Three internal fixation methods for Danis-Weber-B distal fibular fractures: A biomechanical comparison in an osteoporotic fibula model

A common agreement for the surgical treatment of osteoporotic ankle fractures has not been defined yet although locking plates are preferred for fractures with poor bone quality. This study aims to evaluate the mechanical stability of locked and conventional plates on osteoporotic Danis-Weber-B-fibula fracture models.Fractured custom-made osteoporotic fibulae were treated with neutralization plate plus lag screw, locking plate plus lag screw, or a standalone locking plate. Load until failure was applied mimicking single-leg stance. Stiffness, failureload, and interfragmentary movements were investigated.Stiffness, failureload and axial fragment movement showed no significant differences among groups. Shear movements and fragment rotation around the shaft of the neutralization plate were on average twice as high as those of the locking plates.Although no superiority was shown for overall mechanical performance, the locking plate groups exhibited higher shear and rotational stability than the neutralization plate.     

Tibial pilon fractures: a comparison of treatment methods

OBJECTIVE: This retrospective review of surgically treated distal tibia fractures was undertaken to determine whether treatment with open reduction and internal fixation (ORIF) was more efficacious in achieving fracture union than one of two external fixation methods. METHODS: Of the 60 study patients with pilon fractures, 21 patients were treated with an ankle-spanning half-pin external fixator, 15 patients with a single-ring hybrid external fixator, and 24 patients with ORIF. The severity of injuries was similar across groups. RESULTS: There was no significant difference in complication rates between groups, although two below-knee amputations were required in the ORIF group. A greater (p = 0.03) number of malunions occurred in the fractures treated with external fixation when compared with those treated with ORIF. Fractures in the external fixator groups showed this significant tendency to lose their initial adequate reduction, independent of bone grafting or fibula fixation. There was no significant difference between groups in the need for bone grafting. There was a trend for patients treated with a single ring hybrid frame to require late bone grafting for metaphyseal-diaphyseal nonunion. CONCLUSION: External fixation offers advantages in the treatment of the soft-tissue injury associated with pilon fractures, but malunion continues to be a problem with this method of fixation.     

External fixation in the treatment of tibial pilon fractures: comparison of two frames in torsion

BACKGROUND: Ankle spanning external fixation has become the initial treatment of choice for complex tibial pilon fractures. Many fixator designs exist, but their biomechanical performance has not been studied extensively for this application. The goal of the present study was to compare the torsional performance of two commercially available frames, the Orthofix XCaliber and the Howmedica Hoffmann II. METHODS: The XCaliber and the Hoffmann II were each applied to six fresh cadaver lower extremities and were loaded in a materials testing machine. Strain gauges were attached to the anteromedial cortex of the distal tibia, and each specimen underwent torsional and axial load testing, with and without the external fixator. A simulated pilon fracture was created, and torsional testing was repeated. RESULTS: Results indicated that the XCaliber was significantly more rigid in internal rotation than the Hoffmann II, before (49%) and after (41%) creation of the pilon fracture. Despite the XCaliber's increased rigidity relative to the Hoffmann II (22% to 31%) in external rotation, statistical significance was not attained. Both fixators reduced strain (25% to 85%) at the anteromedial cortex upon torsional testing, but no significant differences between the two frames were noted. CONCLUSIONS: The present study demonstrates that the XCaliber has mechanical advantages over the Hoffmann II in terms of torsional rigidity for a tibial pilon fracture. CLINICAL RELEVANCE: Increased rigidity of the XCaliber could potentially lead to decreased time to union, and a lower incidence of pin loosening and would prove beneficial in a setting in which the external fixator is used as the definitive fixation.     

Distal tibial metaphyseal fractures: the role of fibular fixation

Distal tibial extra-articular fractures are often a result of complex high-energy trauma, which commonly involves associated fibular fractures and soft tissue injury. The goal of tibial fixation is to maximise fracture stability without increasing soft tissue morbidity from surgical intervention. The role of adjunctive fibular fixation in distal tibial metaphyseal fractures has been controversial; although fibular fixation has been shown to improve stability of distal tibial fractures, there has been increased potential for soft tissue-related complications and a delay to tibial fracture healing. Adjunctive fixation of concomitant fibular fractures without associated syndesmotic or ankle pathology is not necessary in surgically stabilised extra-articular metaphyseal fractures of the distal tibia.     

腓骨固定在胫腓骨关节外骨折中治疗效果的Meta分析

目的:通过Meta分析比较腓骨固定在胫腓骨关节外骨折中的作用及重要性。方法:通过对中国知网、维普、万方、The Cochrane Library、Web of science、Pubmed等数据库关于固定腓骨与否对胫腓骨关节外骨折治疗疗效比较的相关文献进行检索,检索时间为2012年1月至2022年2月,使用RevMan 5.3软件进行统计分析。对腓骨固定组与不固定组的复位不良率、旋转畸形率、内翻或外翻畸形率、前或后发畸形率、不愈合率、术后感染率、二次手术率及手术时间进行比较。结果:共纳入11篇文献,6篇随机对照研究和5篇病例对照研究,有8篇为高质量文献,共813例患者,其中腓骨固定治疗383例,未固定腓骨430例。Meta分析结果显示,与未固定腓骨相比,治疗胫腓骨关节外骨折时固定腓骨可以降低术后旋转畸形率[RR=0.22,95%CI(0.10,0.45),P<0.000 1]和内翻或外翻畸形率[RR=0.34,95%CI(0.14,0.84),P=0.02],并促进骨折愈合[RR=0.76,95%CI(0.58,0.99),P=0.04]。而复位不良率[RR=0.48,95%CI(0.10,2.33),P=0.36],前或后畸形率[RR=1.50,95%CI(0.76,2.96),P=0.24],术后感染率[RR=1.43,95%CI(0.76,2.72),P=0.27],二次手术率[RR=1.32,95%CI(0.82,2.11),P=0.25],手术时间[MD=10.21,95%CI(-17.79,38.21),P=0.47]比较差异均无统计学意义(P>0.05)。结论:在治疗胫腓骨关节外骨折时腓骨固定组相较于不固定组在防止旋转畸形和内翻或外翻畸形以及促进愈合方面更具优势。     

Dynamic hip screw in the treatment of intertrochanteric fractures: a comparison of two fixation methods

The study is a prospective evaluation and comparison. A minimally invasive Dynamic Hip Screw (MIDHS) technique is presented. One hundred and two patients with intertrochanteric fractures were treated with either a MIDHS or a conventional dynamic hip screw (CDHS). We used the Singh index as a measure of osteoporosis and also classified the fractures according to three different systems (OTA, Boyd-Griffin, and Evans). All patients were followed up for 12 months with a hip score evaluation. The patients were divided into two groups, based on the method of treatment. The MIDHS group includes 42 patients with an average age of 72.6 years. The CDHS group includes 60 patients, with an average age of 71.3 years. Both groups were similar in injury mechanism, fracture types, mean Singh index and confounding medical condition (all p values >0.05). The CDHS group had significantly larger wound incision, greater haemoglobin level drop, higher pain level, more total analgaesic use and longer hospital stay than the MIDHS group (all p values<0.05). The hip score, union rate, healing time, adequate reduction and adequate screw position rate was not significantly different between the two groups (all p values >0.05). In conclusion, either a MIDHS or a CDHS in the treatment of intertrochanteric fractures is an effective, simple and safe method. The mini-invasive technique as opposed to the conventional technique has smaller wound size, lower pain level, and lower blood loss. Hospital stay and total analgaesic use were decreased, benefitting the patient and reducing hospital cost.     

Direct fixation of fractures of the posterior pilon via a posteromedial approach

The treatment of fractures of the posterior pilon is a timely issue. Restoration of the integrity of the incisura fibularis and subsequent anatomic reduction of the fibula are essential for reconstruction of the ankle mortise after trauma, and syndesmotic stability. Inappropriate treatment ultimately will lead to a poor functional outcome and quality of life. Open reduction and direct internal fixation through a posterolateral or posteromedial approach are increasingly preferred over indirect reduction and anteroposterior screw fixation. The posteromedial approach, although elegant, straightforward, and offering an excellent exposure of the fracture site, is used less frequently than the posterolateral approach. In this technical note we describe the posteromedial approach for the treatment of posterior pilon fractures in a step-by-step fashion. We will discuss the indications, its benefits and limitations.     

Surgical fixation of pathologic fractures: an evaluation of evolving treatment methods

The surgical techniques for the fixation of pathologic fractures continue to evolve. The present study examines clinical outcomes and complications associated with the use of newer generation interlocked intramedullary nails compared with open reduction and internal fixation with plates and screws for pathologic fractures in long bones. Fifty operative procedures performed on 37 patients by five community orthopaedic surgeons were retrospectively reviewed. The operative procedures were separated into two groups based upon the method of fracture fixation; the groups were compared for differences in hardware or fixation failure. The use of intramedullary devices was associated with a significantly lower number of hardware or fixation failures (p < 0.02). This data, in addition to several additional advantages of indirect reduction and intramedullary fixation of pathologic fractures, supports this method of fracture care over open reduction and internal fixation in appropriate cases.     

半环槽式骨外固定器治疗胫腓骨开放性骨折

目的：探讨半环槽式骨外固定器治疗胫腓骨开放性骨折的临床疗效。方法：2005年3月至2011年3月,经闭合手法复位或辅助克氏针撬拨复位半环槽式外固定器治疗94例胫腓骨开放性骨折患者,男63例,女31例;年龄17～65岁,平均39岁。横形骨折5例,斜形与螺旋形骨折19例,粉碎性骨折70例。骨折按Gustilo分类：ⅢA型49例,ⅢB型45例。术后观察伤口感染发生率、骨折愈合时间,并采用Johner-Wruhs评定标准对其功能进行评价。结果：所有患者获随访,时间14～63个月,平均29个月。骨折愈合时间16～39周,平均21.4周,无骨折不愈合、骨髓炎及小腿骨筋膜室综合征等并发症发生。94例中伤口I期愈合者81例,深部伤口感染者2例。功能评价采用Johner-Wruhs评定标准,优52例,良37例,中5例。结论：闭合复位或辅助克氏针撬拨复位及外固定器固定可降低胫腓骨开放性骨折感染率。对于胫腓骨开放性粉碎骨折半环槽式骨外固定器固定3～6周时根据骨折端愈合情况去除中间固定骨折块的克氏针,使支架动力化,可促进骨折愈合。     

The use of external fixation in fractures of the tibial pilon

The authors report the results of a review of 25 cases of fracture of the tibial pilon, treated by external fixation and minimal internal synthesis. Fractures were classified according to Rüedi and Allgower; they were: type 2: 11 (of which one exposed); type 3: 4 (of which 6 exposed). Complications observed during treatment were: pseudarthrosis: 1; osteomyelitis: 2; healing in valgus at 10 degrees: 2; osteolysis of the distal screws of the fixator: 4; these were all resolved with further surgery, except for an osteomyelitis that required amputation. Follow-up ranged from 3 to 10 years and clinical and functional evaluation, based on the Olerud and Molander score system revealed 80% good (56%) and excellent (24%) results.     

单臂多功能外固定支架治疗胫腓骨骨折

1997年2月～2006年10月,笔者运用单臂多功能外固定支架治疗152例胫腓骨骨折患者,疗效较满意。     

克氏针和空心钉张力带内固定治疗横断型髌骨骨折生物力学研究

目的比较空心拉力钉张力带系统和克氏针张力带系统内固定治疗横断型髌骨骨折的生物力学特性。方法对6具新鲜尸体12个下肢标本,开放截骨造成横断型髌骨骨折模型,随机采用空心拉力钉张力带和克氏针张力带固定,在膝关节伸直位加载使髌骨关节面移位达3 mm或最大加载负荷达300 N、周期性牵拉股四头肌腱使膝关节在伸直和屈曲90°之间运动10个周期记录骨折的最大位移以及膝关节固定在屈曲位45°使骨折移位达6 mm的最大载荷进行生物力学测定。结果空心拉力钉张力带组在膝关节伸直位、周期性牵拉股四头肌使膝关节在伸直和屈曲90°之间运动以及屈曲45°时都较克氏针张力带组具有更好的生物力学稳定性。结论空心拉力钉张力带系统较克氏针张力带系统能够提供更稳定的固定效果,为横断型髌骨骨折的一期愈合及患者早期进行功能锻炼以更好地恢复关节功能提供可能。     

髓内钉与外固定治疗胫腓骨骨折疗效的Meta分析

[目的]应用系统评价的方法比较开放性胫腓骨骨折治疗中应用交锁髓内钉与外固定的疗效,为临床实践与研究提供参考。[方法]计算机检索中国期刊全文数据库、中文科技期刊全文数据库、万方数据库、Pubmed、Web of Science关于交锁髓内钉和外固定治疗开放性胫腓骨骨折疗效比较的研究,末次检索时间为2015年7月,选择适合本研究特点的质量评价标准对纳入文献进行质量评价,使用Stata 13.0软件进行Meta分析。[结果]通过检索得到相关文献163篇,根据纳入、排除标准最后筛选得到14篇文献,包括开放性胫腓骨骨折患者1 101例。其中,交锁髓内钉治疗组517例,外固定治疗组584例。对比交锁髓内钉和外固定治疗开放性胫腓骨骨折的愈合优良率(Johner-Wruh标准评定疗效)(OR=2.21,95%CI=1.48-3.31,P=0.0001)差异有统计学意义,而术后感染的发生率(OR=1.52,95%CI=0.91-2.55,P=0.291)、骨折愈合时间(SMD=-0.38,95%CI=-1.08-0.33,P=0.296)、术后延迟愈合或不愈合的发生率(OR=1.38 95%CI=0.79-2.44,P=0.266),术后骨不连的发生率(OR=1.22,95%CI=0.46-3.26,P=0.693),差异没有统计学意义。[结论]交锁髓内钉治疗开放性胫腓骨骨折优于外固定组。     

Open distal tibial shaft fractures: a retrospective comparison of medial plate versus nail fixation

Purpose

Studies comparing open reduction internal fixation (ORIF) vs. intramedullary nailing (IMN) for distal tibia shaft fractures focus upon closed injuries containing small patient series with open fractures. As such, complication rates for open fractures are unknown. To characterize complications associated with ORIF vs. IMN, we compared complications based on surgical approach in a large patient series of open distal tibia shaft fractures.

Methods

Through retrospective analysis at an urban level I trauma center, 180 IMN and 36 ORIF patients with open distal tibia fractures from 2002 to 2012 were evaluated. Patient charts were reviewed to identify patient demographics, fracture grade (G), patient comorbidities, and postoperative complications including nonunion, malunion, infection, hardware-related pain, and wound dehiscence. Fisher’s exact tests compared complications between ORIF and IMN groups. Multivariate regression identified risk factors with statistical significance for the development of a postoperative complication.

Results

One hundred and eighty IMN (G1 22, G2 79, and G3 79) and 36 ORIF (G1 10, G2 16, and G3 10) patients were included for analysis. ORIF patients had a higher rate of nonunion (25.0 %, n = 9) compared with IMN patients (10.6 %, n = 20, p = 0.03). No additional complication had a significant statistical difference between groups. Multivariable analysis shows only surgical method influenced the development of complications: ORIF patients had 2.52 greater odds of developing complications compared with IMN patients (95 % CI 1.05–6.02; p = 0.04).

Conclusions

ORIF leads to higher rates of nonunion and significantly increases the odds of developing a complication compared with IMN for open distal tibia fractures. This is the first study investigating complication rates based on surgical approach in a large cohort of patients with exclusively open distal tibia fractures.

     

Complications encountered in the treatment of pilon fractures.

A total of 52 tibial plafond (pilon) fractures in 51 patients were retrospectively reviewed from the years 1985-1990 to define the rate of complications encountered during their management. All fractures were managed under faculty supervision at a level I trauma center and its two affiliated institutions. The follow-up period was scrutinized to determine whether or not a complicating event occurred. Major local complications, termed events, were defined as those requiring unplanned surgery due to infection, wound breakdown with subsequent flap coverage, and failure of fixation or fracture healing. Reduction accuracy and final clinical results were not specifically examined. There were 14 (27%) type I, 17 (33%) type II, and 21 (40%) type III Ruedi-Allgower fracture types. The majority (79%) of the fractures were closed and 89% were treated by open reduction and internal fixation. The overall local complication rate was 54%. A total of 21 (40%) pilon fractures (six type I, six type II, and nine type III) had major local complicating events requiring 77 additional operations. Patient follow-up time ranged from 1 week (the occurrence of a major local complication) to 200 weeks (no complication), with a mean of 67 weeks. Kaplan-Meier survivorship (K-M) analysis was utilized to statistically estimate the complication rate in this patient population accounting for the occurrence of censored events. The K-M-determined event rate was 42 +/- 7%. Ten (of 21) pilon fractures had events by 3 weeks, while only two occurred beyond 40 weeks.     

两种内固定方法治疗老年骨质疏松性股骨转子间骨折疗效比较

目的探讨两种内固定方法治疗老年骨质疏松性股骨转子间骨折的临床疗效。方法 60例老年骨质疏松性股骨转子间骨折患者根据随机数字法分为动力髋螺钉(DHS)组及股骨近端髓内钉(PFN)组,每组30例,记录两组手术时间、术中出血量、住院时间,以Harris评分标准评定疗效。结果 PFN组手术时间、术中出血量、住院时间均短(少)于DHS组,差异均有统计学意义(P0.05)。患者均获随访,时间6~15个月。术后3个月髋关节功能Harris评分:PNF组(89.0±6.0)分,DHS组(84.0±5.0)分,差异有统计学意义(P0.01)。PFN组患者下床活动时间、生活自理时间、恢复工作时间、骨折愈合时间均短于DHS组,差异均有统计学意义(P0.05、P0.01)。结论对于老年骨质疏松性股骨转子间骨折患者,采用PFN内固定较DHS效果好。