Adult distal humeral metaphyseal fractures: epidemiology and results of treatment

OBJECTIVES: To examine the epidemiology and results of treatment of fractures of the distal humeral metaphysis. DESIGN: Observational cohort study. SETTING: An orthopaedic trauma unit, which provides all the fracture care for a well-defined catchment population. PATIENTS/PARTICIPANTS: A consecutive series of 320 patients with distal humeral fractures admitted to the unit between January 1988 and June 1997. INTERVENTION: We adopted a protocol of open reduction and fixation of all displaced fractures (greater than 5 mm of displacement in any plane) in patients who were medically fit for anesthesia. Postoperative immobilization was a cylinder cast for 6 weeks. Patients with undisplaced fractures or who were medically unfit were also treated nonoperatively in cylinder casts for 6 weeks. MAIN OUTCOME MEASUREMENTS: Epidemiological examination of patient subgroups and the incidence of complications of treatment. RESULTS: The overall incidence of distal humeral fractures in adults during this time was 5.7 cases per 100,000 in the population per year with an almost equal male to female ratio. There was a bimodal age distribution, simple falls were the most common overall cause of fracture, and the majority of the fractures were extra-articular (AO/OTA type A) or complete articular fractures (AO/OTA type C). The risk of complications during treatment was generally low in most patients, and the majority healed their fractures uneventfully. Overall, 90.6% of fractures united within 12 weeks and just under half of the remaining 9.4% patients with union complications healed without requiring further operative intervention by 24 weeks. The risk of union complications was higher following high-energy injuries, open fractures, and nonoperative treatment. Although the AO/OTA classification was not predictive of union complications, the "low" transcondylar (type A2.3 and A3) and simple intercondylar fracture (type C1.3) configuration had a greater risk of union complications than the "high" subtype. The rate of infection, myositis ossificans, and other implant-related complications were higher following operative treatment of type C fractures than type A and B fractures. CONCLUSIONS: The epidemiology of a consecutive unselected series of adult distal humeral fractures is defined in this study. The majority of these fractures are best treated surgically by rigid open reduction and internal fixation, except for "low" Type A and C fractures, which have a higher risk of union complications. The role of total elbow arthroplasty to treat these more complex injuries requires further evaluation.     

To fix or not to fix? The role of fibular fixation in distal shaft fractures of the leg

Background

The role of stabilisation of the fibula in distal two-bone fractures of the leg is controversial. Some studies indicate the need for fibular stabilisation in 43 AO fractures, but few studies consider the role of the fibula in 42 AO fractures. The aim of the current paper is to explain the role of stabilisation of the fibula in 42 AO fractures, correlating the rates of healing and non-union between patients with and without fibula fixation.

Materials and methods

A total of 60 patients with 42 AO (distal) shaft fracture of the tibia with associated fracture of the fibula were selected. Patients were divided into two groups according to whether or not the fibula was fixed: Group I (n = 26) comprised patients who had their fibula fixed while Group II (n = 34) comprised patients who did not. The fibular fracture was classified according to the AO and related to the level of the tibial fracture. Other parameters examined were the union rate of the two groups correlated to the fracture pattern and position of the fibular fracture; the demographic data, such as age and gender; the presence of an open fracture, and the type of tibial fixation device used (nail or plate).

Results

None of the parameters considered (open injury, AO classification, device used and level of the fibular fracture relative to the tibial) were shown to have an influence on the development of a non-union.

Conclusion

This study showed a higher non-union rate when the fracture of the tibia and fibula were at the same level, the tibia was fixed with a bridging plate and the fibula left untouched. For this reason, we recommend fibular fixation in all 42 distal fractures when both fractures lie on the same plane and the tibial fracture is relatively stabilised.     

Combination of hook plate and tibial pro-fibular screw fixation of osteoporotic fractures: a clinical evaluation of operative strategy

BACKGROUND: Internal fixation of osteoporotic ankle fractures is technically difficult and may fail because of unreliable purchase. This study was undertaken to determine if a combination of a hook plate and tibial pro-fibular screws can provide secure fixation until fracture union. METHODS: Thirty-one patients between the ages of 55 and 90 years had open reduction and internal fixation of ankle fractures between April, 2001, and April, 2003. Sixteen patients with an average age of 71.4 years had ankle fracture fixation with a combination of hook plate and tibial pro-fibular screws for the distal fibular fracture, and 15 patients with an average age of 71.9 years had fixation of their ankle fractures with standard fixation technique using AO/ASIF principles but no tibial pro-fibular screws. All patients were followed with clinical and radiologic assessment at 2 weeks, 6 weeks, and 12 weeks postoperatively. At an average of 15.8 months after injury, patients also completed a mailed questionnaire with the Olerud-Molander ankle score and the AOFAS ankle-hindfoot score for preoperative and postoperative status. RESULTS: All patients who had tibial pro-fibular screw fixation had fracture union without hardware failure or complications. In the standard fixation group two patients had wound breakdown and one had a valgus malunion with screw pull out. The AOFAS and Olerud-Molander scores for the standard open reduction and internal fixation were 57.3 and 82.8 before injury and 37 and 43.8 postoperatively, respectively. The AOFAS and Olerud-Molander scores for the hook plate and tibial pro-fibular fixation group were 55.9 and 81.3 before injury and 42.4 and 50.3 postoperatively, respectively. CONCLUSIONS: The combination of hook plate and tibial pro-fibular screws in osteoporotic ankle fractures in a series of patients has not been reported before. This novel technique provides stable fixation for osteoporotic ankle fractures in elderly patients until union is achieved with good clinical scores.     

Unstable pertrochanteric femoral fractures

BACKGROUND: Fractures in the trochanteric region of the femur are classified as AO/OTA 31-A, as they are extracapsular. This report analyzes the relatively rare 31-A3 fracture, which has also been referred to as an "intertrochanteric femur fracture with subtrochanteric extension," "reverse obliquity intertrochanteric femur fracture," "unstable intertrochanteric femur fracture," or a "subtrochanteric femur fracture." The A3 fracture is characterized by having a fracture line exiting the lateral femoral cortex distal to the vastus ridge. Possible fixation constructs include compression hip screws, intramedullary hip screws, trochanteric intramedullary nails, cephalomedullary antegrade intramedullary nails, and 95 degrees plates. Most reports investigating 31-A fractures do not describe the 31-A3 fracture. For this analysis, only reports clearly indicating that the fracture treated was a 31-A3 were included. It should be understood that this approach therefore excludes reports on generic "subtrochanteric fractures" or "intertrochanteric fractures," some of which may have been 31-A3 fractures. OBJECTIVE: To determine the effect of fixation technique for the AO/OTA 31-A3 fracture on rates of union, infection, risk of reoperation, and functional outcomes.     

Transient retrograde interfragmentary compression technique in AO/OTA type 33-C distal femur fractures: A surgical technique and short-term radiographic follow up results

Surgical treatment of AO/OTA type 33-C fractures is a therapeutic challenge despite advances in surgical instruments and techniques. We introduce a novel surgical technique named transient retrograde interfragmentary compression (TRIC) to help intraarticular fragment reduction in AO/OTA type 33-C fracture. We inserted a partial threaded 7.0-cannulated screw with a washer along the transepicondylar axis from the medial femoral epicondyle during the articular block reduction process of AO/OTA type 33-C fractures to strengthen the compressive force between the condylar fragments and to enhance the handling of the articular block fragment in the alignmental correction stage. Following the provisional reduction and fixation using lateral distal femur locking compression plate, TRIC screw was removed. Fifteen AO/OTA type 33-C distal femoral intraarticular fractures of thirteen patients were surgically treated using the TRIC technique. We analyzed the radiographic result of the patients by measuring the horizontal gap and vertical step-off in the postoperative radiographs. Mean horizontal fracture gap was 0.34 mm and mean vertical step-off between bicondylar fragments was 0.63 mm. The median value of the horizontal fracture gap and vertical step off was 0 and 0.46 mm, respectively. Mean time to union in the bicondylar fracture fragment was 9 week. TRIC is considered to be a valuable surgical reduction technique in the treatment of the AO/OTA 33-C type fractures.     

A Pilon Fracture With Fibular Head Dislocation Treated With the Use of 3D Preoperative Planning: A Case Report and Literature Review

Pilon fractures with intact fibula have been associated with low-energy trauma. However, the compression force onto the ankle joint can damage the tibiofibular linkage as in a Maisonneuve fracture. Herein, we describe a case of a patient who had a pilon fracture (AO type 43 C3.2) without a fibular fracture. Three-dimensional preoperative simulation by reduction with the surface registration technique was performed as the fibular length was intact and there was no reference for the tibial length. The preoperative simulation revealed superior fibular head dislocation and shortening of the distal tibia. After emergency external fixation on the day of arrival, a 2-staged surgery was performed. During the first operation, the fibular head was reduced and the tibial posterolateral fragment was fixed to restore the tibia length. During the second operation, medial and anterolateral fragments were fixed in order to reduce joint surface of the distal tibia. In general, proximal fibular head fractures are easily overlooked. In the case of pilon fractures with severe length shortening of the tibia without a fibular fracture, a proximal tibiofibular injury should be suspected.     

Biomechanical analysis of different internal fixation methods for special Maisonneuve fracture of the ankle joint based on finite element analysis

ObjectiveThe objective of this study was to evaluate the biomechanical properties of different internal fixation methods for Maisonneuve fractures under physiological loading conditions.MethodsFinite element analysis was used to numerically analyze various fixation methods. The study focused on high fibular fractures and included six groups of internal fixation: high fibular fracture without fixation + distal tibiofibular elastic fixation (group A), high fibular fracture without fixation + distal tibiofibular strong fixation (group B), high fibular fracture with 7-hole plate internal fixation + distal tibiofibular elastic fixation (group C), high fibular fracture with 7-hole plate internal fixation + distal tibiofibular strong fixation (group D), high fibular fracture with 5-hole plate internal fixation + distal tibiofibular elastic fixation (group E), and high fibular fracture with 5-hole plate internal fixation + distal tibiofibular strong fixation (group F). The finite element method was employed to simulate and analyze the different internal fixation models for the six groups, generating overall structural displacement and Von Mises stress distribution maps during slow walking and external rotation motions.ResultsGroup A demonstrated the best ankle stability under slow walking and external rotation, with reduced tibial and fibular stress after fibular fracture fixation. Group D had the least displacement and most stability, while group A had the largest displacement and least stability. Overall, high fibular fracture fixation improved ankle stability. In slow walking, groups D and A had the least and greatest interosseous membrane stress. Comparing 5-hole plate (E/F) and 7-hole plate (C/D) fixation, no significant differences were found in ankle strength or displacement under slow walking or external rotation.ConclusionCombining internal fixation for high fibular fractures with elastic fixation of the lower tibia and fibula is optimal for orthopedic treatment. It yields superior outcomes compared to no fibular fracture fixation or strong fixation of the lower tibia and fibula, especially during slow walking and external rotation. To minimize nerve damage, a smaller plate is recommended. This study strongly advocates for the clinical use of 5-hole plate internal fixation for high fibular fractures with elastic fixation of the lower tibia and fibula (group E).     

重度开放性Pilon骨折的治疗

目的 探讨重度开放性Pilon骨折的手术时机、手术方法选择及其对治疗效果的影响.方法 2003年4月至2008年7月收治开放性Pilon骨折患者21例,骨折按AO/OTA分类,均为C型,C2型17例,C3型4例;软组织损伤程度按照Gustilo标准,Ⅱ度18例,Ⅲ A度2例,Ⅲ B度1例.根据骨折类型、软组织损伤程度及受伤时间的不同采用两种不同的治疗方法,GustiloⅡ度C2型16例,GustiloⅡ度C3型2例,Gustilo ⅢA度C2型l例,采用创面清创胫骨有限内固定结合支架外固定术;GustiloⅢA度C3型1例,Gustilo ⅢB度C3型1例,采用创面清创跟骨牵引、延期手术.结果 所有患者术后获得6～48个月的随访,平均24个月.骨折复位情况影像学评估结果(Burwell-Charnley标准):解剖复位6例,复位一般14例,复位差1例.骨折全部愈合,愈合时间2.5～11个月,平均4.7个月,其中骨折延迟愈合2例,延迟愈合率9.5%.创面皮肤浅表坏死2例,浅表感染2例,深部感染1例,感染率14.3%.早期出现踝关节创伤性关节炎8例,发生率38.1%.按美国骨科协会足踝外科分会(American Orthopedic Foot Ankle Society,AOFAS)评分标准:评分为66～94分,平均85.2分.主要并发症包括皮肤、软组织坏死、感染,骨折延迟愈合,创伤性关节炎等.结论 治疗开放性Pilon骨折要根据骨折类型、软组织损伤程度及受伤时间的不同选择适当的手术时机和手术方式,正确评估软组织损伤情况、骨与软组织血运的保护是治疗关键.严格的清创、合理应用抗生素、酌情植骨、适时的功能锻炼可以减少并发症的发生.     

Intramedullary tibial nailing of distal tibiofibular fractures: additional fibular fixation or not?

Introduction

The anatomy of the distal tibia accounts for reduced biomechanical stability and higher complication rates when treating distal tibiofibular fractures with an intramedullary tibia nail (IMTN). The goal of this study was to identify variables that affect the stability of IMTN. We assessed the value of additional fibular fixation, angular stable interlocking screws (ASLS) and multiplanar screw configuration in IMTN.

Patients and methods

A retrospective cohort study was performed including 184 distal tibial fractures and associated fibula fracture treated with IMTN. Relevant demographic, fracture-related (type and level of the tibia and fibula fracture) and operative variables (depth of the nail, screw type and configuration, use of polar screws, fibular fixation) were studied. Coronal and sagittal alignment was assessed directly and 3–6 months after IMTN. Loss of reduction (LOR) was classified as 5–9° or ≥10°.

Results

48.4% of the patients showed ≥5° LOR in one or both planes. Coronal LOR 5°–9° significantly correlated with low tibial fractures (p = 0.034), AO/OTA type 43 distal tibial fractures (p = 0.049), and sagittal LOR 5°–9° (p = 0.015). Although sagittal LOR 5°–9° was associated with fibular fractures (non-fixated suprasyndesmotic, p = 0.011), conversely we could not demonstrate the added value of (suprasyndesmotic) fibula fixation in IMTN. Coronal LOR ≥10° significantly correlated with AO/OTA type 43 distal tibial fractures (p = 0.009). In contrast to multiplanar configuration, we found a clear benefit of ASLS in distal IMTN locking.

Conclusions

The level of the tibial fracture (AO/OTA type) and (suprasyndesmotic) fibular fractures were the main determinants of LOR after IMTN. ASLS was found to increase the stability of IMTN. Due to heterogeneity, however, we could not demonstrate the value of fibular fixation in IMTN. Therefore, a future prospective study with uniform treatment strategy for IMTN of distal tibiofibular fractures, with or without fixation of the fibula, is mandatory.

     

三种固定方法治疗胫腓骨骨折的疗效比较

目的比较3种固定方法治疗胫腓骨骨折的疗效。方法回顾性分析从1996年12月～2004年12月不同方法治疗的胫腓骨骨折160例,其中外固定架10例,AO加压钢板50例,交锁钉100例。结果随访8～12个月,平均11个月,疗效优良率:外固定架84%,AO钢板90%,交锁钉99%。3种方法固定骨折均愈合,但有并发症。延迟愈合5例:交锁钉1例,外固定支架1例,AO加压钢板3例;感染4例:外固定支架2例,AO加压钢板2例;固定物断裂3例。AO加压钢板2例,交锁钉1例;骨不连4例:外固定支架1例,AO加压钢板3例;畸形愈合3例:外固定支架1例,AO加压钢板2例。结论交锁钉可广泛应用于闭合性胫腓骨复杂骨折且优于AO钢板及外固定支架,它具有微创及符合生物学内固定的优点,术后骨折愈合较为理想,若能早期功能锻炼,相对并发征较少。AO钢板应慎用于胫骨中下1/3段复杂闭合性骨折,外固定支架对于开放性骨折是上述方法的补充。     

胫骨远端骨折:经皮钢板内固定优于切开复位内固定吗?

目的 对闭合复位经皮钢板固定及切开复位内固定两种方法治疗胫骨远端骨折进行回顾性比较研究,明确两种方法的不同指征和疗效. 方法 2006年10月至2007年6月,对采用钢板内固定治疗闭合胫骨远端骨折(不累及关节面)的94例患者进行回顾性研究.研究对象分为切开组和闭合组,其中切开组42例,闭合组52例.研究内容为骨折愈合时间、有无畸形愈合及并发症发生率.结果 平均随访时间14.5个月(8～24个月).切开组中骨折愈合35例,延迟愈合3例,骨不连4例.平均愈合时间3.83个月(3～8个月),无畸形愈合患者,切口感染2例.闭合组中骨折愈合47例,延迟愈合5例,无骨不连患者.平均愈合时间3.66个月(2～8个月).两组的总愈合时间,A1型、A2型、B型愈合时间之间差异无统计学意义;A3型愈合时间闭合组长于切开组;C型愈合时间闭合组短于切开组.闭合组中出现5例畸形愈合患者(其中2例外旋畸形,3例向后成角畸形),8例出现踝关节异物不适感,钢板取出后症状好转. 结论胫骨远端骨折总体上切开组与闭合组的愈合时间差异无统计学意义.但A3型骨折中切开组要优于闭合组,而C型骨折中闭合组要优于切开组.如闭合复位经皮固定的患者术后存在前后成角畸形,则其存在较高的骨延迟愈合率.     

胫骨远端骨折:经皮钢板内固定优于切开复位内固定吗?

目的 对闭合复位经皮钢板固定及切开复位内固定两种方法治疗胫骨远端骨折进行回顾性比较研究,明确两种方法的不同指征和疗效. 方法 2006年10月至2007年6月,对采用钢板内固定治疗闭合胫骨远端骨折(不累及关节面)的94例患者进行回顾性研究.研究对象分为切开组和闭合组,其中切开组42例,闭合组52例.研究内容为骨折愈合时间、有无畸形愈合及并发症发生率.结果 平均随访时间14.5个月(8～24个月).切开组中骨折愈合35例,延迟愈合3例,骨不连4例.平均愈合时间3.83个月(3～8个月),无畸形愈合患者,切口感染2例.闭合组中骨折愈合47例,延迟愈合5例,无骨不连患者.平均愈合时间3.66个月(2～8个月).两组的总愈合时间,A1型、A2型、B型愈合时间之间差异无统计学意义;A3型愈合时间闭合组长于切开组;C型愈合时间闭合组短于切开组.闭合组中出现5例畸形愈合患者(其中2例外旋畸形,3例向后成角畸形),8例出现踝关节异物不适感,钢板取出后症状好转. 结论胫骨远端骨折总体上切开组与闭合组的愈合时间差异无统计学意义.但A3型骨折中切开组要优于闭合组,而C型骨折中闭合组要优于切开组.如闭合复位经皮固定的患者术后存在前后成角畸形,则其存在较高的骨延迟愈合率.     

RhBMP-7 accelerates the healing in distal tibial fractures treated by external fixation

External fixation of distal tibial fractures is often associated with delayed union. We have investigated whether union can be enhanced by using recombinant bone morphogenetic protein-7 (rhBMP-7). Osteoinduction with rhBMP-7 and bovine collagen was used in 20 patients with distal tibial fractures which had been treated by external fixation (BMP group). Healing of the fracture was compared with that of 20 matched patients in whom treatment was similar except that rhBMP-7 was not used. Significantly more fractures had healed by 16 (p=0.039) and 20 weeks (p=0.022) in the BMP group compared with the matched group. The mean time to union (p=0.002), the duration of absence from work (p=0.018) and the time for which external fixation was required (p=0.037) were significantly shorter in the BMP group than in the matched group. Secondary intervention due to delayed healing was required in two patients in the BMP group and seven in the matched group. RhBMP-7 can enhance the union of distal tibial fractures treated by external fixation.     

Percutaneous plating of distal tibial fractures

This article presents our experience with 24 patients who had distal tibial fractures and were treated by percutaneous plate fixation. Distribution of the fractures according to the AO/OTA classification was as follows: five patients suffered from a 43 A type fracture, six from a 43 B type fracture, and 13 from a 43 C type fractures. Four of the fractures were open. Exclusion criteria included 43 C3 fractures and Gustilo III open fractures. All fractures showed radiographic signs of union enough to enable full weightbearing within an average time of 12.3 weeks. All patients showed a good range of motion (average dorsiflexion 12 degrees and average plantiflexion 18 degrees). Two fractures united with mal-union: one with an 8 degrees valgus deformity and another with a 7 degrees varus deformity. Both cases, which had a metaphyseal component, were treated by means of a "soft" (flexible and manually adjustable) AO 3.5 mm reconstruction plate. Except for one case of superficial infection, no infections were detected in any of the patients. The biological percutaneous plate fixation of distal tibial fractures with no extensive intra-articular involvement is a good soft tissue preserving technique. It provides a rigid and anatomical fixation in most cases. We conclude that type B fractures with one intact column can be fixed with either "soft" or "rigid" plates, and type A and C fractures with a metaphyseal component should be fixed with "rigid" plates (AO 4.5 mm Dynamic Compression Plate). In these fractures the reduction should be performed cautiously due to the tendency of sagittal plane mal-reduction.     

不同固定方法治疗青少年胫骨骨折的比较

目的：通过对3种固定方法的疗效及并发症比较并研究其有关影响因素,探讨治疗青少年胫骨骨折固定方式的选择.方法：2007年1月至2012年1月收治青少年胫骨骨折患者79例（83处骨折）,男55例,女24例;年龄11～17.6岁,平均13.9岁.分别采用弹性髓内钉、钢板及外固定支架进行固定治疗,并行回顾性分析.观察比较各组住院时间、骨折愈合时间以及并发症发生率和再手术发生率等.结果：所有患者得到随访,平均随访时间为15.8个月.骨折愈合时间与固定方式、高能量损伤、多发骨折、开放性骨折因素显著相关.且外固定支架组愈合时间明显长于弹性髓内钉组和钢板组.外固定支架组并发症发生率明显高于弹性髓内钉组和钢板组.4例弹性髓内钉固定患者需再手术（复位丢失2例、延迟愈合和畸形愈合各1例）.6例外固定支架患者需再手术（复位丢失3例,畸形愈合2例,钉道感染1例）.2例钢板固定患者因不愈合、成角畸形行二次手术.通过统计学分析：外固定支架与弹性髓内钉固定术比较有7.56倍（95％可信区间=3.74～29.87）的复位丢失和（或）畸形愈合风险.未次随访时,3组疗效结果差异无统计学意义（P＞0.05）.结论：不同方法治疗青少年胫骨干骨折中,外固定支架固定术并发症发生率最高,弹性髓内钉可以达到其他固定系统效果并可避免大部分并发症,手术方式选择取决于医生的经验以及患者基本情况和骨折类型.     

Comparative study of intertrochanteric fracture fixation using proximal femoral nail with and without distal interlocking screws

BACKGROUNDIntertrochanteric (IT) fracture is one of the most common fractures seen in an orthopaedic practice. Proximal femoral nailing (PFN) is a common modality of fixing IT femur fracture. We retrospectively studied whether a PFN with two proximal lag screws can be done without distal interlocking screws in the 31-A1 and 31-A2 fracture patterns according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) guidelines for IT femur fractures.AIMTo compare the outcomes of IT fractures (AO/OTA 31-A1 and 31-A2) treated by PFN with and without distal interlocking screws.METHODSWe carried out a retrospective study of 140 patients in a tertiary care centre who had AO/OTA type 31-A1 and 31-A2 IT fractures. We divided the patients into two groups, in which one of the groups received distal interlocking screws (group 1) and the other group did not (group 2). The subjects were followed up for a mean period of 14 mo and assessed for radiological union time, fracture site collapse, mechanical stability of implant, and complications associated with the PFN with distal interlocking and without distal interlocking. Then, the results were compared.RESULTSPFN without distal interlocking screws has several advantages and gives better results over PFN with distal interlocking screws in the AO/OTA 31-A2 fracture pattern. However, similar results were observed in both groups with the fracture pattern AO/OTA 31-A1. In patients with fracture pattern AO/OTA 31-A2 treated by PFN without distal interlocking screws, there were minimal proximal lock-related complications and no risk of distal interlock-related complications. The operative time, IITV radiation time and time to radiological union were reduced. These patients also had better rotational alignment of the proximal femur, and the anatomy of the proximal femur was well maintained. It was also noted that in the cases where distal interlocking was performed, there was a gradual decrease in neck shaft angle, which led to varus collapse and failure of bone-implant construct in 21.40%.CONCLUSIONIn fracture pattern AO/OTA 31-A2, PFN without distal interlocking had better results and less complications than PFN with distal interlocking.     

Fibular fixation in mid and distal extra-articular tibia fractures – A systematic review and meta-analysis

BackgroundThe surgical management of extra-articular mid and distal tibia fractures has primarily focused on reducing rates of non-union and malunion, preserving hip-knee-ankle alignment and improving functional outcomes. Fibular fractures commonly accompany these injuries and the contributory role of fixation of these fractures has been increasingly studied. A systematic review and meta-analysis were performed to determine whether concurrent fibular fixation (FF) during extra-articular mid and distal tibia fracture fixation (AO/OTA 42 and 43-A) altered the risk of malunion, non-union and post-operative complications when compared to no fibular fixation (NF).MethodsA systematic search of literature in the databases of MEDLINE (via OvidSP), PubMed, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) from the dates of inception was performed for randomised and non-randomised controlled trials. All studies published in English were included. Risk of Bias in Non-randomised Studies (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05.ResultsA total of ten studies with 1174 patients were included for analysis. There was a statistically significant reduced risk of overall malunion in the FF group compared to the NF group (11.8% vs 21.9%, RR 0.63, 95% CI: 0.41–0.98, p = 0.04) and this was supported through a sensitivity analysis of only randomised controlled trials (21.8% vs 40.3%, RR 0.37, 95% CI: 0.18–0.76, p = 0.006). There was no statistically significant difference in rates of non-union between groups (p > 0.05). Overall, there were similar incidences of diabetes, open fractures and smoking history between groups (p > 0.05). Detailed information regarding methods of tibial fixation were not available for subgroup analysis.ConclusionIn conclusion, in extra-articular mid and distal tibia (AO/OTA 42 and 43-A) fracture fixation, additional fibular fixation (FF) appears to significantly reduce the risk of overall malunion (RR, 0.37, 95% CI: 0.18–0.76, p = 0.006) without increasing the risk of non-union. These results should be interpreted with caution given the lack of subgroup analysis for methods of tibial fixation. Future high-quality randomised controlled trials should therefore delineate between types of tibial fixation.     

VSD结合外固定支架在西藏高原地区胫腓骨开放性骨折分期治疗中应用

目的：探讨负压吸引敷料结合外固定支架技术在西藏高原地区胫腓骨开放性骨折分期治疗中的应用及临床疗效。方法2014年8月-2015年8月收治16胫腓骨开放性骨折患者,其中男性12例,女性4例,年龄19~66岁,平均年龄39.4岁(19~66岁);胫腓骨中上段骨折4例,下段骨折12例。待患者病情稳定后患者生命体征稳定后,无继发性损伤,予行清创、外固定支架固定骨折端,并采用负压吸引敷料覆盖创面或创腔。7 d后更换VSD或予行二期缝合或软组织覆盖。 X线检查明确骨折愈合时间并记录相关并发症。结果本组16例创面均二期愈合,未见感染、皮肤或皮瓣坏死等软组织并发症。本组共随访患者12例(电话通知来院复诊),4例失访,平均随访18个月(12~24个月)。影像学检查明确平均骨折愈合时间为5.5个月(3~7个月),其中骨折一期临床愈合9例(75%),延迟愈合3例(25%)。随访期间除2例出现钉道感染,经保守治疗后治愈,余患者未见深部感染、植皮或皮瓣坏死、畸形愈合、骨不连或骨髓炎发生。结论负压吸引敷料结合外固定支架治疗西藏高原地区胫腓骨开放性骨折,在迅速有效地稳定骨折的同时,能安全有效地封闭创面,缩短二期创面修复时间,促进骨折愈合,减少并发症。     

Rates and odds ratios for complications in closed and open tibial fractures treated with unreamed, small diameter tibial nails: a multicenter analysis of 467 cases

OBJECTIVE: A multicenter trial analyzed complications and odds for complications in open and closed tibial fractures stabilized by small diameter nails. DESIGN: Retrospective. SETTING: Four Level I trauma centers. PATIENTS: Four hundred sixty-seven tibial fractures were included in the study. There were fifty-two proximal fractures, 219 midshaft fractures, and 196 distal fractures. Breakdown into different AO/OTA groups showed 135 Type A fractures, 216 Type B fractures, and 116 Type C fractures. Two hundred sixty-five were closed fractures and 202 were open fractures. OUTCOME MEASUREMENTS: Clinical and radiographic analysis. METHODS: 467 patients' tibial fractures were stabilized with small diameter tibial nails using an unreamed technique. Indications for the use of small diameter tibial nails using an unreamed technique included all types of open or closed diaphyseal fractures. The operating surgeons decided whether or not to ream based on personal experience, fracture type, and soft-tissue damage. Surgeons of Center 1 preferred to treat AO Type A and B fractures with unreamed nails, and surgeons of Centers 2, 3, and 4 preferred to treat AO Type B and C fractures with unreamed nails. Closed and open fractures were treated in approximately the same ratio. RESULTS: Analysis showed five (1.1 percent) deep infections (with a 5.4 percent rate of deep infections in Gustilo Grade III open fractures), forty-three delayed unions (9.2 percent), and twelve (2.6 percent) nonunions. Compartment syndromes occurred in sixty-two cases (13.3 percent), screw fatigue in forty-seven cases (10 percent), and fatigue failure of the tibial nail in three cases (0.6 percent). CONCLUSIONS: Fracture distraction of more than three millimeters should not be tolerated when stabilizing tibial fractures with unreamed, small-diameter nails as this increases the odds of having a delayed union by twelve times (p < 0.001) and a nonunion by four times (p = 0.057). There was a significant increase of complications in the group of Grade III open fractures (p < 0.001), AO/OTA Type C fractures (p = 0.002), and to a lesser extent in distal fractures. However, the rate of severe complications resulting in major morbidity was low.     

Distal Tibial Fracture Fixation with Locking Compression Plate (LCP) Using the Minimally Invasive Percutaneous Osteosynthesis (MIPO) Technique

Abstract Background:   Treatment of distal tibial fractures has always been a challenge. Distal tibia is more superficial, with less soft tissue coverage and blood supply. Therefore, operative treatment can lead to complications. We aim to see the results of the distal tibial fracture fixation with LCP using MIPO. Patients and Methods:   Twenty-one consecutive patients were prospectively reviewed. AO types 43A, 43B and 43C were included. Fourteen male and seven female patients with a mean age of 51 years were included. Results:   Mean time to union was 5.5 months (range 3–13 months). Seventeen fractures healed with good functional outcome. One patient had delayed union. One patient had nonunion and underwent revision; the fracture ultimately healed with good functional outcome. Two patients developed superficial wound infections but the fractures united completely. Discussion:   The MIPO technique for distal tibia has shown good results with many additional advantages over the conventional methods. Early mobilization without risk of secondary displacement helps to prevent stiffness and contracture.