Single allograft medial collateral ligament and posterior oblique ligament reconstruction: a technique to improve valgus and rotational stability

We present a novel and simple method for single hamstring allograft MCL and PMC reconstruction, which can improve both joint valgus and external rotational stability and maximize utilization of allograft. All patients received arthroscopic evaluation through inferomedial and inferolateral knee incisions to ascertain whether there were intra-articular injuries. An 8-cm-length longitudinal incision was made from 1 cm above adductor tubercle to 5-cm proximal medial tibia joint line. The anterior tibia insertion was defined as 15 mm lateral from the medial tibia edge and 45 mm below the medial tibia joint line. The posterior tibia insertion was defined as 15 mm lateral from the medial tibia edge and 20 mm below the medial tibia joint line. A 5- or 6-mm reamer was used to drill the tibia tunnel along with guide pin, and a 6 or 7 mm drill was used to drill the femur tunnel to a depth of 25 or 30 mm until the proximal adductor tubercle. The allograft was harvested from tibia and placed into the tunnel and fixed with absorbable interference screw. All patients performed active rehabilitation exercises after the operation periodically.     

腓骨内固定在治疗胫腓骨骨折中的作用

目的 探讨腓骨内固定在治疗胫腓骨骨折中的作用。方法 50例胫腓骨骨折，采用腓骨内固定、胫骨闭合手法复位加外固定方法治疗。其中闭合性骨折28例，开放性骨折12例，Pilon骨折10例；粉碎性骨折28例，斜形骨折12例、螺旋形骨折10例。结果 50例均达临床愈合。平均临床愈合时间为5个月，骨折位置良好，关节功能恢复正常，无皮肤坏死及感染发生。结论 腓骨固定适合于胫前皮肤条件不好的闭合性或开放性胫腓骨骨折和胫骨下1/3粉碎性骨折合并腓骨骨折的治疗。     

Neonatal osteofibrous dysplasia associated with pathological tibia fracture: a case report and review of the literature

Osteofibrous dysplasia is a rare and benign disease that originates from the tibia or fibula. The symptoms of osteofibrous dysplasia include painless enlargement and bowing of the tibia and pain occurring in the presence of pathological fracture. Herein a male infant who was admitted with redness and swelling on the right leg and diagnosed as pathological tibia fracture due to left tibia osteofibrous dysplasia on the third day of life was presented. To our knowledge, this is the earliest presentation of osteofibrous dysplasia with a pathological fracture in a neonate. Therefore, it must be suspected in neonatal bone fractures.     

Femoral deformity in tibia vara

BACKGROUND: Previous studies have suggested that compensatory valgus deformity of the femur is common in patients with tibia vara, or Blount disease. The availability and routine use of standing long-cassette radiographs of the lower extremities to assess angular deformities has allowed quantitative evaluation of this hypothesis. METHODS: The cases of all patients with tibia vara, two years of age or older, seen at our institution prior to treatment, over a thirteen-year period, were reviewed. Seventy-three patients with a total of 109 involved lower limbs were identified and were classified as having either infantile tibia vara (thirty-seven patients with fifty-six involved limbs) or late-onset tibia vara (thirty-six patients with fifty-three involved limbs). Standardized standing radiographs of the lower extremity were examined to assess the deformity at the distal part of the femur and the proximal part of the tibia by measuring the lateral distal femoral angle and the medial proximal tibial angle. RESULTS: The distal part of the femur in the children with infantile tibia vara either was normal or had mild varus deformity, with a mean lateral distal femoral angle of 97 degrees (range, 82 degrees to 129 degrees). The mean medial proximal tibial angle in these children was 72 degrees (range, 32 degrees to 84 degrees). Older children with infantile tibia vara were noted to have little distal femoral deformity, with no more than 4 degrees of valgus compared with either normal values or the contralateral, normal limb. Children with late-onset tibia vara had a mean lateral distal femoral angle of 93 degrees (range, 82 degrees to 110 degrees) and a mean medial proximal tibial angle of 73 degrees (range, 52 degrees to 84 degrees). On the average, the varus deformity of the distal part of the femur constituted 30% (6 degrees of 20 degrees) of the genu varum deformity in these patients. CONCLUSIONS: Patients with infantile tibia vara most commonly had normal alignment of the distal parts of the femora; substantial valgus deformity was not observed. Distal femoral varus constituted a substantial portion of the genu varum in children with late-onset disease. When correction of late-onset tibia vara is planned, the surgeon should be aware of the possibility that distal femoral varus is a substantial component of the deformity.     

Fracture of the tibia with additional injury of the ankle joint. A frequent and undervalued combination

Summary There are 2 types of a combined tibia fracture and ankle injury: in Type I the tibia fracture extends directly into the ankle joint, in Type II the tibia fracture goes along with a fracture of the fibula and disruption of the fibular-tibial syndesmosis. This type of fracture must be distinguished from a pilon tibiale fracture. The typical mechanism for this combined tibia and ankle injury is the indirect torsional trauma with pronation-eversion. From 1995 to 1997 188 patients with fractures of the tibia were treated by internal fixation in our Trauma Department. 27 of these patients (13.6 %) had a combined tibia and ankle injury. Most of the tibia fractures were located in the distal third, a spiral fracture (16 patients) or a comminuted fracture (6 patients), and another group extending directly into the ankle (5 patients). The ankle lesion was a distal fibular fracture (Weber Typ B + C) in 14 patients, a proximal fibular fracture (Type maisoneuve) in 6 patients, a postero-lateral fragment in 11 cases and a fracture of the medial melleolus in 10 cases. A disrupture of the anterior tibio-fibular syndesmosis was seen in 18 patients, 3 times as an isolated lesion of the ankle joint without fracture of the fibula. The osteosynthesis of the tibia fracture was performed with an unreamed tibia nail in 20 patients, with elastic-biologic plate fixation in 6 and with external fixation in 1 patient. The fibula fractures were stabilized by small fragment titaneum plates, the dorsolateral fragment and the medial malleolus were stabilized by lag-screws, the tibio-fibular ligament was sutured and, in a few cases only, held in place by a positioning screw. The outcome was controlled after 20,7 month according to the Phillip's Score (1996). We found not more than one pour results. It must be considered, that most of the combined injuries of the tibia and the ankle joint concerning 13,6 % of all tibia shaft fractures are usually not recognized and may result in an arthrosis of the ankle joint. The attention should be focused to the ankle joint in any spiral fractures of the distal tibia after indirect trauma, especially with a proximal fibular fracture or an intact fibula. Additional X-ray examination of the ankle joint is recommended during internal fixation of the tibia. Posttraumatic arthrosis of the ankle joint can be prevented by diagnosis and adequate anatomical reconstruction of the additional ankle joint injury.      

Fracture of the tibia with additional injury of the ankle joint. A frequent and undervalued combination Eine h?ufige, aber wenig beachtete Kombination

There are 2 types of a combined tibia fracture and ankle injury: in Type I the tibia fracture extends directly into the ankle joint, in Type II the tibia fracture goes along with a fracture of the fibula and disruption of the fibular-tibial syndesmosis. This type of fracture must be distinguished from a pilon tibiale fracture. The typical mechanism for this combined tibia and ankle injury is the indirect torsional trauma with pronation-eversion. From 1995 to 1997 188 patients with fractures of the tibia were treated by internal fixation in our Trauma Department. 27 of these patients (13.6 %) had a combined tibia and ankle injury. Most of the tibia fractures were located in the distal third, a spiral fracture (16 patients) or a comminuted fracture (6 patients), and another group extending directly into the ankle (5 patients). The ankle lesion was a distal fibular fracture (Weber Typ B + C) in 14 patients, a proximal fibular fracture (Type maisoneuve) in 6 patients, a postero-lateral fragment in 11 cases and a fracture of the medial melleolus in 10 cases. A disrupture of the anterior tibio-fibular syndesmosis was seen in 18 patients, 3 times as an isolated lesion of the ankle joint without fracture of the fibula. The osteosynthesis of the tibia fracture was performed with an unreamed tibia nail in 20 patients, with elastic-biologic plate fixation in 6 and with external fixation in 1 patient. The fibula fractures were stabilized by small fragment titaneum plates, the dorsolateral fragment and the medial malleolus were stabilized by lag-screws, the tibio-fibular ligament was sutured and, in a few cases only, held in place by a positioning screw. The outcome was controlled after 20,7 month according to the Phillip's Score (1996). We found not more than one pour results. It must be considered, that most of the combined injuries of the tibia and the ankle joint concerning 13,6 % of all tibia shaft fractures are usually not recognized and may result in an arthrosis of the ankle joint. The attention should be focused to the ankle joint in any spiral fractures of the distal tibia after indirect trauma, especially with a proximal fibular fracture or an intact fibula. Additional X-ray examination of the ankle joint is recommended during internal fixation of the tibia. Posttraumatic arthrosis of the ankle joint can be prevented by diagnosis and adequate anatomical reconstruction of the additional ankle joint injury.     

Biomechanical analysis of tibial strength after harvesting unicortical tibial grafts of two different lengths

BACKGROUND: It is not known whether the use of the proximal tibia as a source of strut graft compromises the strength of the tibia. Our hypothesis was that unicortical proximal tibial grafts in two different sizes would not significantly decrease the torsional strength of the tibia. MATERIALS AND METHODS: Ten matched pairs of human cadaver tibiae were stripped of all soft tissues. One tibia in each pair was randomly assigned to receive an osteotomy of 2 x 1.5 cm or 6 x 1.5 cm placed 1 cm dorsal to the tibial crest with the proximal graft edge 6 cm from the tibial plateau. Specimens were loaded at 720 N and in external rotational torque at 5 degrees per second to failure. Axial force or torque at failure were analyzed via T-test (p < or = 0.05). RESULTS: There was no significant difference in torque to failure between specimens with an osteotomy of 1.5 x 2 cm versus the matched intact specimens. Torque to failure for specimens with an osteotomy 1.5 x 6 cm was lower than that of the matched intact specimens (28.69 Nm +/- 4.2 Nm versus 60.95 Nm +/- 9.49 Nm; p = 0.01) and lower than that found in the 2-cm osteotomy group (p = 0.04). CONCLUSION: Torque to failure was significantly decreased with the larger 6-cm graft as compared with the intact tibia and with the graft 1.5 x 2 cm. The smaller graft did not result in a significant change in torsional strength of the tibia. CLINICAL RELEVANCE: Though this study cannot be extrapolated directly to the clinical setting, the longer graft tested in this study may raise concerns regarding the strength of the tibia after graft removal.     

Epidemiology and incidence of tibia fractures in the Swedish Fracture Register

IntroductionThere is a lack of epidemiological studies of fractures in all segments of the tibia classified by orthopaedic surgeons according to the AO/OTA classification. Since 2011, the Swedish Fracture Register (SFR) has provided prospectively collected, population-based data on fractures of all types, treated both surgically and non-surgically. The aim of this study was to describe the epidemiology and incidence of fractures in all segments of the tibia in a cohort of consecutive tibia fractures over a period of five years at Sahlgrenska University Hospital, Gothenburg, Sweden.MethodsInformation on age, gender, date and mechanism of injury, fracture classification according to AO/OTA, affected side and high- or low-energy trauma was extracted from the SFR for all patients, aged 16 years and above, with tibia fractures treated at Sahlgrenska University Hospital, Gothenburg, during the five-year period 1 January 2011 to 31 December 2015.Results1325 patients sustained 1371 tibia fractures. There were 712 proximal tibia fractures, 417 tibial shaft fractures and 242 distal tibia fractures. Patients with proximal tibia fractures had a higher mean age (54.3) and 58% were women, whereas patients with shaft and distal fractures had a slightly lower mean age (47.0 and 48.7 respectively) and a dominance of men (59% and 54% respectively). The overall incidence of tibia fractures was 51.7 per 100,000 and year. The incidence of proximal, diaphyseal and distal tibia fractures was 26.9, 15.7 and 9.1 respectively per 100,000 and year. Among women, tibia fractures showed an increasing incidence with age in all segments, whereas men had a fairly flat incidence curve, except for tibial shaft fractures, which displayed a peak among young males. The incidence of tibia fractures and graphs for age-specific incidence for each segment of the tibia are presented.ConclusionsThis study describes the epidemiology and incidence of fractures in the whole of the tibia classified by orthopaedic surgeons according to the AO/OTA classification.     

Tibia vara. A critical review

Since Blount's classic article was published in 1937, many authors have contributed to the knowledge of tibia vara. Tibia vara is characterized by an abrupt angulation of the tibia into varus in the proximal end. The term does not reveal the etiology of the anatomic deformity, which may be developmental, posttraumatic, or postinfectious. There are four types: (1) Infantile tibia vara (Blount's disease) is a developmental condition that manifests itself between the ages of one and four years. Roentgenographic findings are typical. (2) Adolescent tibia vara is caused by partial closure of the growth plate after trauma or infection between the ages of six and 13 years. (3) Late-onset tibia vara appears in obese black children between the ages of six and 15 years. The roentgenographic findings differ from those of the other types, but the histopathology is similar to infantile tibia vara. (4) Tibia vara may also be caused by focal fibrocartilaginous dysplasia. Eight cases in which there was an area of fibrocartilaginous dysplasia in the medial aspect of the tibia have been reported in the literature. Several problems have been encountered in the treatment of infantile tibia vara.     

Version of the osteoarthritic knee

Version of normal and osteoarthritic knees is evaluated by computed tomography in this study. Version of the knee is defined as the static rotation of the tibia with respect to the femur in full knee extension. It is measured as the difference between the transverse axes of the femoral condyles and tibia. The average knee version, or external rotation of the tibia with respect to the femur across the normal knee, was 0°. Version of the osteoarthritic knee was 5°. Rotation of the tibia with respect to the femur across the extended osteoarthritic knee is a relationship that will affect the placement of components in total knee arthroplasty. This relationship should be addressed in alignment instrumentation and technique to avoid component malalignment in total knee arthroplasty.     

Proximal tibiofibular joint dislocation associated with tibial shaft fractures – 7 Cases

ObjectiveLower leg fractures of the tibia with or without fracture of the fibula are very common. Proximal tibiofibular joint (PTFJ) dislocation is a very rare injury that can occur together with a tibia shaft fracture. As there is only scarce literature about this injury available, we would like to present our experience with the treatment of this entity.MethodsWe present a small case series of seven patients. In most cases, the tibia fracture was nailed in a closed technique. After distal locking the proximal fibula was exposed by a lateral approach exposing and preserving the peroneal nerve. After anatomical reduction into the corresponding articular facet of the proximal tibia, the fibula was transfixed to the tibia with a positioning screw. This indirectly provided a correct length and rotation of the tibia, which could finally be locked to the nail by inserting the proximal locking bolts. The positioning screw was removed after six weeks prior to full loading. Six of seven patients had been followed up by at least 7 months post-treatment.ResultsOut of 663 prospectively collected tibia shaft fractures treated at our institution from 1/2001 to 7/2014, we found seven patients with associated PTFJ dislocation. All except one had been caused by a high energy trauma. After one year, five patients showed excellent results with full range of motion and returning to their sporting activities as before the accident. Two patients have impaired function due to associated injuries. None complained of persistent pain or instability of the PTFJ.ConclusionPTFJ dislocation with tibia shaft fracture can easily be overlooked if one is not familiar with this injury. It is important to diagnose and treat this uncommon dislocation anatomically to achieve good results. Otherwise, as the literature shows, it can lead to chronic instability of the proximal fibula with snapping, proximal fibular pain and even peroneal nerve palsy. Furthermore in complex tibial fractures correct length and rotation only can be restored after referencing with the fibula. We recommend a high index of suspicion of this injury with high energy tibia shaft fractures especially in cases with intact fibula.     

Precision of Bone Mineral Density Scans at the Proximal Tibia in Osteoarthritic Subjects

This study was conducted to assess the precision of dual-energy X-ray absorptiometry (DXA) measurements at the proximal tibia and compare it with precision at other skeletal sites. Precision at the proximal tibia was determined in two groups: 14 subjects with knee osteoarthritis (OA) and 14 normal subjects who were scanned bilaterally four times each, with repositioning. Precision of femoral neck, trochanter, and total hip was also determined in both groups. Group mean bone mineral density (BMD), standard deviation (SD), and root mean squared coefficient of variation (%CV) were determined for both tibias and hips, lumbar spine (L2-L4) and total body. The %CV of the proximal tibia ranged from 1.01% to 1.24% and did not differ significantly in the two groups. The %CV of the hips, spine, and total body ranged from 0.79% to 2.28%. We conclude that DXA scans at the proximal tibia are highly reproducible and that precision at the proximal tibia is comparable to that of the hip, spine, and total body. A larger study is needed to determine whether proximal tibia BMD measurements have research or clinical application for osteoarthritis or other conditions.     

游离髌骨移植修复骨巨细胞瘤术后膝关节缺损

目的　探讨游离髌骨移植对股骨下端或胫骨上端骨巨细胞瘤患者膝关节缺损的修复治疗效果。方法　本组共 9例股骨下端或胫骨上端骨巨细胞瘤患者 ,肿瘤侵袭关节软骨造成膝关节缺损 ,采用游离髌骨移植术对膝关节缺损进行修复。结果　患者随访 3～ 12 1个月 ,平均 6 5个月 ,无 1例复发转移 ,膝关节功能经综合评价效果优良 (8/ 9) ;膝关节屈伸活动范围 70°～ 12 0° ,平均 90° ;股四头肌肌力均达到 5级。1例患者术后 9年出现髌骨退行性改变。结论　对侵袭关节软骨的股骨下端或胫骨上端骨巨细胞瘤患者 ,行包括肿瘤在内的髁部大块切除后 ,游离髌骨移植是一种可行的膝关节修复方法。     

Comparison between suprapatellar and parapatellar approaches for intramedullary nailing of the tibia. Cadaveric study

Intramedullary nailing is one viable option for treating fractures of the tibia with a short, proximal segment. For a procedure being carried out with the knee in a semi-extended position, either a suprapatellar or parapatellar approach may be used. The objective of this study is to demonstrate whether the entry point for tibia nails is obtainable through suprapatellar or parapatellar approaches and to evaluate the most frequent injuries of the knee with these two approaches.Materials and methodsPaired legs from 10 fresh frozen cadavers were used. An arthroscopy was performed in each knee, documenting the status of the knee prior to the insertion of the tibia nail. In a random manner, the left or right leg underwent nailing with a suprapatellar or parapatellar approach in a semi-extended position. Fluoroscopy was utilized in each case to localize the entry point, and a tibia nail was inserted in all cases. A knee arthrotomy was then performed and the status of the following structures was assessed: patella and trochlea cartilage, tibia plateau cartilage, inter-meniscal ligament, lateral and medial meniscus, and the ACL.ResultsThe correct fluoroscopy entry point was achieved in all of the specimens (20). Three legs (3/10) with parapatellar approach had intra-articular disruption. In legs with a suprapatellar approach, patellar cartilage and trochlea cartilage damage was found in two of the specimens, respectively. There was one specimen with cartilage damage in the parapatellar approach. There were no meniscal injuries. Partial laceration of the intermeniscal ligament was found in three of the knees for each approach. One ACL injury was found in the suprapatellar group. Mean distance from the entry point to major structures is not significantly different with either approach. (p = 0.45).ConclusionsA good fluoroscopic entry point can be achieved using either the parapatellar or suprapatellar approach. The parapatellar approach for tibia nailing has similar rate of soft tissue damage compared to the suprapatellar approach. The suprapatellar approach damaged the cartilage in one-third of the cases and if cartilage injury occurs with the parapatellar approach, this is located in a low risk area.     

One-Stage Total Knee Arthroplasty With Pre-Existing Fracture Deformity : Post-Fracture Total Knee Arthroplasty

The aim of the study was to assess the results of treating knee osteoarthrosis with total knee arthroplasty (TKA) after previous tibia and/or femur fractures resulting in axial limb deformities. Thirty-six knees (34 patients) were operated on. At the most recent follow-up, 4.8 years after surgery, all but one patient demonstrated an improvement in both clinical and functional KSS. This male patient required revision after 2 years. Improved range of motion was generally noted, especially extension, however, two patients with both tibia and femur fractures had worse results. TKA is an effective method of treatment for patients with arthrosis after a previous femur or tibia fractures. When deformity is severe semi-constrained or constrained, implants with extensions may be necessary.     

后内侧入路胫骨远端后内侧解剖板治疗胫骨下段骨折

目的探讨后内侧入路胫骨远端后内侧解剖板治疗胫骨下段粉碎性骨折的临床疗效。方法采用小腿后内侧入路胫骨远端后内侧解剖型钢板内固定对30例胫骨下段粉碎性骨折患者进行治疗。结果术后随访8—16（12．9±3）个月,伤口均一期愈合,所有病例获得骨性愈合,愈合时间9～17（12±3）周。按Mazur等踝关节功能评分标准：优23例,良5例,可2例。结论胫骨远端后内侧解剖板符合胫骨骨远端后内侧的解剖形态,固定确切可靠,对于胫骨下段粉碎性骨折的治疗是理想的内固定物,伴局部内外侧软组织损伤重或皮肤条件差者尤为适用。     

Assessment of Bone Mineral Density in the Distal Tibia Using Quantitative Hounsfield Samples From Computer Tomography

The distal tibia bone quality is of paramount importance for ankle fractures, total ankle implants, ankle fusions, and osteotomy procedures. Despite this fact relatively little is known regarding the overall bone quality for this section of the tibia. Previous literature suggest that there is a statistically significant decrease in bone mineral density within the distal 5% to 10% segment of the tibia medullary canal. This segment of medullary bone is considerable in size and thus valuable for fixation constructs as it is oftentimes utilized for medial malleolar fractures, distal tibia fractures, total ankle replacements, ankle fusions, and other procedures. This study assessed bone attenuation between the distal 5% and 10% mark of the tibia in 1% slices via Hounsfield unit measurements on CT scans based on previously established correlation between Hounsfield units and bone mineral density found on DEXA scans. One hundred five distal tibia segments were assessed with an average interval in percentile slices of 3.8 mm. As expected there was a gradual decrease in bone attenuation noted with each proximal percentile segment. There exists a statistically significant difference in bone attenuation among males versus females as well as those older than 60 years versus younger than 60 years. The findings suggest fixation constructs in the tibia medullary canal may find limited benefit proximal from 7% segment in females ≥60, or 26.1 mm from tibial plafond. Fixation constructs in tibia medullary canal may find limited benefit proximal from 8% segment in males <60, or 32.3 mm from tibial plafond.     

Role of the fibula in lower leg fractures: An in vivo investigation in rats

Whether or not the fibula should be fixated in combined fractures of the tibia and fibula remains controversial. Several clinical and biomechanical studies have investigated the role of the fibula in lower leg fractures without leading to a common conclusion. We assumed that an intact or stable fibula would provide better healing conditions in lower leg fractures treated with an intramedullary nail. In an in vivo study, 40 male Wistar rats were randomly assigned to two groups. In both groups, the tibia was osteotomized, whereas the fibula was left intact in one group and osteotomized in the other group. The tibia fracture was fixated with an intramedullary nail. After sacrifice of the animals, mineral density, mineral content, and mechanical characteristics of the healing osteotomies were evaluated. We found that a combination of tibia and fibula fracture significantly impaired fracture healing during the early phase after the incident, when treated with an intramedullary nail, suggesting that an intact or stabilized fibula provides additional support and better healing conditions to a tibia fracture. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 26:1027–1031, 2008     

Secondary intramedullary nailing osteosynthesis in primarily conservative treatment of fractures of tibia and fibula shafts (author's transl)

In a retrospective trial 235 patients with fractures of the tibia and/or fibula shafts were followed up. In 16 cases non-union of the fracture occurred after closed reduction and plaster cast treatment. In 16 of these patients closed nailing of the tibia was performed 8--14 weeks after the accident. The healing of the fracture was uncomplicated and occurred in 10--14 weeks p. op. The results in primary nailing cases 8--14 days after the accident were much better than in cases treated with plaster casts, with regard to joint mobility, venous insufficiency and duration of treatment; however two serious complications occurred. In two patients, osteitis occurred after primary nailing of the tibia. Localisation of the fractures (distal part of the tibia) and type of the fracture (short torsion fracture) correlated more frequently with formation of non-union than the rare changes in blood chemistry observed in our study. We regard intramedullary nailing of the tibia as the best available method in treating non-union or pseudarthrosis of the tibia.     

Adamantinoma of the Tibia: Local Resection and Distraction Osteogenesis

We describe a case of adamantinoma of the distal tibia in a 31-year-old woman. Segmental resection of the part of the tibia containing the tumour in normal bone was done and the bone defect was bridged with bone transport and external fixation. The tibia healed uneventfully and one year after the operation the patient resumed full activity. Three years postoperatively no local recurrence or metastasis has occurred.