drawing a line along the tibial axis and another perpendicular to the healthy plateau to measure the reduction and subsequent behavior. The incorporation of the allograft was evaluated by radiological analysis assessing its integration, non-union, resorption, or sclerosis. We used the clinical-radiological Rasmussen system and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to objectify the outcomes. Results: 78 TPFs were included, with a median age of 51.5 (40.7-62.2) years and a median follow-up of 66 (24-89) months. Two (2.5 %) patients presented loss of joint reduction (subsidence) during the follow-up regarding the achieved in the surgery. Seventy-six (94.7 %) patients presented integration, two (2.5 %) resorption, and one (1.3 %) sclerosis. Seventy-two (92.3 %) patients presented excellent and good results in the Rasmussen radiological score, and 72 (92.3 %) patients presented excellent or good clinical scores. The mean WOMAC at two years postoperatively was 15 ± 6.5. Conclusion: Our results demonstrate that allograft is an adjuvant in maintaining a reduction in type II, III, and IV Schatzker's tibial plateau fractures. Low rates of loss of reduction during follow-up can be expected with its use.

A Randomized Controlled Study on the Efficacy of Different Approaches of Intramedullary Nailing with Blocking Screws for Proximal Tibial Fractures

SUMMARY: The objective of this study was to compare and analyze the clinical efficacy of different approaches of intramedullary nailing with blocking screws for proximal tibial fractures. One hundred cases of proximal tibial fractures treated in the orthopedic department from April 2021 to September 2023 were included in the study and divided into control and treatment groups using a random number table. A control group (n=50) treated with infrapatellar intramedullary nailing with blocking screws, and a treatment group (n=50) treated with suprapatellar intramedullary nailing with blocking screws. We observed the excellent and good rates in both groups, compared various perioperative indicators, changes in joint range of motion (ROM), Visual Analog Scale (VAS) pain scores, Lysholm knee joint function scores, changes in inflammatory factors, and various bone markers before and after treatment, and analyzed postoperative complications. There were no significant differences in baseline data such as age, sex, body mass index, fracture site, concomitant fibular fractures, time from fracture to surgery, injury mechanism, and AO/OTA fracture classification between the two groups (P>0.05). The excellent and good rate in the treatment group after treatment was 90.00 % (45/50), significantly higher than 72.00 % (36/50) in the control group (P0.05). However, the treatment group had shorter surgical times and fewer fluoroscopy times than the control group (P<0.05). After treatment, both groups showed increased ROM and Lysholm scores, as well as decreased VAS scores. Moreover, compared to the control group, the treatment group had higher ROM and Lysholm scores and lower VAS scores (P<0.05). Inflammatory factors including interleukin-1β (IL-1β), C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), osteocalcin (BGP), and calcitonin (CT) increased in both groups after treatment, while total n- terminal propeptide of type I procollagen (Total-PINP) and b-C-terminal telopeptide of type I collagen (β-CTX) decreased. Compared to the control group, the treatment group exhibited greater increases in inflammatory factors and lower levels of Total-PINP and β-CTX, but higher BGP and CT levels (P<0.05). The incidence of postoperative complications was 8.00 % (4/50) in the treatment group and 24.00 % (12/50) in the control group, with statistically significant differences (P=4.762, X2=0.029). In the treatment of proximal tibial fractures, intramedullary nailing with blocking screws using the suprapatellar approach achieves significant clinical efficacy. It reduces surgical time, minimizes radiation exposure to healthcare workers and patients, improves knee joint range of motion and function, decreases postoperative pain and complication rates, suppresses inflammatory reactions, and promotes the improvement of bone markers related to fracture healing.

El objetivo de este estudio fue comparar y analizar la eficacia clínica de diferentes abordajes de clavo intramedular con tornillos de bloqueo para las fracturas de tibia proximal. Se incluyeron en el estudio 100 casos de fracturas de tibia proximal tratados en el departamento de ortopedia desde abril de 2021 hasta septiembre de 2023 y se dividieron en grupos de control y de tratamiento mediante una tabla de números aleatorios. Un grupo control (n=50) tratado con clavo intramedular infrapatelar con tornillos de bloqueo, y un grupo tratamiento (n=50) tratado con clavo intramedular suprapatelar con tornillos de bloqueo. Observamos excelentes y buenas tasas en ambos grupos, comparamos varios indicadores perioperatorios, cambios en el rango de movimiento articular (ROM), puntuaciones de dolor en la escala visual analógica (EVA), puntuaciones de función Lysholm de la articulación de la rodilla , cambios en factores inflamatorios y varios marcadores óseos, antes y después del tratamiento, y se analizaron las complicaciones postoperatorias. No hubo diferencias significativas en los datos iniciales como edad, sexo, índice de masa corporal, sitio de fractura, fracturas de fíbula concomitantes, tiempo desde la fractura hasta la cirugía, mecanismo de lesión y clasificación de fractura AO/OTA entre los dos grupos (P>0,05). La tasa de excelente y buena en el grupo con tratamiento después del tratamiento fue del 90,00 % (45/50), significativamente mayor que el 72,00 % (36/50) en el grupo control (P0,05). Sin embargo, el grupo con tratamiento tuvo tiempos quirúrgicos más cortos y menos tiempos de fluoroscopía que el grupo control (P <0,05). Después del tratamiento, ambos grupos mostraron un aumento de las puntuaciones de ROM y Lysholm, así como una disminución de las puntuaciones de VAS. Además, en comparación con el grupo control, el grupo con tratamiento tuvo puntuaciones ROM y Lysholm más altas y puntuaciones EVA más bajas (P <0,05). Los factores inflamatorios que incluyen interleucina-1β (IL-1β), proteína C reactiva (CRP), factor de necrosis tumoral-α (TNF-α), osteocalcina (BGP) y calcitonina (CT) aumentaron en ambos grupos después del tratamiento, mientras que el total disminuyó el propéptido n-terminal del procolágeno tipo I (Total-PINP) y el telopéptido β-C-terminal del colágeno tipo I (β-CTX). En comparación con el grupo control, el grupo con tratamiento mostró mayores aumentos en los factores inflamatorios y niveles más bajos de Total-PINP y β-CTX, pero niveles más altos de BGP y CT (P <0,05). La incidencia de complicaciones postoperatorias fue del 8 % (4/50) en el grupo de tratamiento y del 24 % (12/50) en el grupo control, con diferencias estadísticamente significativas (P=4,762, X2=0,029). En el tratamiento de las fracturas de tibia proximal, el clavo intramedular con tornillos de bloqueo mediante el abordaje suprapatelar logra una eficacia clínica significativa. Reduce el tiempo quirúrgico, minimiza la exposición a la radiación de los trabajadores de la salud y los pacientes, mejora el rango de movimiento y la función de la articulación de la rodilla, disminuye el dolor postoperatorio y las tasas de complicaciones, suprime las reacciones inflamatorias y promueve la mejora de los marcadores óseos relacionados con la curación de las fracturas.

Use of Three-dimensional Printing for Tibial Pilon Fracture Diagnosis and Treatment / Uso da impressão tridimensional para auxílio diagnóstico e terapêutico das fraturas de pilão tibial

Abstract Objective To evaluate whether three-dimensional (3D) printing increases agreement in the classification of tibial pilon fractures. Methods Orthopedists and traumatologists reviewed radiographs, computed tomography scans with 3D reconstruction, and prototyping 3D printing, and classified the fractures based on the Rüedi-Allgöwer and Arbeitsgemeinschaft für Osteosynthesefragen (AO, Association for the Study of Internal Fixation) Foundation/Orthopedic Trauma Association (AO/OTA) classification systems. Next, data evaluation used Kappa agreement coefficients. Results The use of the 3D model did not improve agreement for tibial pilon fractures regarding the treatment proposed by the groups. Regarding the classification systems, the agreement only improved concerning the AO/OTA classification when the 3D model was used in the assessment by the foot and ankle specialists. Conclusion Although 3D printing is statistically relevant for surgeons specializing in foot and ankle, its values remain lower than optimal.

Resumo Objetivo Avaliar se a impressão tridimensional (3D) aumenta a concordância na classificação de fraturas do pilão tibial. Métodos Foram selecionadas radiografias, tomografias com reconstrução 3D e impressão de prototipagem em impressora 3D. Os exames foram apresentados a profissionais da área de Ortopedia e Traumatologia que classificaram as fraturas com base nas classificações da Arbeitsgemeinschaft für Osteosynthesefragen (AO, Associação para o Estudo da Fixação Interna) Foundation/Orthopedic Trauma Association (AO/OTA) e de Rüedi-Allgöwer. Posteriormente, os dados foram avaliados pelos coeficientes de concordância de Kappa. Resultados O uso do modelo 3D não melhorou a concordância na fratura do pilão tibial quanto ao tratamento proposto pelos grupos. Em relação aos sistemas de classificação, somente a concordância na classificação AO/OTA melhorou quando foi utilizado o modelo 3D na avaliação pelos especialistas em pé e tornozelo. Conclusão Apesar de o uso da impressão 3D ter relevância estatística para os cirurgiões especialistas em pé e tornozelo, ainda apresenta valores menores do que os ideais.

The Applicability of Dynamic External Fixator in a Prospective Evaluation of Open Tibial Fracture Treatment.

Aim: This prospective study assessed the clinical and radiological outcomes of open tibia fractures treated with a dynamic external fixator. Materials and methods: Twenty-five patients underwent surgical debridement and stabilisation with a dynamic external fixator between November 2016 and April 2022. Regular follow-up evaluated bone healing progression. Results: Favourable outcomes were demonstrated in 20 patients. However, there were three cases of non-union, two of which subsequently deformed, and two cases of pin site-related infection. There were no fracture site infections. Conclusion: This study demonstrates the use of dynamic external fixation in the treatment of open tibia fractures. The low incidence of complications suggests its effectiveness and potential. How to cite this article: Bezerra BS, Araujo TA, Cardonia GG, et al. The Applicability of Dynamic External Fixator in a Prospective Evaluation of Open Tibial Fracture Treatment. Strategies Trauma Limb Reconstr 2024;19(1):36-39.

The effects of the industrial transition on lower limb bone structure: A comparison of the inhabitants of Pecos Pueblo and present-day Indigenous peoples of New Mexico.

OBJECTIVES: Comparisons between Indigenous peoples over time and within a particular geographic region can shed light on the impact of environmental transitions on the skeleton, including relative bone strength, sexual dimorphism, and age-related changes. Here we compare long bone structural properties of the inhabitants of the late prehistoric-early historic Pecos Pueblo with those of present-day Indigenous individuals from New Mexico. MATERIALS AND METHODS: Femora and tibiae of 126 adults from Pecos Pueblo and 226 present-day adults were included in the study. Cross-sectional diaphyseal properties-areas and second moments of area-were obtained from past studies of the Pecos Pueblo skeletal sample, and from computed tomography scans of recently deceased individuals in the present-day sample. RESULTS: Femora and tibiae from Pecos individuals are stronger relative to body size than those of present-day Indigenous individuals. Present-day individuals are taller but not wider, and this body shape difference affects cross-sectional shape, more strongly proximally. The tibia shows anteroposterior strengthening among Pecos individuals, especially among males. Sexual dimorphism in midshaft bone shape is stronger within the Pecos Pueblo sample. With aging, Pecos individuals show more medullary expansion but also more subperiosteal expansion than present-day individuals, maintaining bone strength despite cortical thinning. DISCUSSION: Higher activity levels, carried out over rough terrain and throughout adult life, likely explain the relatively stronger lower limb bones of the Pecos individuals, as well as their greater subperiosteal expansion with aging. Greater sexual dimorphism in bone structure among Pecos individuals potentially reflects greater gender-based differences in behavioral patterns.

Insulin Therapy on Bone Macroscopic, Microarchitecture, and MechanicalProperties of Tibia in Diabetic Rats.

BACKGROUND: This study evaluated tibia's macroscopic structure, mechanical properties, and bone microarchitecture in rats with type 1 diabetes mellitus (T1DM). METHODS: Eighteen animals were divided into three groups (n=6): Non-diabetic (ND), diabetic (D), and diabetic+insulin (DI). T1DM was induced by streptozotocin; insulin was administered daily (4IU). The animals were euthanized 35 days after induction. The tibiae were removed and analyzed using macroscopic, micro-computed tomography (micro-CT) and three-point bending. The macroscopic analysis measured proximal-distal length (PD), antero-posterior thickness (AP) of proximal (AP-P) and distal (AP-D) epiphysis, and lateral-medial thickness (LM) of proximal (LM-P) and distal (LM-D) epiphysis. Micro-CT analysis closed porosity, tissue mineral density, and cortical thickness. The three-point bending test measured maximum strength, energy, and stiffness. RESULTS: The macroscopic analysis showed that D presented smaller measures of length and thickness (AP and AP-P) than ND and DI. More extensive measurements were observed of LM and AP-D thickness in DI than in D. In micro-CT, DI showed larger cortical thickness than D. Mechanical analysis showed lower strength in D than in other groups. CONCLUSIONS: T1DM reduces bone growth and mechanical strength. Insulin therapy in diabetic rats improved bone growth and fracture resistance, making diabetic bone similar to normoglycemic animals.

Osteogenic organoid for bone regeneration: Healing of bone defect in congenital pseudoarthrosis of the tibia.

BACKGROUND: Congenital pseudoarthrosis of the tibia (CPT) is an uncommon disease associated with failure to achieve bone union and recurrent fractures. There is evidence showing that CPT is associated with decreased osteogenesis. Based on the capacity of mesenchymal stromal cells (MSCs) to induce osteogenesis, we develop an osteogenic organoid (OstO) constituted by these cells, and other components of the bone niche, for inducing bone formation in a child diagnosed with CPT. AIM: To evaluate the capacity of an OstO to induce bone formation in a patient with CPT. METHODS: The OstO was fabricated with allogeneic bone marrow MSCs from a healthy donor, collagen microbeads (CM) and PRP clot. The CM and PRP function as extracellular matrix and scaffolds for MSC. The OstO was placed at the site of non-union. Internal and external fixation was placed in the tibia. Radiological evaluation was performed after MSCs transplantation. RESULTS: After 4 months of MSCs transplantation, radiographic imaging showed evidence of osteogenesis at the site of CPT lesion. The tibia showed bone consolidation and complete healing of the non-union CPT lesion after 6 months. Functional improvement was observed after 1 year of MSC transplantation. CONCLUSIONS: The OstO is a bone-like niche which promote osteogenesis in patients with failure in bone formation, such as CPT. To our knowledge, these results provide the first evidence showing CPT healing induced by an OstO constituted by allogeneic MSCs. Future studies incorporating a larger number of patients may confirm these results.

The polymicrobial infection affects the infection recurrence rate (not failure) in treating femoral and tibial bone defects with the Masquelet technique-a comparative retrospective analysis of 54 patients with mono- and polymicrobial infections.

INTRODUCTION: This study evaluated whether polymicrobial infection affects reoperation rates due to infection recurrence and treatment failure with the Masquelet technique in infected posttraumatic segmental bone defects of the femur and tibia. METHODS:  We retrospectively analyzed patients treated between 2012 and 2021 in two trauma referral centers. We evaluated demographic data, injury, treatment, infection recurrence, failures, and bone healing rates according to whether the infection was mono- or polymicrobial. After uni-bivariate analysis between patients with polymicrobial and monomicrobial infection, we identified the variables associated with infection recurrence and failure through multivariate analysis. RESULTS:  We analyzed 54 patients, 30 (55.55%) with tibial and 24 (44.44%) femoral segmental bone defects, with a mean follow-up of 41.7 ± 15.0 months. Forty-four (81.48%) presented monomicrobial, and 10 (18.51%) polymicrobial infections. Comparatively, the need for soft tissue reconstruction and the infection recurrence rate was significantly higher in patients with polymicrobial infections. There was no significant difference in the failure rate (20 vs. 6.81% p = 0.23). Multivariable logistic regression analysis identified the polymicrobial infection as the only independent variable associated with infection recurrence (Odds Ratio = 11.07; p = 0.0017). CONCLUSION:  Our analysis suggests that polymicrobial infection is associated with a higher risk of infection recurrence in treating the femur and tibia segmental bone defects with the Masquelet technique. This information can help surgeons to inform patients about this and give them a realistic expectation of the outcome and the possibility of reoperation.

Effects of copper nanoparticles on performance, muscle and bone characteristics and serum metabolites in broilers / Efeitos de nanopartículas de cobre no desempenho, características musculares e ósseas e metabólitos séricos em frangos de corte

Three hundred and twenty day old Hubbard broilers were randomly allocated to four treatments (8 replicates, 10 birds/pen) and were raised under standard management conditions. Birds in the first group served as control and were fed a corn based diet, while birds in the remaining three groups i.e.; A, B and C were fed with a basal diet supplemented with copper nanoparticles (CuNP) at 5, 10 and 15 mg /kg of diet respectively for 35 days. Supplementation of CuNP linearly increased (P≤0.05) body weight (BW), average daily weight gain (ADWG) and feed intake (FI) in broilers. Uric acid, glucose levels in blood and feed conversion ratio (FCR) reduced linearly (P≤0.05) with CuNP supplementation in diet. Supplementation of CuNP in the diet also linearly increased (P≤0.05) tibia weight, length, diameter, weight/length index (W/L) and Tibiotarsal index (TT index). Inclusion of CuNP in broilers diet linearly increased the measured parameters of muscle i.e.; pH, fiber diameter, fiber cross-sectional area, fascicle diameter, fascicle cross-sectional area (P≤0.05). Concentration of copper, iron, calcium and phosphorous in blood also increased line-arly (P ≤ 0.05) with CuNP supplementation. Overall, CuNP positively affected the growth performance, histological characteristics of muscles, bone strength and serum metabolites in broilers.

Frangos de corte Hubbard com 320 dias de idade foram alocados aleatoriamente em quatro tratamentos (8 repetições, 10 aves/curral) e foram criados em condições de manejo padrão. As aves do primeiro grupo serviram como controle e foram alimentadas com uma dieta à base de milho, enquanto as aves dos três grupos restantes, ou seja, A, B e C, foram alimentadas com dieta basal suplementada com nanopartículas de cobre (CuNP) a 5, 10 e 15 mg/kg de dieta, respectivamente, por 35 dias. A suplementação de CuNP aumentou linearmente (P ≤ 0,05) o peso corporal (PC), o ganho de peso médio diário (GPDA) e o consumo de ração (FI) em frangos de corte. O ácido úrico, os níveis de glicose no sangue e a conversão alimentar (TCF) reduziram linearmente (P ≤ 0,05) com a suplementação de CuNP na dieta. A suplementação de CuNP na dieta também aumentou linearmente (P ≤ 0,05) peso, comprimento, diâmetro, índice peso/comprimento (P/L) e índice tibiotársico (índice TT) da tíbia. A inclusão de CuNP na dieta de frangos de corte aumentou linearmente os parâmetros medidos de músculo, ou seja; pH, diâmetro da fibra, área da seção transversal da fibra, diâmetro do fascículo, área da seção transversal do fascículo (P ≤ 0,05). A concentração de cobre, ferro, cálcio e fósforo no sangue também aumentou linearmente (P ≤ 0,05) com a suplementação de CuNP. No geral, CuNP afetou positivamente o desempenho de crescimento, características histológicas dos músculos, resistência óssea e metabólitos séricos em frangos de corte.

Bone reconstruction in the treatment of tibial hemimelia: an alternative to amputation? / Reconstrução óssea no tratamento da hemimelia tibial: uma alternativa para amputação?

ABSTRACT Objective: To evaluate the advantages and disadvantages of bone reconstruction and lengthening compared to amputation in the treatment of tibial hemimelia for patients and their families. Methods: Systematic review of articles published in English and Portuguese between 1982 and 2022 in the MEDLINE, PubMed, Cochrane and SciELO databases. The variables of interest were: year of publication, sample characteristics, classification of tibial hemimelia according to Jones, treatment outcome and follow-up time. Results: A total of eleven articles were included in the scope of this review. The studies involved 131 patients, 53.4% male and 46.6% female. The age of the patients who underwent a surgical procedure ranged from 1 year and 10 months to 15 years. The most common type was Jones' I (40.9%). The most recurrent complications in the reconstruction treatment were: infection of the external fixator path, flexion contracture (mainly of the knee), reduction in the range of motion of the knee and ankle. Conclusion: We did not find enough relevant studies in the literature to prove the superiority of reconstruction. Amputation remains the gold standard treatment for tibial hemimelia to this day. Level of Evidence III, systematic review of level III studies

RESUMO Objetivo: Avaliar as vantagens e desvantagens da reconstrução óssea e alongamento comparada à amputação no tratamento da hemimelia tibial para pacientes e familiares. Métodos: Revisão sistemática, com análise de artigos publicados nas línguas inglesa e portuguesa entre 1982 e 2022, nas bases de dados MEDLINE, PubMed, Cochrane e SciELO. As variáveis de interesse foram: ano de publicação, característica da amostra, classificação da hemimelia tibial segundo Jones, desfecho do tratamento e tempo de seguimento. Resultados: Fizeram parte do escopo desta revisão onze artigos. Os estudos envolveram 131 pacientes, 53,4% do sexo masculino e 46,6% do feminino. A idade dos pacientes submetidos a algum procedimento cirúrgico variou de 1 ano e 10 meses a 15 anos. O tipo mais comum foi o I de Jones (40,9%). As complicações mais recorrentes no tratamento pela reconstrução foram: infecção do trajeto de pinos do fixador externo, contratura em flexão (principalmente do joelho), redução do arco de movimento de joelho e tornozelo. Conclusão: Não encontramos na literatura estudos suficientemente relevantes para comprovar a superioridade da reconstrução. A amputação se mantém até os dias de hoje o tratamento padrão-ouro para hemimelia tibial. Nível de evidência III; revisão sistemática de estudos de nível III.

Risk factors at non-union of tibial fracture treated with intramedullary nail / Fatores de risco para não-união da fratura de tíbia tratada com haste intramedular

ABSTRACT Objective: Identify the predictors associated with delayed union at 6 months and non-union at 12 months in tibial shaft fractures treated with intramedullary nailing (IMN). Methods: This retrospective longitudinal study included a cohort of 218 patients who sustained tibial shaft fractures and received IMN between January 2015 and March 2022. We gathered data on a range of risk factors, including patient demographics, trauma intensity, associated injuries, fracture characteristics, soft tissue injuries, comorbidities, addictions, and treatment-specific factors. We employed logistic bivariate regression analysis to explore the factors predictive of delayed union and non-union. Results: At the 6-month follow-up, the incidence of delayed union was 28.9%. Predictors for delayed union included flap coverage, high-energy trauma, open fractures, the use of external fixation as a staged treatment, the percentage of cortical contact in simple type fractures, RUST score, and postoperative infection. After 12 months, the non-union rate was 15.6%. Conclusion: the main predictors for non-union after IMN of tibial shaft fractures are related to the trauma energy. Furthermore, the initial treatment involving external fixation and postoperative infection also correlated with non-union. Level of Evidence III; Retrospective Longitudinal Study.

RESUMO Objetivo: identificar os fatores preditivos associados ao atraso de consolidação em 6 meses e à não união em 12 meses em fraturas da diáfise da tíbia tratadas com haste intramedular (HIM). Métodos: O estudo longitudinal retrospectivo de coorte incluiu 218 pacientes, que apresentaram fraturas da díafise da tíbia e receberam HIM entre janeiro de 2015 e março de 2022. Os desfechos principais pesquisados foram atraso de consolidação em 6 meses de acompanhamento, e não união em 12 meses. Coletou-se dados de uma variedade de fatores de risco. Utilizou-se análise de regressão logística bivariada para explorar os fatores preditivos de atraso de consolidação e não união. Resultados: Aos 6 meses, a incidência de atraso de consolidação foi de 28,9%. Os preditores de atraso de consolidação incluem cobertura de retalho, trauma de alta energia, fraturas expostas, uso de fixação externa como tratamento estagiado, porcentagem de contato cortical em fraturas simples, escore RUST e infecção pós-operatória. Após 12 meses, a taxa de não união foi de 15,6%, com fatores preditivos sendo necessidade de cobertura por retalho, lesão vascular, trauma de alta energia, fraturas expostas, uso de fixação externa como tratamento estagiado, porcentagem de contato cortical em fraturas simples e infecção pós-operatória. Nível de Evidência III; Estudo Longitudinal Retrospectivo.

Tibial Eminence Avulsion in a Tibial Plateau Fracture - Our Approach: A Clinical Case / Avulsão da eminência tibial em uma fratura do platô tibial - Nossa abordagem: Um caso clínico

Abstract A middle-aged female patient with a tibial plateau fracture combined with an avulsion of the tibial eminence was treated with a combination of medial plate fixation for the plateau and an arthroscopic aided nonabsorbable suture of the eminence. Our technique for tibial eminence avulsion fractures has no interference with tibial plateau osteosynthesis materials and has proven, once again, to have good results in the treatment of combined and complex injuries of the knee.

Resumo Uma paciente de meia-idade com fratura do platô tibial e avulsão da eminência tibial foi tratada com uma combinação de fixação do platô com placa medial e sutura da eminência com fio não absorvível auxiliada por artroscopia. Nossa técnica para fraturas com avulsão da eminência tibial não interfere nos materiais de osteossíntese do platô tibial e, mais uma vez, teve bons resultados no tratamento de lesões combinadas e complexas do joelho.

Gradual Correction of Valgus Deformities of the Tibia Using a Monolateral External Fixator.

Objective: To present a review of patients subjected to gradual correction of a valgus deformity of the tibia using a monolateral external fixator. Method: This retrospective review included patients from January 2012 to May 2022 who met the following inclusion criteria: deviation of mechanical axis of the limb due to valgus deformity of the tibia; tibial deformity in the coronal plane on radiographic examination; a documented outpatient pre-operative evaluation by an orthopaedic surgeon and age between 10 and 70 years. The following exclusion criteria were applied: the presence of another tibia deformity preventing gradual correction using the proposed assembly; skin conditions incompatible with the surgical procedure; inadequate pre- or post-operative radiological evaluation; and insufficient information in the medical records. Results: The mean age of patients with a valgus deformity of the tibia was 30.8 ± 15.9 years. These patients had a body mass index (BMI) of 26.1 ± 5.5 kg/m2. A congenital or developmental aetiology was attributed to 58.3% of the cases. Most commonly, the deformity was found in the middle third of the tibia with a mean deformity of 14.7 ± 6.6 degrees. The total external fixator time ranged from 73 to 229 days (average 149.7 ± 36.1 days). The mean medial proximal and lateral distal tibial angles differed significantly for pre- and post-operative measurements (p ≤ 0.05). There were complications in eight cases; five cases of pin site infections, two cases of medial cortical fracture and one case of peroneal nerve neuropraxia. Conclusion: The proposed correction technique produces a satisfactory angular correction and with similar outcomes as described in the literature. How to cite this article: Motta DP, Faria JLR, Couto A, et al. Gradual Correction of Valgus Deformities of the Tibia Using a Monolateral External Fixator. Strategies Trauma Limb Reconstr 2023;18(2):123-132.

RESECTION OF ANKLE TUMOR LESION AND RECONSTRUCTION WITH THE USE OF ALLOGRAFT.

Reconstruction of the distal third of the tibia due to resection of a malignant tumor has some hindering factors, such as a thin subcutaneous layer, neurovascular bundles that cross compartments, prolonged operative duration, specific orthopedic material, and a trained multidisciplinary team. Allografting with material from tissue banks is part of this orthopaedic arsenal. OBJECTIVE: To describe the protocol used at Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad. METHODS: Series of six cases subjected to resection with oncologic margins, allograft reconstruction, and use of a retrograde ankle nail as limb-salvage surgery. Three of the six patients were women, the lesions were on average 9.3 cm long, and the average operative duration was 3.25 hours. RESULTS: The main short-term complication (≤ 30 days) was peroneal nerve palsy, while the main long-term complication (> 30 days) was surgical site infection (two cases). Consolidation of the two foci occurred in three patients, and two patients developed asymptomatic pseudoarthrosis of the proximal focus with consolidation of the distal focus. CONCLUSION: Despite the complications, the proposed surgery gives patients the chance to preserve their limb in the face of immediate radical surgery. Level of Evidence IV, Case Series.

A reconstrução do terço distal da tíbia devido à ressecção de tumor maligno apresenta alguns fatores que dificultam sua realização, como camada subcutânea delgada, feixes neurovasculares que transpassam os compartimentos, tempo cirúrgico prolongado, material ortopédico específico e equipe multidisciplinar treinada. O aloenxerto de banco de tecido faz parte deste arsenal ortopédico. Objetivo: Descrever o protocolo realizado no Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad. Métodos: Série de seis casos submetidos à ressecção com margens oncológicas, reconstrução com aloenxerto e uso de haste retrógrada de tornozelo como cirurgia preservadora do membro. Três dos seis pacientes eram do sexo feminino, as lesões tinham em média 9,3 cm de comprimento e o tempo cirúrgico médio foi de 3,25 horas. Resultados: A principal complicação de curto prazo (≤ 30 dias) foi a paralisia do nervo fibular, enquanto a principal complicação de longo prazo (> 30 dias) foi a infecção do sítio cirúrgico (dois casos). A consolidação dos dois focos ocorreu em três pacientes, e dois pacientes evoluíram para pseudoartrose assintomática do foco proximal com consolidação do foco distal. Conclusão: Apesar das complicações, a cirurgia proposta permite ao paciente a chance de preservar seu membro diante de uma cirurgia radical imediata. Nível de Evidência IV, Série de Casos.

Treatment of Infected Pseudarthrosis of the Tibia Using the Ilizarov Method and the Orr Dressing.

Objective This study aims to analyze outcomes and clinical and epidemiological data of infected tibial pseudarthrosis using the Ilizarov method and the Orr dressing. Methods Data from n = 43 patients diagnosed with infected tibial pseudarthrosis were analyzed by descriptive and inferential statistical methods. In addition, Paley's assessment criteria evaluated bone and functional outcomes. Qualitative variables were presented as the distribution of absolute and relative frequencies. The presentation of quantitative variables followed the D'Agostino-Pearson test. Results Thirty-seven (86.04%) subjects were males, and six (13.95%) were females. The most frequent age group among patients was 50 to 59 years old (25.6%), with a p-value = 0.8610. The treatment time was longer for the trifocal treatment (23.8 months) when compared to the bifocal treatment (15.6 months), with a p-value = 0.0010* (highly significant). Excellent bone outcomes represented 72.09% of the sample; 23.25% of outcomes were good. Functional outcomes were excellent in 55.81%, good in 6.97%, and regular in 27.90% of subjects. The Orr dressing (using Vaseline gauze) proved effective, achieving wound healing with soft tissue coverage in all patients evaluated. Conclusions The Ilizarov method resulted in a substantial change in the treatment of bone infections, especially infected pseudarthrosis. The versatility of this method has turned it into an effective tool, allowing the healing of the infectious process and the correction of potential deformities and shortening.

Avulsion Fracture of the Tibial Tuberosity in an Adolescent: Case Report / Fratura por avulsão da tuberosidade da tíbia em adolescente: Relato de caso

Abstract The present study reports a rare case of avulsion fracture of the tibial tuberosity in an adolescent. A 14-year-old male patient sprained his left knee during a soccer match. At the first emergency-room visit, he presented pain in his left knee, 2 +/4+ edema, and inability to walk and flex the affected knee, but no neurovascular changes or signs of compartment syndrome. Radiographs revealed a physeal fracture at the left proximal tibia, classified by Ogden, Tross and Murphy, and modified by Ryu and Debenham, as type IV, and complemented by Aerts et al. as type IV-B. Immobilization was performed with a plaster cast from the inguinal to malleolar regions, followed by analgesia. The patient was operated on the next day, when open reduction and internal fixation using 4.5-mm cannulated screws were performed. The patient was discharged one day after surgery, with plaster cast immobilization and load restraint for four weeks, and bone consolidation was radiologically confirmed three months after the procedure. The patient evolved with a range of motion similar to that of the contralateral limb, no length discrepancy in the lower limbs, and no complaints after one year of follow-up.

Resumo O presente estudo tem como objetivo relatar um caso raro de fratura por avulsão da tuberosidade da tíbia em adolescente. Um paciente de 14 anos, do sexo masculino, sofreu entorse de joelho esquerdo durante partida de futebol. No primeiro atendimento em pronto-socorro, ele apresentava dor no joelho esquerdo, edema 2 +/4 + , incapacidade de deambulação e de flexo-extensão do joelho acometido, sem alterações neurovasculares ou sinais de síndrome compartimental. Nas radiografias, identificou-se fratura fisária na tíbia proximal esquerda, classificada por Ogden, Tross e Murphy, com modificação por Ryu e Debenham, como tipo IV, e complementada por Aerts et al. como tipo IV-B. Foi realizada imobilização com tala gessada inguino-maleolar e analgesia, e o paciente submetido a cirurgia no dia seguinte, com redução aberta e fixação interna utilizando parafusos canulados 4,5 mm. O paciente recebeu alta no dia seguinte à cirurgia, sendo mantida a imobilização com tala gessada e a restrição de carga por quatro semanas, e apresentou consolidação óssea confirmada por radiografia com três meses do pós-operatório. O paciente evoluiu sem discrepância de comprimento dos membros inferiores, arco de movimento igual ao do membro contralateral, e sem queixas no seguimento de um ano.

COMPARATIVE ANALYSIS OF OPEN AND CLOSED FLOATING KNEE INJURIES.

Objective: To compare the functional outcomes between floating knee injuries with open femur and tibia fractures and closed floating knee injuries. Methods: Floating knee injuries (followed up and treated in our clinic) were retrospectively analyzed. Patients were divided into two groups: floating knee injuries with open femur and tibia fractures (Group 1) and floating knee injuries with closed femur and tibia fractures (Group 2). Patients were compared according to their demographic characteristics and clinical and functional outcomes. Results: Of 52 study patients, 28 had Group 1 injuries and 24, Group 2 injuries. We found a statistically significant difference in length of hospital stay between the two groups (p = 0.01) and a statistically significant difference in Karlström-Olerud functional scores between the groups (p = 0.02). We found osteomyelitis in five (17%) patients in Group 1 and in one (4%) patient in Group 2. Conclusion: Patients with floating knee injuries and open fractures showed poorer outcomes than those with closed fractures. Those with open floating knee injuries show complications more often and longer hospital stays. Level of Evidence III, Therapeutic Studies Investigating the Results of Treatment.

Objetivo: Comparar os resultados funcionais entre lesões do tipo joelho flutuante com fraturas expostas de fêmur e tíbia e lesões de joelho flutuante fechadas. Métodos: As lesões de joelho flutuante acompanhadas e tratadas em nossa clínica foram analisadas retrospectivamente. Os pacientes foram divididos em dois grupos: lesões de joelho flutuante com fraturas expostas de fêmur e tíbia (Grupo 1) e lesões de joelho flutuante com fraturas fechadas de fêmur e tíbia (Grupo 2). Os pacientes foram comparados de acordo com as características demográficas e os desfechos clínicos e funcionais. Resultados: Entre os 52 pacientes do estudo, 28 tiveram lesões do Grupo 1 e 24 do Grupo 2. A diferença no tempo de internação entre os dois grupos foi estatisticamente significativa (p = 0,01). Também houve diferença estatisticamente significativa nos escores funcionais de Karlström e Olerud entre os grupos (p = 0,02). Osteomielite foi identificada em 5 (17%) pacientes do Grupo 1 e em 1 (4%) paciente do Grupo 2. Conclusão: Comparados aos pacientes com lesões de joelho flutuante com fraturas fechadas, aqueles com fraturas expostas têm piores resultados, uma vez que as complicações são mais comuns e a permanência hospitalar é mais longa nestes casos. Nível de Evidência III, Estudos Terapêuticos - Investigação dos Resultados do Tratamento.

Treatment of Infected Pseudarthrosis of the Tibia Using the Ilizarov Method and the Orr Dressing / Tratamento das pseudoartroses infectadas da tÍbia pelo mÉtodo de Ilizarov associado ao curativo de Orr

Abstract Objective This study aims to analyze outcomes and clinical and epidemiological data of infected tibial pseudarthrosis using the Ilizarov method and the Orr dressing. Methods Data from n = 43 patients diagnosed with infected tibial pseudarthrosis were analyzed by descriptive and inferential statistical methods. In addition, Paley's assessment criteria evaluated bone and functional outcomes. Qualitative variables were presented as the distribution of absolute and relative frequencies. The presentation of quantitative variables followed the D'Agostino-Pearson test. Results Thirty-seven (86.04%) subjects were males, and six (13.95%) were females. The most frequent age group among patients was 50 to 59 years old (25.6%), with a p-value = 0.8610. The treatment time was longer for the trifocal treatment (23.8 months) when compared to the bifocal treatment (15.6 months), with a p-value = 0.0010* (highly significant). Excellent bone outcomes represented 72.09% of the sample; 23.25% of outcomes were good. Functional outcomes were excellent in 55.81%, good in 6.97%, and regular in 27.90% of subjects. The Orr dressing (using Vaseline gauze) proved effective, achieving wound healing with soft tissue coverage in all patients evaluated. Conclusions The Ilizarov method resulted in a substantial change in the treatment of bone infections, especially infected pseudarthrosis. The versatility of this method has turned it into an effective tool, allowing the healing of the infectious process and the correction of potential deformities and shortening.

Resumo Objetivo Analisar os resultados e os dados clínicos e epidemiológicos do tratamento das pseudoartroses infectadas da tíbia pelo método de Ilizarov associado ao curativo de Orr. Métodos Para analisar os dados de n = 43 pacientes com diagnóstico de pseudoartrose infectada da tíbia foram aplicados métodos estatísticos descritivos e inferenciais e os resultados ósseos e funcionais foram avaliados de acordo com os critérios de avaliação de Paley. As variáveis qualitativas foram apresentadas por distribuição de frequências absolutas e relativas. As variáveis quantitativas foram apresentadas pelo teste de DAgostino-Pearson. Resultados Foi encontrado que 37 (86,04%) eram do sexo masculino, 6 (13,95%) femininos. A faixa etária mais frequente entre os pacientes foi de 50 a 59 anos (25.6%), p-valor = 0.8610. O tempo de tratamento é maior no tratamento trifocal (23.8 meses) quando comparado com o Bifocal (15.6 meses), p-valor =0.0010* (altamente significante). Os resultados ósseos excelentes representaram 72,09%, 23,25% foram de resultados considerados bons. Os resultados funcionais considerados excelentes foram 55,81%, os resultados bons foram 6,97%, resultados regulares foram 27,90. O curativo com gaze vaselinada (curativo de Orr) mostrou-se eficaz, alcançando assim a cicatrização das feridas com cobertura de partes moles em todos os pacientes avaliados. Conclusões O método de Ilizarov proporcionou uma mudança substancial no tratamentos das infecções ósseas, especialmente das pseudoartroses infectadas. A versatilidade deste método se transformou em uma ferramenta eficaz, permitindo a cura do processo infeccioso, bem como correção das possíveis deformidades e do encurtamento.

Orthoplastic management of distal tibia bone infection using Masquelet technique and PRECICE nail: A case report.

The orthoplastic treatment of post-traumatic bone infections is complex and requires a multidisciplinary approach using both orthopedic and plastic surgery principles. Its primary goal is to achieve rapid control of the infection through aggressive debridement of the affected tissue, in order to perform a complete reconstruction of the limb. This allows both its salvage and restoration of function. We present a patient with septic non-union secondary to distal tibia fracture with a bone defect of 7 cm and severe soft tissue injury. The treatment was divided into three stages. First, the infection was controlled by radical debridement, limb shortening, and temporary stabilization. Second, early reconstruction was initiated utilizing the first stage of the Masquelet's induced membrane technique (MIMT), and soft tissue coverage with free flap. Third, MIMT was finalized, and bone lengthening with PRECICE nail was performed. We consider this approach effective as it can offer early recovery with optimal functional and aesthetic results in bone defects associated with coverage defects.

Anatomy of the Medial Meniscotibial Ligament of the Knee: A Systematic Review.

Objectives To perform a systematic review of the literature on the anatomy of the medial meniscotibial ligaments (MTLs), and to present the most accepted findings, as well as the evolution of the anatomical knowledge on this structure. Materials and Methods An electronic search was conducted in the MEDLINE/PubMed, Google Scholar, EMBASE and Cochrane library databases with no date restrictions. The following index terms were used in the search: anatomy AND meniscotibial AND ligament AND medial . The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We included anatomical studies of the knee were included, such as cadaver dissections, histological and/or biological investigations, and/or imaging of the medial MTL anatomy. Results Eight articles that met the inclusion criteria were selected. The first article was published in 1984 and the last, in 2020. The total sample in the 8 articles was of 96 patients. Most studies are purely descriptive in terms of the macroscopic morphological and microscopic histological findings. Two studies evaluated the biomechanical aspects of the MTL, and one, the anatomical correlation with the magnetic resonance imaging examination. Conclusion The main function of the medial MTL, a ligament that originates in the tibia and is inserted in the lower meniscus, is to stabilize and maintain the meniscus in its position on the tibial plateau. However, there is a limited amount of information regarding medial MTLs, primarily in terms of anatomy, especially vascularization and innervation.