Outcomes of early versus late irrigation and debridement of pediatric open long bone fractures.

BACKGROUND: Open long bone fractures are a major concern for pediatric patients due to the risk of surgical site infection (SSI). Early studies have recommended irrigation and debridement of open fractures within 6 hours-8 hours for the prevention of SSI. According to the American College of Surgeons (ACS) Best Practice Guidelines, in 2015, irrigation and debridement should be done within 24 hours. AIM: To identify whether early irrigation and debridement, within 8 hours, vs late, between 8 hours and 24 hours, for pediatric open long bone fractures impacts rate of SSI. METHODS: Using retrospective data review from the National Trauma Data Bank, Trauma Quality Improvement Project (TQIP) of 2019. TQIP database is own by the ACS and it is the largest database for trauma quality program in the world. Propensity matching analysis was performed for the study. RESULTS: There were 390 pediatric patients with open long bone fractures who were included in the study. After completing propensity score matching, we had 176 patients in each category, irrigation and debridement within 8 hours and irrigation and debridement between 8 hours and 24 hours. We found no significant differences between each group for the rate of deep SSI which was 0.6% for patients who received surgical irrigation and debridement within 8 hours and 1.1% for those who received it after 8 hours [adjusted odd ratio (AOR): 0.5, 95%CI: 0.268-30.909, P > 0.99]. For the secondary outcomes studied, in terms of length of hospital stay, patients who received irrigation and debridement within 8 hours stayed for an average of 3.5 days, and those who received it after 8 hours stayed for an average of 3 days, with no significant difference found, and there were also no significant differences found between the discharge dispositions of the patients. CONCLUSION: Our findings support the recommendation for managing open long bone fractures from the ACS: Complete surgical irrigation and debridement within 24 hours.

Exploring consistent ratios in morphometry of the proximal tibia: insights for knee arthroplasty.

INTRODUCTION: The current study, which delves into proximal tibia morphometric parameters in a Greek sample, not only analyzes whether specific linear distance ratios are consistent but also paves the way for a potential novel metric system for knee arthroplasty imaging studies using constant ratios. These findings could have significant implications for future enlarged research and clinical practice. METHODS: A total of 38 dried tibiae were evaluated by two independent investigators. The following distances were measured with a digital Vernier sliding caliper: (1) the mediolateral distance of the proximal surface (A), (2) the anteroposterior distance of the proximal surface (B), (3) The longitudinal length of the bone (C), (4) the line connecting the anterior margin of the proximal surface with the highest peak of the tibia tuberosity (D), (5) the depth of the proximal margin of the medial articular facet (AF) (medial plateau) (E) and (6) the depth of the proximal margin of the lateral AF (lateral plateau) (F). RESULTS: The A, B, C, D, E, and F mean distances were 71.3 mm, 47.4 mm, 340.2 mm, 37.1 mm, 42 mm, and 35.9 mm. Reliability analysis for each observer on all measurements revealed an interclass correlation (ICC) score of 0.975 (observer 1) and 0.971 (observer 2). The ratio A/B was 1.5, A/C was a constant 0.2, and D/C was 0.1. The ratio E/F was 1.2. The six measurements (A-F) showed excellent inter-observer reliability (all ICC values > 0.990). CONCLUSIONS: The study established constant ratios of the studied linear distances around the proximal tibia. Considering these ratios, asymmetrical tibial components in knee arthroplasty seem to replicate the native anatomy more closely. Furthermore, the distance from the anterior margin of the proximal surface to the tibial tuberosity peak, constituting one-tenth of the longitudinal length of the tibia, shows promise as a metric system for imaging studies, especially in assessing lesions around tibial components.

Evaluation of distal tibia slope in pilon fractures after surgical fixation.

INTRODUCTION: Alteration of sagittal alignment during fracture fixation directly impacts ankle motion in dorsiflexion and plantarflexion. Previously research measured the anterior distal tibia angle (ADTA) in a normal healthy population. The null hypothesis for this study is that ADTA is restored to normal range following unstable pilon fractures. The aim of this study is to identify the range of the ADTA in distal tibia fractures after surgical fixation, compared to a previously published normal population. MATERIAL AND METHODS: A retrospective review of operative distal tibia fractures (AO/OTA classification 43A and 43C - 43B were excluded due to lower likelihood of fracture changing the ADTA) was performed. ADTA on lateral radiograph was measured as the angle relative to the tibia shaft. RESULTS: 100 patients with post-operative radiographs that met inclusion criteria were analyzed. The average ADTA was 6.9° (⌠=4.62°) with a maximum slope of 19.2° (i.e. anterior orientation) and a minimum of -3.3° (i.e. posterior orientation). The uninjured population had an average ADTA of 6.0° (range -2.0°-14°, ⌠=3.0°). CONCLUSION: This analysis shows the average distal tibia sagittal alignment in the post-surgical group is similar to a normal, uninjured population. Large alterations in ADTA would directly impact the ankle in the plane of motion (i.e. negative ADTA would decrease ankle dorsiflexion). Considering ADTA as an objective intra-operative parameter optimizes sagittal plane alignment.

Comparison of postoperative clinical outcomes and knee stability of cruciate-retaining total knee arthroplasty using the tibia-first gap navigation technique with a computer-aided system and measured-resection technique: A retrospective analysis of a propensity-matched cohort.

Purpose: This study aimed to clarify whether the range of motion (ROM), anterior and posterior (AP) stability and other clinical measures changed in patients who underwent tibia-first total knee arthroplasty (TF-TKA) using navigation with a computer-aided system after surgery. Methods: This is a retrospective study and we conducted a matched cohort analysis of 60 measured resection (MR)-TKAs and 52 TF-TKAs performed by a single surgeon. All the surgeries used the same implant and approach. Baseline differences between the groups were adjusted using propensity score matching. We compared each patient's measured ROM and Oxford Knee Score (OKS) and performed knee AP laxity measurements by using a device during routine follow-ups. Results: A total of 40 MR-TKAs with a mean age of 73.5 ± 5.6 years and sex (male 10, female 30) were compared to 40 TF-TKAs with a mean age of 74.0 ± 5.7 years and sex (male 13, female 27) at 2-year follow-ups. Two years postoperatively, there was a significant difference in the AP laxity at 30° of knee flexion between both groups (7.0 ± 3.4 mm vs. 5.2 ± 2.3 mm, p < 0.01). In contrast, no differences were found between both groups for knee flexion (120.8 ± 9° vs. 116.7 ± 9.8°, p = 0.07) and OKS score (41.8 ± 6.9 vs. 41.0 ± 5.9, p = 0.61). Conclusion: The AP stability in the midflexion obtained using the tibia-first technique remained consistent even after 2 years. However, OKS and ROM were not significantly different from those of the MR-TKA group. Level of Evidence: Retrospective comparative LEVEL III study.

Modified Radiological Union Score of Tibia (RUST) Scores in Diaphyseal Fractures Treated by the Ilizarov Frame: A Retrospective Analysis Evaluating Reliability.

Introduction The number of cases of tibia diaphyseal fractures treated by Ilizarov fixation is increasing. Fractures with infective etiology and altered bone biology due to the requirement of revision surgery or open wounds, which are often treated by the Ilizarov method, have challenges in ascertaining radiological signs of union. In this study, we aim to demonstrate the application of the modified Radiological Union Score of Tibia (m-RUST) scores in the assessment of fracture union in patients operated by the Ilizarov method. The secondary aim is to assess the interobserver and intraobserver variability of the m-RUST score validated by orthopaedicians and radiologists. Methodology A total of 119 patients who were treated with an Ilizarov fixator from February 2017 to December 2023 were included in the study. Four observers (two orthopaedicians and two radiologists) independently applied the m-RUST score for the included patients. Clinical data were not disclosed to the observers who worked independently of each other. Intraclass correlation coefficients (ICC) with 95% confidence intervals (CI) were used to measure the reliability of the m-RUST score. Interobserver reliability was measured by examining the scores of four observers from the second assessment, and intra-observer variability was assessed by a repeat evaluation after two weeks following the first assessment. Results The m-RUST score of the 119 X-rays analysed ranged from 8 to 16. The mean score in the first assessment was 11.36±3.51, and in the second assessment was 11.42±3.39. The reliability between all the observers was "substantial agreement" (ICC: 0.74, 95% CI). The ICC among the orthopaedicians was 0.77 and that among the radiologists was 0.72. Conclusion The m-RUST score has potential in other long bone fractures such as femur or humerus. Assessment of the m-RUST score in the healing of infective sequel and bone grafting conditions has been found effective. The m-RUST score is a dependable score in evaluating union in tibia fractures treated by the Ilizarov frame.

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

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

[ZHANG Weihua's experience in treatment of cervical spondylotic radiculopathy with ulna-tibia needling therapy combined with decompression-loosening manual manipulation].

The paper introduces professor ZHANG Weihua's experience in treatment of cervical spondylotic radiculopathy (CSR) with ulna-tibia needling therapy combined with decompression-loosening manual manipulation. Using "palpating, detecting and imaging observing", professor ZHANG Weihua gives the accurate diagnosis for the location, the stage and the severity of the disease. According to the nature of the disease, CSR is treated in three stages. He proposes the academic thought, "taking the tendons as the outline, regarding the meridians as the essential, rooting at qi and blood, co-regulating tendons and bones". The ulna-tibia needling therapy and decompression-loosening manual manipulation are combined in treatment. In the ulna-tibia needling therapy, the acupuncture is delivered at the lower 1/3 of the cutaneous regions of taiyang and shaoyang meridians, on the ulnar region (belt-like distribution). The decompression-loosening manual manipulation is operated in 3 steps, i.e. relaxing the nape region, decompressing and relaxing (includes positioning rotational wrenching, upward and backward elevation) and supination wrenching, and analgesia and regulating tendons; and the manipulation for analgesia and regulating tendons is supplemented to enhance the effect.

Comparing the effects of pre-emptive oxycodone, diclofenac, and gabapentin on postoperative pain after tibia fracture surgery: A randomized clinical trail.

Background: Postoperative pain (POP) is one of the most common and most important types of pain. Objectives: The aim of this study was to compare the effects of pre-emptive oxycodone, diclofenac, and gabapentin on postoperative pain (POP) among patients with tibia fracture surgery. Materials and Methods: This double-blind three-group randomised controlled trial was conducted in 2023. Participants were 111 candidates for tibia fracture surgery under general anaesthesia. They were randomly allocated to oxycodone, gabapentin, and diclofenac groups through block randomisation. Baseline arterial oxygen saturation, heart rate, and blood pressure were documented before surgery and POP and sedation status were measured during postoperative recovery and 2, 4, 6, 12, and 24 h after surgery. Postoperative opioid analgesic use was also documented. The data were analysed using the SPSS software (v. 20.0) at a significance level of less than 0.05. Results: Groups did not significantly differ from each other respecting participants' baseline age, gender, body mass index, arterial oxygen saturation, heart rate, blood pressure, and surgery duration (P > 0.05). Moreover, there were no significant differences among the groups respecting POP and sedation status at different measurement time points (P > 0.05), except for six hours after surgery at which the POP mean score in the gabapentin group was significantly less than the other two groups (P = 0.001). Among-group differences respecting postoperative use of opioid analgesics and medication side effects were also insignificant (P > 0.05). Conclusion: Pre-emptive oxycodone, diclofenac, and gabapentin significantly reduce POP among patients with tibia fracture surgery, though gabapentin may produce more significant analgesic effects. All these three medications can be used for pre-emptive analgesia. Of course, the best pre-emptive analgesic agent is determined based on the opinion of the treating physician.

Reconstruction of gap non-union tibia with composite use of extramedullary fixation and bone transport by monorail fixator: a prospective case series.

Introduction: Non-union is a complex, multifactorial orthopaedic problem that requires multiple treatment modalities for its management. It can result from infection, segmental bone loss, soft-tissue loss, and associated host factors. External fixators as management of gap non-union are bulky and give rise to a number of complications In our study, we have described a technique where we have used extramedullary fixation in the form of a tibial locking plate and transportation of part of the tibial bone after corticotomy by a monorail fixator. Materials and Methods: The procedure was done in two stages where internal and external fixation was done after creating a gap at the non-union site. The bone was transported after corticotomy and fixed to the internal fixation device in the second stage. The external fixator was removed in the second stage and the patient was then followed up till the bony union. The evaluation was done by functional and radiological assessment along with the complications noted with the described procedure. Results: Ten patients were enrolled in the study with a mean age of 33 years. The mean age of the patients was 33.7 ± 11.32 years with a mean size of the defect was 4.8 ± 1.7 cm. At 30 weeks out of nine patients, three patients had excellent and six had good functional results on the Association of Surgeons for Application and Methodology of Ilizarov (ASAMI) scale. The composite Musculoskeletal Tumor Society (MSTS) score was 76.66 % at the end of 30 weeks of follow-up. The mean time of consolidation was 134.4 days, whereas the mean union time was 145 days from index surgery. Ankle stiffness was the most common complication affecting 50% of the patients. Following closely was pin tract infection, which was present in 40% of the patients. According to Paley's classification, there were 11 obstacles, two problems and none were true complications. Conclusion: The integrated fixation is both safe and effective and has the advantage of early removal of the external fixator and a low complication rate as compared to use of a bulky conventional fixator alone. Moreover, it gives protection to the regenerated bone for a long period. So, this technique can be recommended for the management of segmental tibial defects.

Is Staged Surgery Always Necessary for Schatzker Type IV-VI Tibial Plateau Fractures? A Comparison Study.

AIMS: This study aims to compare the outcomes of immediate (followed by closed-incision negative-pressure therapy use) versus delayed ORIF in patients with Schatzker type IV-VI TPFs. PATIENTS AND METHODS: A prospective study of patients undergoing ORIF between January 2018 and December 2019 was performed. The inclusion criteria were patients (>18 years) with a closed fracture sent to the emergency room (ER) within 24 h of injury. All the patients underwent preoperative image evaluation. Two senior orthopedic trauma surgeons evaluated the soft tissue condition in the ER by 5P's of the compartment syndrome, judging the timing of the operation of definitive ORIF. Group 1 (n = 16) received delayed ORIF. Group 2 (n = 16) received immediate ORIF and ciNPT use. Patient follow-up occurred after 2 and 6 weeks and 3, 6, and 12 months after surgery. The assessments included the time to definitive fixation, the length of hospital stay, the time to bone union, surgical site complications, and reoperation within 12 months. A universal goniometer was used to measure the postoperative 3 m, 6 m, and 12 m ROM. RESULTS: The patient demographics were similar between the groups (p > 0.05). Group 2 displayed significantly a shorter time to definitive fixation (5.94 ± 2.02 vs. 0.61 ± 0.28, p < 0.0001) and hospital stay (14.90 ± 8/78 vs. 10.30 ± 6.78, p = 0.0016). No significant difference was observed in the time to bone union, surgical site complication incidence, and reoperation rates (p > 0.05). Flexion and flexion-extension knee ROM were demonstrated to be significantly improved in Group 2, 3, 6, and 12 months postoperatively (p < 0.0001). CONCLUSIONS: In this study, early ORIF and ciNPT use resulted in a shorter hospital length of stay, a reduced time to early active motion of the knee, and improved knee ROM. These results suggest that early ORIF with ciNPT for Schatzker type IV-VI TPFs is safe and effective in some patients. However, further research to confirm these findings across larger and more diverse populations is needed.

Is single-stage bilateral medial opening wedge high tibial osteotomy advisable?

PURPOSE: To validate the safety and clinical results of single-stage bilateral versus unilateral medial opening wedge high tibial osteotomy (HTO). METHODS: A propensity-matched cohort study was performed from March 2020 to March 2021 in our medical center. Data were prospectively collected. Including 34 patients who underwent single-stage bilateral medial opening HTO(SSBHTO), and 68 cases in the unilateral group. Propensity-matched ration was 2:1 based on age, sex, and body mass index using R software. Comparisons of the length of hospital stay, operative time, blood loss, postoperative adverse events, 90-day readmission rate, conversion to TKA rate, self-reported VAS and WOMAC scores were made to investigate the safety and clinical results of bilateral HTO. RESULTS: The mean length of hospital stay was 7.36 ± 2.23 days for SSBHTO and 7 days (IQR, 3 days; range, 4 to 23 days) for the unilateral group (P = 0.219). The mean operative time was 144 ± 47 min for bilateral HTO and 105(37.5) mins for a unilateral OWHTO (P < 0.001). The mean blood loss was 150(100) ml for SSBHTO and 100(50) ml for unilateral OWHTO (P < 0.001). There were no significant difference of the adverse events and 90-day readmission rate between two groups. No failed HTO or conversion to knee arthroplasty were observed at the end of follow-up. VAS, pain, stiffness, and functional scores of the WOMAC scale were essentially comparable of two groups one year after surgery (P > 0.05). CONCLUSIONS: A single-stage bilateral medial opening wedge high tibial osteotomy is advisable for patients with knee osteoarthritis. Patients benefit from avoiding secondary anesthesia, postoperative complications, and substantial cost savings. LEVEL OF EVIDENCE: Therapeutic Level III.

Risk factors for acute compartment syndrome in one thousand one hundred and forty seven diaphyseal tibia fractures.

PURPOSE: Acute compartment syndrome (ACS) remains a devastating complication of orthopaedic trauma. The tibial diaphysis is especially implicated in the development of ACS, both at the time of injury and after operative management. Identification of risk factors for ACS for these distinct scenarios has been investigated in a large cohort of patients. METHODS: This is a retrospective cohort study of all adults (age 18 years and older) presenting to a level 1 trauma centre with a diaphyseal tibia fracture. ACS was determined by a combination of clinical signs and symptoms and compartmental pressure monitoring. Potential risk factors were subject to univariate analysis with significant variables undergoing binary logistic regression analysis. RESULTS: 1147 tibial diaphyseal fractures over a twelve year period were studied. Age, multifragmented fracture pattern, male gender, high energy mechanism and intra- articular extension all showed a statistically significant association for ACS. Increasing body mass index (BMI) and treatment with an intramedullary nail favoured development of ACS post-operatively. CONCLUSION: Risk factors for the development of ACS specifically in tibial diaphyseal fractures have been highlighted. Patients managed with IMN or high BMI may warrant particular observation following operative intervention.

Medial cortical bone thickness of the tibial diaphysis in osteoarthritis is related to lower extremity alignment and tibial morphology.

BACKGROUND: The purpose of this study was to clarify (1) the differences in cortical bone thickness (CBT) of the tibial diaphysis between healthy and osteoarthritic knees and (2) the influences of the femorotibial angle (FTA) and inclination of the medial compartment of the proximal tibia (MCT) on tibial CBT. METHODS: The study assessed 60 subjects with varus knee osteoarthritis (OA) (22 males and 38 females; mean age, 74 ± 7 years) and 53 healthy elderly subjects (28 males and 25 females; mean age, 70 ± 6 years). Three-dimensional estimated CBT of the tibial diaphysis was automatically calculated for 2752-11,296 points using high-resolution measurements from CT. The standardized CBT was assessed in 24 regions by combining six heights and four areas. Additionally, the association between the CBT, each FTA, and MCT inclination was investigated. RESULTS: The OA group showed a thicker CBT in the medial areas than in the lateral areas of the proximal tibia, while the healthy group had a thicker lateral CBT. The medial-to-lateral ratio of the proximal tibia was significantly higher in the OA group than in the healthy group. The proximal-medial CBT correlated with FTA and MCT inclinations in the OA group. CONCLUSIONS: This study demonstrated that varus osteoarthritic knees showed a different trend of proximal-medial CBT with associations in FTA and MCT inclination from healthy knees, possibly due to medial load concentration.

Difference in Correction Power between Hybrid Lateral Closed-Wedge High Tibial Osteotomy and Medial Open-Wedge High Tibial Osteotomy was Associated with Severity of Varus Deformity and Different Hinge Distance from Center of Deformity.

Hybrid lateral closed-wedge high tibial osteotomy (HBHTO) carries certain advantages over medial open-wedge high tibial osteotomy (OWHTO). We investigated the potential difference in the required correction angle between HBHTO and OWHTO to achieve an equal amount of whole lower-extremity alignment correction, retrospectively analyzing the preoperative plain radiographic images of 100 patients. The medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), mechanical lateral distal femoral angle (mLDFA), hip-knee-ankle axis (HKA), length of the tibia, width of the tibial plateau, length of the lower limb (leg length), and location of the center of deformity (CD) were measured. Differences in the required correction angle at the hinge point between the two techniques (CAD) were compared, and correlation analysis was performed to reveal the influential factors. The mean difference in CAD between HBHTO and OWHTO was 0.78 ± 0.22 (0.4~1.5)°, and mean WBL position change per correction angle was 3.9 ± 0.3 (3.0~4.6)% in HBHTO and 4.1 ± 0.3 (3.1~4.7)% in OWHTO. Correlation analysis revealed a strong positive correlation between CAD and HKA. mLDFA, JLCA, MPTA, leg length, OWCD, HBCD, and HCD were also significantly correlated with CAD. HBHTO required a 5.6% larger correction angle at the hinge point to achieve the same amount of alignment correction as OWHTO.

Tension-Band Plating for Infantile Blount Disease: Efficacy and Outcomes Comprehensive Review.

Infantile Blount disease (IBD) is a pathologic varus knee deformity that, if left untreated, can lead to abnormal gait, limb length discrepancy, and pain. Traditionally, bracing and tibial osteotomy have been the primary treatments. More recently, guided growth with tension-band plating (TBP) has gained popularity, although there is a lack of data stratifying between the infantile, juvenile, and adolescent disease types. Therefore, the present review aims to determine the efficacy and complications of TBP in the IBD population. A systematic review was conducted following the PRISMA guidelines. Eligible studies included those focused on guided growth correction for IBD. Studies that did not stratify subjects by subgroup (infantile, juvenile, and adolescent) within their analysis were excluded. The outcomes of interest included demographic information, correction rate, failure rate, recurrence rate, and postoperative complications. Database review identified 541 studies. After screening, seven studies met our inclusion criteria, all of which were retrospective observational studies published between 2012 and 2022. In total, 92 limbs afflicted with Infantile Blount Disease underwent treatment with TBP. The recorded follow-up period ranged from four months to eight years. The age of patients at the time of surgery varied from 1.8 to nine years. On average, there was a 78.99% correction of deformities, with a range of 57.14% to 100%. Six studies provided data on failure and recurrence rates, with an average rate of 23.47%. Notably, infection and hardware failure emerged as the most prevalent postoperative complications, with mean rates of 11.44% and 9.50%, respectively. The average reoperation rate was 29.90%, with a range from 0.00% to 47.06%. The current literature shows a high rate of deformity correction with a relatively low risk of complications after TBP for IBD. Given the reported reoperation rates greatly varied, further data is needed to determine risk factors for reoperation following TBP. Our results suggest that guided growth with TBP may be a preferable first-line treatment for IBD.

Medial Tibial Stress Syndrome (Shin Splint): Prevalence, Causes, Prevention, and Management in Saudi Arabia.

Background/aims Medial tibial stress syndrome (MTSS), also known as "shin splint", is most often described as exertional leg pain along the shinbone (tibia), which occurs due to the inflammation of the muscles, tendons, and bone tissue in this area. This study aims to assess the prevalence, risk factors, and their association with the development of MTSS, as well as the effective treatments that reduce pain and improve functions among the Saudi general population. Materials and method The present cross-sectional study was conducted on the general population of Saudi Arabia through an electronic survey over a period of three months. The study sample of 443 patients was deemed and considered. The study included participants from the general population in Saudi Arabia above the age of 18. A structured self-response questionnaire was given to the participants after institutional research ethical approval was obtained for the study. Results Among the 443 participants, the majority were male (n = 228, 51.5%), aged 18-29 (n = 227, 51.2%), and residing in the central region of Saudi Arabia (n = 398, 89.8%). Most participants reported engaging in sporting activities (n = 211, 47.6%), with high-intensity training being the most common (n = 93, 44.1%). Only a small proportion (n = 8, 1.8%) reported a previous diagnosis of MTSS. Analysis revealed associations between MTSS prevalence and certain demographic factors, including walking surface preferences and engagement in specific sports. Treatment strategies for MTSS included rest, ice application, physiotherapy, and pain-relieving medication, with varying degrees of satisfaction and recurrence rates among participants. Conclusion The study provides valuable insights into the prevalence, risk factors, management, and preventive measures related to MTSS among the Saudi general population. While certain demographic factors and exercise practices were associated with MTSS prevalence, effective treatment options such as rest, physiotherapy, and appropriate footwear were reported. Moreover, adherence to preventive measures such as stretching, proper footwear selection, and gradual training progression may help mitigate the risk of MTSS development.

Modified elastic intramedullary nail internal fixation for distal tibial metaphyseal junction fracture.

Objective: To investigate the application of modified elastic intramedullary nail and the outcomes between modified elastic stable intramedullary nailing and traditional elastic stable intramedullary nailing in children with distal tibial metaphyseal junction fracture. Methods: A retrospective study was conducted. From January 2018 to January 2021, a total of 36 children with distal tibial metaphyseal junction fracture were treated in our hospital. All of them were treated with closed reduction and elastic stable intramedullary nailing internal fixation. A total of 18 children were treated by modified elastic stable intramedullary nailing and 18 children were treated by traditional elastic stable intramedullary nailing. Postoperative imaging, clinical efficacy, and complications were analyzed. Results: The mean follow-up time was 20 (15-36) months in modified group and 22 (16-33) months in traditional group. There were no complications such as infection, loss of reduction, and unequal length of lower limbs in modified group while loss of reduction occurred in two cases in traditional group. In these two cases of loss of reduction, we preformed manual reduction and replacement of long leg casts, and there was no loss of reduction, and the patient achieved a good prognosis. In the last follow-up, American Orthopaedic Foot & Ankle Society score was used. In modified group, excellent outcome achieved in 17 cases, good outcome achieved in 1 case, and satisfactory therapeutic effect was achieved. In traditional elastic stable intramedullary nailing group, excellent outcome achieved in 14 cases, and good outcome achieved in 4 cases. There was no statistical difference in the scores between the two groups. Conclusion: It was concluded that modified elastic stable intramedullary nailing fixation is a safe and effective treatment.

Excision of a Distal Tibial Interosseous Osteochondroma Through Posterolateral Approach: A Case Report.

Osteochondromas arising from the interosseous border of the distal tibia are rare, but cases have been reported previously in the literature. In long-standing cases, they can cause a "mass effect" resulting in the deformation of the bones around the ankle joint, mechanical restriction of joint movement, and even degenerative joint disease. Hence, they need to be resected if patients present with such impending complications. Several surgical techniques have been described previously for tumor resection including the anterior approach and the trans-fibular approach, the latter of which required a fibular osteotomy with or without fibular reconstruction. The surgical technique described here utilizes the posterolateral approach to the ankle joint for tumor excision, thus avoiding the need for any osteotomy or fibular reconstruction and reducing the risk of injury to major neurovascular structures. It also reduces the need for long-term immobilization and promotes a faster return to activity.

Minimally Invasive Osteotomy for Correction of Post-Traumatic Tibia Internal Rotation Deformity: A Case Report.

Introduction: Intramedullary nailing is a commonly performed surgery for tibia diaphysis fractures. However, in selected cases, this procedure can get complicated with rotational malalignment if not checked carefully intra-operatively. Case Report: A 29 year-old male sustained polytrauma and was treated with intramedullary nailing for bilateral femur and right-side tibia fractures. Postoperatively, the patient noticed extreme in-toeing suggesting an internal rotation deformity, which caused great difficulty in walking. The patient was planned for a revision surgery to correct the internal rotation deformity, 6 months after the index surgery. A minimally invasive metaphyseal osteotomy was performed, away from his fracture site by drilling multiple holes. The distal locking bolts of the interlocking nail were removed, and two K wires used to achieve the desired correction angle. After rotating the distal fragment, locking bolts were reinserted in new holes. We kept the patient on our regular follow-up till he achieved sound union at the osteotomy site, after which we allowed him unrestricted activities. Conclusion: The presence of an intramedullary nail can hence help the surgeon in correcting such isolated rotational deformities without getting into the hassle of implant removal to achieve the same.

Response of Recurrent Aggressive Aneurysmal Bone Cyst of Distal Tibia to Denosumab Treatment.

Introduction: Aneurysmal bone cysts (ABCs) are aggressive and benign tumors that primarily affect children and adolescents. The standard course of treatment for ABCs involves surgical excision or curettage with a bone transplant or cement to repair the deficiency. Denosumab, a monoclonal antibody that inhibits receptor activator of nuclear kappa B ligand, is used to treat osteoporosis, skeletal metastasis, and giant cell tumors of the bones. Case Report: This case study details the therapeutic treatment of a female patient, age 22, who had a recurring aggressive ABC of the distal tibia. The patient was initially treated using curettage and lesion filling. However, recurrence of the osteolysis was observed 9 months later that led to subsequent interventions involving absolute alcohol sclerotherapy in multiple sessions. However, these interventions failed to achieve ossification. Following unsuccessful surgical and sclerotherapy treatments, the patient was administered denosumab, which led to a positive response. Regular radiographic and clinical follow-up demonstrated significant improvements in ossification and pain reduction. During the course of the 12-month treatment, the frequency of visits was gradually reduced. Further, follow-up and monitoring revealed the effectiveness of the local control and long-term treatment. Conclusion: This case report highlights the ability of denosumab to manage recurrent aggressive ABCs after surgical or sclerotherapy failure.