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.

3D PRINTING IN COMPLEX TIBIAL FRACTURE CLASSIFICATION & PLANNING.

Objective: Tibial plateau fractures are common intra-articular fractures that pose classification and treatment challenges for orthopedic surgeons. Objective: This study examines the value of 3D printing for classifying and planning surgery for complex tibial plateau fractures. Methods: We reviewed 54 complex tibial plateau fractures treated at our hospital from January 2017 to January 2019. Patients underwent preoperative spiral CT scans, with DICOM data processed using Mimics software. 3D printing technology created accurate 1:1 scale models of the fractures. These models helped subdivide the fractures into seven types based on the tibial plateau's geometric planes. Surgical approaches and simulated operations, including fracture reduction and plate placement, were planned using these models. Results: The 3D models accurately depicted the direction and extent of fracture displacement and plateau collapse. They facilitated the preoperative planning, allowing for precise reconstruction strategies and matching intraoperative details with the pre-printed models. Post-surgery, the anatomical structure of the tibial plateau was significantly improved in all 54 cases. Conclusion: 3D printing effectively aids in the classification and preoperative planning of complex tibial plateau fractures, enhancing surgical outcomes and anatomical restoration. Level of Evidence IV, Prospective Study.

Objetivo: As fraturas do planalto tibial são fraturas intra-articulares comuns de classificação e tratamento desafiadores aos cirurgiões ortopédicos. Objetivo: Este estudo investiga o uso de impressão 3D para classificar e planejar a cirurgia de fraturas complexas do planalto tibial. Métodos: 54 fraturas complexas do planalto tibial tratadas em nosso hospital de janeiro de 2017 a janeiro de 2019 foram revisadas. Os pacientes foram submetidos a tomografias computadorizadas em espiral pré-operatórias, com dados DICOM processados usando o software Mimics. A tecnologia de impressão 3D gerou modelos precisos em escala 1:1 das fraturas. Estes modelos ajudaram a subdividir as fraturas em sete tipos com base nos planos geométricos do planalto tibial. As abordagens cirúrgicas e as operações simuladas, incluindo a redução da fratura e a colocação de placa, foram planejadas utilizando estes modelos. Resultados: Os modelos 3D representaram com precisão a direção e a extensão da deslocação da fratura e do colapso do planalto. Os modelos facilitaram o planejamento pré-operatório, viabilizando estratégias de reconstrução precisas e a correspondência dos detalhes intraoperatórios com os modelos pré-impressos. Após a cirurgia, a estrutura anatômica do planalto tibial melhorou significativamente em todos os 54 casos. Conclusão: A impressão 3D ajuda na classificação e no planejamento pré-operatório de fraturas complexas do planalto tibial, melhorando os resultados cirúrgicos e a restauração anatômica. Nível de Evidência IV, Estudo Prospectivo.

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.

RISK FACTORS AT NON-UNION OF TIBIAL FRACTURE TREATED WITH INTRAMEDULLARY NAIL.

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.

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.

Use of Three-dimensional Printing for Tibial Pilon Fracture Diagnosis and Treatment.

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.

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.

Weight-bearing Ultrasound to Diagnose Talar Dislocation Causing Tarsal Tunnel Syndrome.

The neuropathic compression of the tibial nerve and/or its branches on the medial side of the ankle is called tarsal tunnel syndrome (TTS). Patients with TTS presents pain, paresthesia, hypoesthesia, hyperesthesia, muscle cramps or numbness which affects the sole of the foot, the heel, or both. The clinical diagnosis is challenging because of the fairly non-specific and several symptomatology. We demonstrate a case of TTS caused by medial dislocation of the talar bone on the calcaneus bone impacting the tibial nerve diagnosed only by ultrasound with the patient in the standing position.

Ladder-based resistance training with the progression of training load altered the tibial nerve ultrastructure and muscle fiber area without altering the morphology of the postsynaptic compartment.

Scientific evidence regarding the effect of different ladder-based resistance training (LRT) protocols on the morphology of the neuromuscular system is scarce. Therefore, the present study aimed to compare the morphological response induced by different LRT protocols in the ultrastructure of the tibial nerve and morphology of the motor endplate and muscle fibers of the soleus and plantaris muscles of young adult Wistar rats. Rats were divided into groups: sedentary control (control, n = 9), a predetermined number of climbs and progressive submaximal intensity (fixed, n = 9), high-intensity and high-volume pyramidal system with a predetermined number of climbs (Pyramid, n = 9) and lrt with a high-intensity pyramidal system to exhaustion (failure, n = 9). myelinated fibers and myelin sheath thickness were statistically larger in pyramid, fixed, and failure. myelinated axons were statistically larger in pyramid than in control. schwann cell nuclei were statistically larger in pyramid, fixed, and failure. microtubules and neurofilaments were greater in pyramid than in control. morphological analysis of the postsynaptic component of the plantar and soleus muscles did not indicate any significant difference. for plantaris, the type i myofibers were statistically larger in the pyramid and fixed compared to control. the pyramid, fixed, and failure groups for type ii myofibers had larger csa than control. for soleus, the type i myofibers were statistically larger in the pyramid than in control. pyramid and fixed had larger csa for type ii myofibers than control and failure. the pyramid and fixed groups showed greater mass progression delta than the failure. We concluded that the LRT protocols with greater volume and progression of accumulated mass elicit more significant changes in the ultrastructure of the tibial nerve and muscle hypertrophy without endplate changes.

BONE RECONSTRUCTION IN THE TREATMENT OF TIBIAL HEMIMELIA: AN ALTERNATIVE TO AMPUTATION?

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.

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.

Comparative digital study using four methods of measurements of the tibial distal anatomical axes for determining the anatomical-mechanical angle in dogs with cranial cruciate ligament rupture.

OBJECTIVE: This study evaluates the amplitude of the anatomical-mechanical angle (AMA-angle) using 4 measuring methods of the tibial distal anatomical axes (DAA) previously described, comparing the literature results to determine if there are significant differences in patients with cranial cruciate ligament (CrCL) rupture. ANIMALS: This study was comprised of 30 tibiae (29 dogs), including 1 bilateral case. METHODS: A retrospective study was selected for this research. DAA measurements were performed on all surgically confirmed cases of canine CrCL rupture at Hospital Veterinário de Especialidades Bruselas from 2019 to 2022. Four different published methods (identified by surname of the corresponding author of the original publication) were compared. Tibial measurements were made using Veterinary Preoperative Orthopedic Planning Pro software (https://vpop-pro.com/) on mediolateral radiographic projections obtained from a digital database. RESULTS: The mean (range) in the DAA method conducted by Hulse obtained a AMA-angle of 5.4° (3.3 to 8.1°), 3.0° (0 to 5.8°) for Osmond et al, 3.2° (0.9 to 6°) for Miles, and 5.9° (2.4 to 8.8°) for Tudury. Differences among the means of the AMA-angle of the authors methods were found with a statistical difference (P < .05), except between Osmond and Miles. The mean AMA-angle with the Osmond method concurred with previous study results that determined the magnitude using the same measurement method of DAA in patients with CrCL rupture. CLINICAL RELEVANCE: The AMA-angle magnitude has been associated with higher sensitivity and specificity for predicting the development of CrCL rupture compared to other anatomical factors evaluated; therefore, future comparisons with different methods of measurement of the DAA between healthy and affected patients are recommended to determine whether any of them can increase the percentage value as a predictive factor for the occurrence of this condition.

Epidemiology of Knee Injuries in Baseball Players from the State of São Paulo.

Objective This study aimed to identify the main knee complaints and injuries associated with baseball and their prevalence in the state of São Paulo, Brazil. Methods This epidemiological study analyzed data from an online questionnaire sent to baseball athletes from the state of São Paulo, Brazil, from 2019 to 2022. Results Ninety-eight athletes participated in the study. Their average age was 24.3 years, and 85.72% of the subjects were men. The most prevalent ethnicities were yellow (50%) and white (42.86%). Most athletes had incomplete or complete higher education (75.5%). Most (88.77%) have been training for over 1 year, and 40.82% played in more than 1 position. More than half also practiced another sport. Most (66.32%) athletes present knee complaints or symptoms, and 37.75% had suffered a knee injury playing baseball, with several mechanisms (contact with the ground, contact with another player, or no contact). More than half (59.45%) of the athletes required time away from baseball due to complaints, symptoms, or injuries. Conclusion Among the athletes interviewed, 66.32% had a knee complaint, and 37.75% had already had a knee injury, especially meniscal and ligament injuries. The injury rate was highest in the first year of practice.

Treatment of Tibial Plateau Fractures with a Circular External Fixator: A Comparative Analysis of Two Assembly Methods.

Objective To compare the functional outcomes of two circular external fixation techniques to treat complex fractures of the proximal end of the tibia. Materials and Methods The present is a retrospective cohort study with 51 patients who underwent surgical treatment for complex fractures of the tibial plateau with a circular external fixator. There were two groups of patients: 12 subjects underwent treatment with the classic assembly technique, and 39 subjects underwent treatment with the simplified technique. The variables analyzed included age, sex, injury mechanism, trauma energy, associated injuries, fixator type, time of fixator use, and clinical-radiographic outcomes. The classic technique mainly uses transfixing Kirschner wires, while the simplified one replaces the Kirschner wires with Schanz pins in the distal block of the circular external fixator. Result There were no statistically significant differences ( p > 0.05) between the two groups concerning the clinical-radiographic outcomes, including fracture consolidation, quality of joint fracture reduction, range of motion, lower limbs residual discrepancy, and postoperative pain. Conclusion We suggest that the simplified technique, using Schanz pins instead of Kirschner wires, can be a viable and effective alternative to treat complex fractures of the proximal end of the tibia with a circular external fixator. This simplified approach can offer benefits, such as a lower infection rate and greater patient comfort, without compromising clinical and radiographic outcomes, thus justifying its use.

Manejo de fractura de platillo tibial medial utilizando placas rim anteromedial y posteromedial / Management of Medial Tibial Plateau Fracture using Antero- and Posteromedial Rim Plates

INTRODUCCION En los últimos años, se ha descrito el uso de placas horizontales para la fijación de fracturas que comprometen el reborde articular de los platillos tibiales, lo que se conoce como placa rim. La mayoría de las publicaciones al respecto describen su uso en columnas posteriores y posterolaterales de los platillos tibiales, y a la fecha hay escasos reportes del uso de este tipo de placa en la columna anteromedial y ninguno para la posteromedial. El objetivo de este artículo es presentar dos casos clínicos de fracturas conminutas del platillo tibial medial mostrando su tratamiento con el uso de placas rim. CASOS CLINICOS El primer caso presentaba compromiso anteromedial y posteromedial, y el segundo, compromiso posteromedial. En ambos casos, se logró la reducción mediante un abordaje posteromedial y su fijación con placa bloqueada de 2,7 mm como placa rim. En cada caso, se detalló la estrategia de reducción y el manejo postoperatorio. RESULTADOS Ambos pacientes consiguieron la consolidación ósea entre las semanas 14 y 18 tras la osteosíntesis definitiva, sin presentar pérdidas de reducción. Ambos lograron rango de movilidad articular completo (0°­125°), y retornaron a sus trabajos a los 4 y 6 meses respectivamente. CONCLUSIONES Estas placas ofrecen una buena opción de tratamiento para fracturas articulares conminutas del borde del platillo tibial, tanto en la columna anteromedial como en la posteromedial. A pesar de la ausencia de grandes series de pacientes con uso de placas rim mediales, el resultado de los casos presentados aquí nos permite plantear su utilidad al momento de enfrentarnos a fracturas del reborde articular

INTRODUCTION In recent years, the use of horizontal plates has been described to achieve fixation of fractures that compromise the articular ridge of the tibial plateau; these plates are known as "rim plates." Most publications report their use in the posterior and posterolateral columns of the tibial plateau, and to date there are few reports of its use for the fixation of the anteromedial column and none for the posteromedial column. The objective of the present article is to report two clinical cases of comminuted fractures of the medial tibial plateau, showing their treatment with the use of medial rim plates. CLINICAL CASES The first case presented with an anteromedial and posteromedial tibial plateau fracture, and the second, a posteromedial fracture. In both cases, reduction was achieved through a posteromedial approach, and the fixation was performed with a 2.7-mm locked rim plate. The reduction strategy and postoperative management were detailed in each case. RESULTS Both patients achieved bone consolidation during the 14th and 18th weeks after the definitive osteosynthesis, without presenting loss of reduction. Both patients achieved full range of joint motion (0°­125°) and returned to work after four and six months respectively. CONCLUSION These plates offer a good treatment option for comminuted fractures of the rim of the tibial plateau, for both the anteromedial and posteromedial columns. Despite the absence of large series of patients with the use of medial rim plates, the results of the two cases herein presented enables us to propose it as a useful tool when dealing with fractures of the medial rim of the tibial plateau

INTRODUCTION In recent years, the use of horizontal plates has been described to achieve fixation of fractures that compromise the articular ridge of the tibial plateau; these plates are known as "rim plates." Most publications report their use in the posterior and posterolateral columns of the tibial plateau, and to date there are few reports of its use for the fixation of the anteromedial column and none for the posteromedial column. The objective of the present article is to report two clinical cases of comminuted fractures of the medial tibial plateau, showing their treatment with the use of medial rim plates. CLINICAL CASES The first case presented with an anteromedial and posteromedial tibial plateau fracture, and the second, a posteromedial fracture. In both cases, reduction was achieved through a posteromedial approach, and the fixation was performed with a 2.7-mm locked rim plate. The reduction strategy and postoperative management were detailed in each case. RESULTS Both patients achieved bone consolidation during the 14th and 18th weeks after the definitive osteosynthesis, without presenting loss of reduction. Both patients achieved full range of joint motion (0°­125°) and returned to work after four and six months respectively. CONCLUSION These plates offer a good treatment option for comminuted fractures of the rim of the tibial plateau, for both the anteromedial and posteromedial columns. Despite the absence of large series of patients with the use of medial rim plates, the results of the two cases herein presented enables us to propose it as a useful tool when dealing with fractures of the medial rim of the tibial plateau

Predictive factors for infection after osteosynthesis of tibial plateau fractures: a retrospective study of 314 patients.

INTRODUCTION: The reported incidence of infection related with tibial plateau fractures (IRTPF) ranges from 2 to 23%. This complication can result in catastrophic consequences such as deformity, post-traumatic osteoarthritis, chronic pain, loss of function, and substantial economic burdens on healthcare systems due to extended hospital stays and the resources required for treatment. Consequently, it is imperative to emphasize the identification of infection risk factors. METHODS: A retrospective case-control study was designed, encompassing patients who underwent surgery for tibial plateau fractures between 2015 and 2020. Frequencies and measures of central tendency were compared between infected patients (cases) and non-infected patients (controls) using rank-based statistical tests. Subsequently, two logistic regression models were employed to control for potential confounding variables. RESULTS: A total of 314 patients were included, predominantly male (71.15%). Average age of 44.41 years. IRTPF were observed in 7.64% of the patients. In the univariate inferential statistical analysis, high-energy fractures (OR 6.35, p < 0.001), fractures with compartment syndrome (OR 7.10, p < 0.001), two-stage management with temporary external fixation (OR 8.18, p < 0.001), the use of 2 or more approaches in definitive surgery (OR 2.93, p = 0.011), and the use of two or more plates (OR 9.17, p < 0.001) were identified as risk factors for infection. On average, the duration of surgery in infected patients was 201.2 min, compared to 148.4 min in non-infected patients (p < 0.001). When performing two logistic regression models, the following independent risk factors were identified: high-energy fractures (OR 5.04, p = 0.012), the presence of compartment syndrome (OR 4.53, p = 0.007), and the use of two or more plates in definitive surgery (OR 5.04, p = 0.023). CONCLUSIONS: High-energy tibial plateau fractures (Schatzker IV, V, and VI), the presence of concomitant compartment syndrome, and the use of 2 or more plates in definitive surgery are associated with a higher risk of infection related to fracture following open reduction and osteosynthesis treatment. LEVEL OF EVIDENCE: Case-Control Study.

Tibial tubercle to trochlear groove and the roman arch method for tibial tubercle lateralisation are reliable and distinguish between subjects with and without major patellar instability.

PURPOSE: Patellofemoral (PF) instability recurrence depends on several factors including the relative lateralisation of tibial tubercle (TT) regarding the trochlear groove (TG). TT relative lateralisation quantification has long been a topic of debate. Multiple measuring techniques have been described including TT-trochlear groove (TT-TG), TT-posterior cruciate ligament (TT-PCL) and TT-roman arch (TT-RA), with no clear consensus regarding the most reliable index or pathologic threshold. We set out to determine the normal value range of each index and their association with age, sex and PF instability status. Also, this study aims to determine a reliable pathologic distance threshold to effectively predict patellar dislocation. METHODS: Skeletally mature patients up to 45 years of age who presented a CT Scan and an MRI of the same knee between 2014 and 2018 were included and divided into subgroups based on history of PF instability. Three indexes (TT-TG, TT-PCL and TT-RA) were assessed by two independent observers blinded to instability history. ROC curves were performed for each index to obtain the cut point that better predicts instability. Univariate and multivariate models adjusted by age, sex, instability history and type of imaging technique were performed to test the influence of these variables. RESULTS: 208 patients were included. Mean age was 27.93 â€‹± â€‹8.48 years, 67.3% were female and 71 patients (34.1%) presented major instability history. Good or excellent inter and intraobserver reliability was found for all three indexes. All indexes presented significantly different distributions between subjects with and without major instability (p â€‹< â€‹0.001), except for TT-PCL. Different cut point values differing between imaging modalities were found: 11.4 â€‹mm for MRI TT-TG, 17 â€‹mm for CT TT-TG, 15.6 â€‹mm for MRI TT-RA and 18.2 â€‹mm for CT TT-RA. CONCLUSIONS: All indexes studied had good or excellent inter and intraobserver reliability. Measurements between imaging techniques (CT and MR) are not interchangeable. Both TT-TG and TT-RA correctly distinguish between subjects with and without major instability, while TT-PCL does not, recommending caution when evaluated on its own. Specific threshold values depending on imaging technique should be considered for surgical decision-making. LEVEL OF EVIDENCE: Level IV, Diagnostic Test.

Measurement of tibial slope using biplanar stereoradiography (EOS®).

OBJECTIVES: Posterior tibial slope (PTS) is an important anatomic parameter of the knee related to anteroposterior instability. Biplanar stereoradiography allows for simultaneous low-dose acquisition of anteroposterior and lateral views with 3D capability, enabling separate lateral and medial plateau analyses. We aimed to evaluate the possibility and compare the reproducibility of measuring medial and lateral PTS on EOS® images with two different patient positionings and compare it with CT of the knees as the gold standard. METHODS: This is a retrospective study including volunteers who underwent lower limb stereoradiography and knee CT from 01/08/2016 to 07/31/2019. Sixty legs from 30 patients were studied. PTS were measured using stereoradiography and CT by two radiologists. Intraclass correlation was used to calculate intrarater and interrater reproducibilities. Pearson's correlation coefficients were used to calculate the correlation between stereoradiography and CT. We also compared the reproducibility of the stereoradiography of volunteers with 2 different positionings. RESULTS: The mean stereoradiography PTS values for right and left knees were as follows: lateral, 12.2° (SD: 4.1) and 10.1° (SD: 3.5); medial,12.2° (SD: 4.4) and 11.6° (SD: 3.9). CT PTS mean values for right and left knee are as follows: lateral, 10.3° (SD:2.5) and 10.6° (SD: 2.8); medial: 8.7° (SD: 3.7) and 10.4° (SD: 3.5). Agreement between CT and EOS for angles between lateral and medial PTS was good (right, 0.874; left, 0.871). Regarding patient positioning on stereoradiography, interrater and intrarater reproducibilities were greater for patients with nonparallel feet (0.738-0.883 and 0.870-0.975). CONCLUSIONS: Stereoradiography allows for appropriate delineation of tibial plateaus, especially in patients with nonparallel feet, for the purpose of measuring PTS. The main advantage is lower radiation doses compared to radiography and CT.

Involvement of the Transient Receptor Channels in Preclinical Models of Musculoskeletal Pain.

BACKGROUND: Musculoskeletal pain is a condition that affects bones, muscles, and tendons and is present in various diseases and/or clinical conditions. This type of pain represents a growing problem with enormous socioeconomic impacts, highlighting the importance of developing treatments tailored to the patient's needs. TRP is a large family of non-selective cation channels involved in pain perception. Vanilloid (TRPV1 and TRPV4), ankyrin (TRPA1), and melastatin (TRPM8) are involved in physiological functions, including nociception, mediation of neuropeptide release, heat/cold sensing, and mechanical sensation. OBJECTIVE: In this context, we provide an updated view of the most studied preclinical models of muscle hyperalgesia and the role of transient receptor potential (TRP) in these models. METHODS: This review describes preclinical models of muscle hyperalgesia induced by intramuscular administration of algogenic substances and/or induction of muscle damage by physical exercise in the masseter, gastrocnemius, and tibial muscles. RESULTS: The participation of TRPV1, TRPA1, and TRPV4 in different models of musculoskeletal pain was evaluated using pharmacological and genetic tools. All the studies detected the antinociceptive effect of respective antagonists or reduced nociception in knockout mice. CONCLUSION: Hence, TRPV1, TRPV4, and TRPA1 blockers could potentially be utilized in the future for inducing analgesia in muscle hypersensitivity pathologies.

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.

3D PRINTING IN COMPLEX TIBIAL FRACTURE CLASSIFICATION & PLANNING / Impressão 3d para a classificação e planejamento de fraturas tibiais complexas

ABSTRACT Objective: Tibial plateau fractures are common intra-articular fractures that pose classification and treatment challenges for orthopedic surgeons. Objective: This study examines the value of 3D printing for classifying and planning surgery for complex tibial plateau fractures. Methods: We reviewed 54 complex tibial plateau fractures treated at our hospital from January 2017 to January 2019. Patients underwent preoperative spiral CT scans, with DICOM data processed using Mimics software. 3D printing technology created accurate 1:1 scale models of the fractures. These models helped subdivide the fractures into seven types based on the tibial plateau's geometric planes. Surgical approaches and simulated operations, including fracture reduction and plate placement, were planned using these models. Results: The 3D models accurately depicted the direction and extent of fracture displacement and plateau collapse. They facilitated the preoperative planning, allowing for precise reconstruction strategies and matching intraoperative details with the pre-printed models. Post-surgery, the anatomical structure of the tibial plateau was significantly improved in all 54 cases. Conclusion: 3D printing effectively aids in the classification and preoperative planning of complex tibial plateau fractures, enhancing surgical outcomes and anatomical restoration. Level of Evidence IV, Prospective Study.

RESUMO Objetivo: As fraturas do planalto tibial são fraturas intra-articulares comuns de classificação e tratamento desafiadores aos cirurgiões ortopédicos. Objetivo: Este estudo investiga o uso de impressão 3D para classificar e planejar a cirurgia de fraturas complexas do planalto tibial. Métodos: 54 fraturas complexas do planalto tibial tratadas em nosso hospital de janeiro de 2017 a janeiro de 2019 foram revisadas. Os pacientes foram submetidos a tomografias computadorizadas em espiral pré-operatórias, com dados DICOM processados usando o software Mimics. A tecnologia de impressão 3D gerou modelos precisos em escala 1:1 das fraturas. Estes modelos ajudaram a subdividir as fraturas em sete tipos com base nos planos geométricos do planalto tibial. As abordagens cirúrgicas e as operações simuladas, incluindo a redução da fratura e a colocação de placa, foram planejadas utilizando estes modelos. Resultados: Os modelos 3D representaram com precisão a direção e a extensão da deslocação da fratura e do colapso do planalto. Os modelos facilitaram o planejamento pré-operatório, viabilizando estratégias de reconstrução precisas e a correspondência dos detalhes intraoperatórios com os modelos pré-impressos. Após a cirurgia, a estrutura anatômica do planalto tibial melhorou significativamente em todos os 54 casos. Conclusão: A impressão 3D ajuda na classificação e no planejamento pré-operatório de fraturas complexas do planalto tibial, melhorando os resultados cirúrgicos e a restauração anatômica. Nível de Evidência IV, Estudo Prospectivo.

Epidemiology of Knee Injuries in Baseball Players from the State of São Paulo / Epidemiologia das lesões do joelho em atletas de beisebol do estado de São Paulo

Abstract Objective This study aimed to identify the main knee complaints and injuries associated with baseball and their prevalence in the state of São Paulo, Brazil. Methods This epidemiological study analyzed data from an online questionnaire sent to baseball athletes from the state of São Paulo, Brazil, from 2019 to 2022. Results Ninety-eight athletes participated in the study. Their average age was 24.3 years, and 85.72% of the subjects were men. The most prevalent ethnicities were yellow (50%) and white (42.86%). Most athletes had incomplete or complete higher education (75.5%). Most (88.77%) have been training for over 1 year, and 40.82% played in more than 1 position. More than half also practiced another sport. Most (66.32%) athletes present knee complaints or symptoms, and 37.75% had suffered a knee injury playing baseball, with several mechanisms (contact with the ground, contact with another player, or no contact). More than half (59.45%) of the athletes required time away from baseball due to complaints, symptoms, or injuries. Conclusion Among the athletes interviewed, 66.32% had a knee complaint, and 37.75% had already had a knee injury, especially meniscal and ligament injuries. The injury rate was highest in the first year of practice.

Resumo Objetivo Identificar as principais queixas e lesões de joelho associadas ao beisebol, e sua prevalência em atletas de beisebol no estado de São Paulo. Métodos Estudo epidemiológico desenvolvido por meio da análise de dados obtidos por um questionário online, entre os anos de 2019 e 2022, distribuído entre atletas de beisebol do estado de São Paulo. Resultados Noventa e oito atletas participaram do estudo, com média de 24,3 anos de idade, sendo que 85,72% eram homens. As etnias mais prevalentes foram os amarelos (50%) e brancos (42,86%), e a maioria dos atletas possuía ensino superior incompleto ou completo (75,5%). Um total de 88,77% treinava há mais de 1 ano e 40,82% atuavam em mais de uma posição. Mais da metade praticava simultaneamente outro esporte. Um total de 66,32% dos atletas apresentava queixas ou sintomas no joelho e 37,75% já haviam sofrido alguma lesão no joelho associada à prática do beisebol através de diversos mecanismos (contato com solo, contato com outro jogador, sem contato). Um total de 59,45% dos atletas precisou ser afastado da prática devido às queixas, sintomas ou lesões apresentadas. Conclusão Dos atletas entrevistados, 66,32% apresentaram alguma queixa no joelho e 37,75% já tiveram alguma lesão diagnosticada nessa articulação, sendo as mais prevalentes as lesões meniscais e as ligamentares. A taxa de lesões foi maior no primeiro ano de prática.