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 incl-uded 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 sig-nificant 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.

Functional Outcomes of Adult Tibia Shaft Fractures Treated with Solid Intramedullary Nails versus Hollow Nails: A Systematic Review

Introduction: The management of fractures of the tibia shaft is an important aspect of orthopaedic care, and the selection of the surgical method for fixation can substantially impact patient outcomes. The current review aims to compare the outcomes of adult tibia fractures treated with solid nails to those treated with hollow nails. Methods: A search on Scopus, PubMed, and Cochrane Library, using three keywords (Outcome, Tibia shaft fractures, Nail) was conducted in April 2023. Results were compiled and two independent reviewers screened and selected eligible articles After removing duplicates, titles and abstracts were read to exclude ineligible studies. Full-text articles of the remaining papers were read to select eligible studies which were further critically appraised to ascertain their methodological quality. The data extracted from the selected papers were synthesized using a combination of pooling of results, tests of statistical difference (t-test and chi-square) and narrative synthesis methods. Results: A total of 2295 articles were obtained from the databases and citation searching. A total of 9 papers were identified as eligible and included in the review. Findings revealed that there is no statistical difference in the outcomes of tibia fractures treated with either solid or hollow nail groups such as duration of surgery (p = 0.541), rate of delayed and non-union (p = 0.342), and rate of surgical site infections (p = 0.395). Conclusion: Intramedullary nailing of tibia shaft fractures with either solid or hollow nails have similar functional outcomes.

Supranutrition of microalgal docosahexaenoic acid and calcidiol improved growth performance,tissue lipid profiles,and tibia characteristics of broiler chickens

Background Docosahexaenoic acid(DHA)and calcidiol could be enriched in chicken for improving public nutrition and health.It remains unclear if supranutritional levels of DHA and calcidiol impair growth performance or metabolism of broiler chickens.This study was to determine singular and combined effects of high levels of supplemental DHA-rich microalgal biomass or oil and calcidiol on growth performance,concentrations of triglycerides,cholesterol,and nonesterfied fatty acids in plasma,liver,breast,and thigh,and biophysical properties of tibia.Methods In Exp.1,144 day-old Cornish chicks were divided into 4 groups(6 cages/treatment,6 birds/cage),and were fed a corn-soybean meal basal diet(BD),BD+10,000 IU calcidiol/kg(BD+Cal),BD HA),and BD+1%DHA-rich Aurantiochytrium(1.2 g DHA/kg;BD+D+Cal+DHA for 6 weeks.In Exp.2,180 day-old chicks were divided into5 groups,and were fed:BD,BD+DHA(0.33%to 0.66%oil,1.5 to 3.0 g DHA/kg),BD EPA/kg),BD+DHA+EPA(1.9%to 3.8%eicosapentaenoic acid-rich Nannochloropsis sp.CO18,0.3 to 0.6 g BD+DHA+calcidiol(6000 to 12,000 IU/kg diet),and+DHA+EPA+Cal for 6 weeks.Results Birds fed BD+Cal diet in Exp.1 and BD lower(P+DHA<0.05)+EPA diet in Exp.2 had higher(P<0.05)body weight gain(10%-11%)and gain:feed ratio(7%),and total cholesterol and triglyceride concentrations in plasma(18%-54%),liver(8%-26%),breast(19%-26%),and thigh(10%-19%),respectively,over the controls.The two diets also improved(P<0.05)tibial breaking strength(8%-24%),total bone volume(2%-13%),and(or)bone mineral density(3%-19%)of chickens.Conclusion Supranutrition of dietary calcidiol and DHA alone or together did not produce adverse effects,but led to moderate improvements of growth performance,lipid profiles of plasma and muscle,and bone properties of broiler chickens.

Knee locking caused by osteochondroma of the proximal tibia adjacent to the pes anserinus:A case report

BACKGROUND Osteochondroma is one of the most common benign bone tumors,and it may cause bone and joint deformities and limited range of motion of an adjacent joint.The pes anserinus region is one of the most frequent sites of osteochondroma,but knee locking caused by osteochondromas in the pes anserinus region is extremely rare.CASE SUMMARY We describe a 13-year-old Japanese girl’s extra-articular knee locking that occurred when the semitendinosus tendon got caught in osteochondroma that had developed in the pes anserinus region.The osteochondroma was surgically resected.The postoperative outcome has been excellent,with no recurrence of knee locking or tumor one-year post-surgery.CONCLUSION When a young person develops knee locking,the possibility of extra-articular as well as intra-articular locking should be considered.Osteochondroma,one of the causes of extra-articular locking,can be treated with surgery with good postoperative results.

Morphological Differences in Africa Ostrich Chicks Suffering from Tibial Disease

[Objective] This study aimed to investigate the differences in morphological structure of tibias between sick and normal ostrich chicks. [Method] Normal and sick ostrich chicks aged 90 days were used in this research for bone mineral density determination, bone demineralization paraffin section preparation （HE staining）, bone abrasive disc preparation and scanning electron microscopy （SEM） observation, to analyze the differences in microstructure and ultrastructure of tibias between sick ostrich chicks and normal ones. [Result] Bone mineral density of ostrich chicks suffering from leg disease was much lower than that of the normal ones. Compared with normal tibias, less trabeculae were observed in sick tibias, which were attenuated and began to disappear. In addition, trabeculae micro-fracture could be observed under scanning electron microscope; resorption pits on bone slices formed by osteoclast could be observed under scanning electronic microscope. [Conclusion] These results indicate that the sick tibias all have lower bone density and trabeculae microfracture phenomenon in tibias with different diseases, which might be resulted from osteoporosis.

Total knee arthroplasty and fractures of the tibial plateau

Tibial plateau fractures are common injuries that occur in a bimodal age distribution. While there are various treatment options for displaced tibial plateau fractures, the standard of care is open reduction and internal fixation(ORIF). In physiologically young patients with higher demand and better bone quality, ORIF is the preferred method of treating these fractures. However, future total knee arthroplasty(TKA) is a consideration in these patients as post-traumatic osteoarthritis is a common long-term complication of tibial plateau fractures. In older, lower demand patients, ORIF is potentially less favorable for a variety of reasons, namely fixation failure and the need for delayed weight bearing. In some of these patients, TKA can be considered as primary mode of treatment. This paper will review the literature surrounding TKA as both primary treatment and as a salvage measure in patients with fractures of the tibial plateau. The outcomes, complications, techniques and surgical challenges are also discussed.

Nonphytate Phosphorus Requirement and Efficacy of a Genetically Engineered Yeast Phytase for Yellow Broilers at 22- to 42-d-Old Age

An experiment was conducted to investigate the requirement of nonphytate phosphorus（nPP） and efficacy of a genetically engineered yeast phytase（PHY A） for Lingnan yellow broilers from 22-to 42-d-old age.A total of 1 320 1-d-old male chicks were randomly divided into 11 dietary treatment groups,which consisted of 4 replicate floor pens with 30 birds per pen.The control group（treatment 1） was fed with basal diet of nPP 0.08% without dicalcium phosphate or phytase supplementation.Dietary levels of nPP were 0.16,0.24,0.32,0.40,0.48,and 0.56%,respectively,for treatments 2 to 7,through addition of dicalcium phosphate（chemistry grade） to the basal diet.Diets of treatments 8 to 11 were supplemented with PHY A at 200,400 and 600 U kg-1,a commercial phytase product（PHY B） at 400 U kg-1 level,respectively.The birds in 0.32-0.56% nPP groups gained more than those of the other groups（P0.05）.The nPP supplementation significantly improved feed intake（P0.05）.The feed gain ratio was significantly decreased by 0.40% nPP diet compared to the control birds（P0.05）.The level of 0.48% nPP was required for optimum tibia development.The additions of PHY A at 400 and 600 U kg-1 level and PHY B all significantly improved ADG（P0.05）,ADFI（P0.05）,and dry defatted tibia weight（P0.05）.Similarly,the percentage of tibia ash was increased by 600 U kg-1 PHY A supplementation（P0.05）.The requirement of nPP for maximal ADG and highest percentage tibia ash both was 0.40%.The phosphorus equivalency value of PHY A was estimated as 685 U kg-1 for male yellow broilers of 22-to 42-d-old age.

Systematic review of periprosthetic tibia fracture after total knee arthroplasties

AIM: To investigate the known incidences, treatment options, and related outcomes of periprosthetic tibia fractures after total knee arthroplasty(TKA).METHODS: A literature search was done to identify studies that fit the inclusion criteria. The database search yielded 185 results, which were further reduced by the exclusion criteria to 13 papers, totaling 157 patients that met these criteria. Incidence rates of the different types of periprosthetic tibia fractures were determined and their treatments were subsequently analyzed based on the fracture's subclass, with patient outcomes being overall favorable.RESULTS: Of the 144 documented patients, 54(37.5%) had a subclass C fracture, which are frequently seen in revision arthroplasties or when using cement intraoperatively. The fractures of subclasses A and B occur postoperatively. There were 90 subclass A and B fractures with incidences of 18.75% and 43.75% respectively. When broken down by type, 62(55.36%) were type 1, 24(21.4%) were type 2, 24(21.4%) were type 3, and 2(1.8%) were type 4. Furthermore, from the studies that included origin of injury, the types were further classified as having non-traumatic or traumatic origins. Type 1 had 78%(40/51) non-traumatic origin and 22%(11/51) traumatic origin. Fifteen fractures were type 2, but 5 were falls and 1 through a motor vehicle accident, giving a trauma causation of 40%(6/15). Of the 24 type 3 fractures, 12 were falls and 2 vehicular accidents, leading to a trauma causation of 58%(14/24).CONCLUSION: Type 1 fractures were the most common. Subclass A was treated with locking plates, B required a revision TKA, and C was treated intraoperatively or nonoperatively.

Aetiology and mechanisms of injury in medial tibial stress syndrome: Current and future developments

Medial tibial stress syndrome(MTSS) is a debilitating overuse injury of the tibia sustained by individuals whoperform recurrent impact exercise such as athletes and military recruits. Characterised by diffuse tibial anteromedial or posteromedial surface subcutaneous periostitis, in most cases it is also an injury involving underlying cortical bone microtrauma, although it is not clear if the soft tissue or cortical bone reaction occurs first. Nuclear bone scans and magnetic resonance imaging(MRI) can both be used for the diagnosis of MTSS, but the patient's history and clinical symptoms need to be considered in conjunction with the imaging findings for a correct interpretation of the results, as both imaging modalities have demonstrated positive findings in the absence of injury. However, MRI is rapidly becoming the preferred imaging modality for the diagnosis of bone stress injuries. It can also be used for the early diagnosis of MTSS, as the developing periosteal oedema can be identified. Retrospective studies have demonstrated that MTSS patients have lower bone mineral density(BMD) at the injury site than exercising controls, and preliminary data indicates the BMD is lower in MTSS subjects than tibial stress fracture(TSF) subjects. The values of a number of tibial geometric parameters such as cross-sectional area and section modulus are also lower in MTSS subjects than exercising controls, but not as low as the values in TSF subjects. Thus, the balance between BMD and cortical bone geometry may predict an individual's likelihood of developing MTSS. However, prospective longitudinal studies are needed to determine how these factors alter during the development of the injury and to find the detailed structural cause, which is still unknown. Finite element analysis has recently been used to examine the mechanisms involved in tibial stress injuries and offer a promising future tool to understand the mechanisms involved in MTSS. Contemporary accurate diagnosis of either MTSS or a TSF includes a thorough clinical examination to identify signs of bone stress injury and to exclude other pathologies. This should be followed by an MRI study of the whole tibia. The cause of the injury should be established and addressed in order tofacilitate healing and prevent future re-occurrence.

Surface effects on in-shoe plantar pressure and tibial impact during running

Purpose： This study aims to explore the effects of running on different surfaces on the characteristics of in-shoe plantar pressure and tibial acceleration. Methods： Thirteen male recreational runners were required to run at 12 km/h velocity on concrete, synthetic track, natural grass, a normal treadmill, and a treadmill equipped with an ethylene vinyl acetate （EVA） cushioning underlay （treadmill_EVA）, respectively. An in-shoe plantar pressure system and an accelerometer attached to the tibial tuberosity were used to record and analyze the characteristics of plantar pressure and tibial impact during running. Results： The results showed that there were no significant differences in the 1 st and 2nd peak plantar pressures （time of occurrence）, pressure-time integral, and peak pressure distribution for the concrete, synthetic, grass, and normal treadmill surfaces. No significant differences in peak positive acceleration were observed among the five tested surface conditions. Compared to the concrete surface, however, running on treadmillEVA showed a significant decrease in the 1st peak plantar pressure and the pressure time integral for the impact phase （p 〈 0.05）. These can be further ascribed to a reduced peak pressure observed at heel region （p 〈 0.05）. Conclusion： There may not be an inevitable relationship between the surface and the lower-limb impact in runners. It is, however, still noteworthy that the effects of different treadmill surfaces should be considered in the interpretation of plantar pressure performance and translation of such results to overground running.

Customized reconstructive prosthesis design based on topological optimization to treat severe proximal tibia defect

A novel reconstructive prosthesis was designed with topological optimization(TO)and a lattice structure to enhance biomechanical and biological properties in the proximal tibia.The biomechanical performance was validated through finite element analysis(FEA)and biomechanical tests.The tibia with inhomogeneous material properties was reconstructed according to computed tomography images,and different components were designed to simulate the operation.Minimum compliance TO subject to a volume fraction constraint combined with a graded lattice structure was utilized to redesign the prosthesis.FEA was performed to evaluate the mechanical performances of the tibia and implants after optimization,including stress,micromotion,and strain energy.The results were analyzed by paired-samples t tests,and p<0.05 was considered significant.Biomechanical testing was used to verify the tibial stresses.Compared to the original group(OG),the TO group(TOG)exhibited lower stress on the stem,and the maximum von Mises stresses were 87.2 and 53.1 MPa,respectively,a 39.1%reduction(p<0.05).Conversely,the stress and strain energy on the tibia increased in the TOG.The maximum von Mises stress values were 16.4 MPa in the OG and 22.9 MPa in the TOG with a 39.6%increase(p<0.05),and the maximum SED value was 0.026 MPa in the OG and 0.042 MPa in the TOG,corresponding to an increase of 61.5%(p<0.05).The maximum micromotions in the distal end of the stem were 135μm in the OG and 68μm in the TOG,almost a 50%reduction.The stress curves of the biomechanical test coincided well with the FEA results.The TO approach can effectively reduce the whole weight of the prosthesis and improve the biomechanical environment of the tibia.It could also pave the way for next-generation applications in orthopedics surgery.

Ilizarov bone transport combined with the Masquelet technique for bone defects of various etiologies (preliminary results)

BACKGROUND The Ilizarov bone transport(IBT)and the Masquelet induced membrane technique(IMT)have specific merits and shortcomings,but numerous studies have shown their efficacy in the management of extensive long-bone defects of various etiologies,including congenital deficiencies.Combining their strong benefits seems a promising strategy to enhance bone regeneration and reduce the risk of refractures in the management of post-traumatic and congenital defects and nonunion that failed to respond to other treatments.AIM To combine IBT and IMT for the management of severe tibial defects and pseudarthrosis,and present preliminary results of this technological solution.METHODS Seven adults with post-traumatic tibial defects(subgroup A)and nine children(subgroup B)with congenital pseudarthrosis of the tibia(CPT)were treated with the combination of IMT and IBT after the failure of previous treatments.The mean number of previous surgeries was 2.0±0.2 in subgroup A and 3.3±0.7 in subgroup B.Step 1 included Ilizarov frame placement and spacer introduction into the defect to generate the induced membrane which remained in the interfragmental gap after spacer removal.Step 2 was an osteotomy and bone transport of the fragment through the tunnel in the induced membrane,its compression and docking for consolidation without grafting.The outcomes were retrospectively studied after a mean follow-up of 20.8±2.7 mo in subgroup A and 25.3±2.3 mo in subgroup B.RESULTS The“true defect”after resection was 13.3±1.7%in subgroup A and 31.0±3.0%in subgroup B relative to the contralateral limb.Upon completion of treatment,defects were filled by 75.4±10.6%and 34.6±4.2%,respectively.Total duration of external fixation was 397±9.2 and 270.1±16.3 d,including spacer retention time of 42.4±4.5 and 55.8±6.6 d,in subgroups A and B,respectively.Bone infection was not observed.Postoperative complications were several cases of pin-tract infection and regenerate deformity in both subgroups.Ischemic regeneration was observed in two cases of subgroup B.Complications were corrected during the course of treatment.Bone union was achieved in all patients of subgroup A and in seven patients of subgroup B.One non-united CPT case was further treated with the Ilizarov compression method only and achieved union.After a follow-up period of two to three years,refractures occurred in four cases of united CPT.CONCLUSION The combination of IMT and IBT provides good outcomes in post-traumatic tibial defects after previous treatment failure but external fixation is longer due to spacer retention.Refractures may occur in severe CPT.

Experimental and finite element analysis of tibial stress fractures using a rabbit model

AIM: To determine if rabbit models can be used to quantify the mechanical behaviour involved in tibial stress fracture(TSF) development.METHODS: Fresh rabbit tibiae were loaded under compression using a specifically-designed test apparatus. Weights were incrementally added up to a load of 30 kg and the mechanical behaviour of the tibia was analysed using tests for buckling, bone strain and hysteresis. Structural mechanics equations were subsequently employed to verify that the results were within the range of values predicted by theory. A finite element(FE) model was developed using cross-sectional computer tomography(CT) images scanned from one of the rabbit bones, and a static load of 6 kg(1.5 times the rabbit's body weight) was applied to represent running. The model was validated using the experimental strain gauge data, then geometric and elemental convergence tests were performed in order to find the minimum number of cross-sectional scans and elements respectively required for convergence. The analysis was then performed using both the model and the experimental results to investigate the mechanical behaviour of the rabbit tibia under compressive load and to examine crack initiation.RESULTS: The experimental tests showed that un der a compressive load of up to 12 kg, the rabbit tibia demonstrates linear behaviour with little hysteresis Up to 30 kg, the bone does not fail by elastic buckling however, there are low levels of tensile stress which predominately occur at and adjacent to the anterio border of the tibial midshaft: this suggests that fatigue failure occurs in these regions, since bone under cycli loading initially fails in tension. The FE model predic tions were consistent with both mechanics theory and the strain gauge results. The model was highly sensi tive to small changes in the position of the applied load due to the high slenderness ratio of the rabbit s tibia. The modelling technique used in the curren study could have applications in the development o human FE models of bone, where, unlike rabbit tibia the model would be relatively insensitive to very sma changes in load position. However, the rabbit mode itself is less beneficial as a tool to understand the me chanical behaviour of TSFs in humans due to the sma size of the rabbit bone and the limitations of human scale CT scanning equipment.CONCLUSION: The current modelling technique could be used to develop human FE models. However, the rabbit model itself has significant limitations in under standing human TSF mechanics.

THE MORPHOLOGICAL MEASURE OF THE TIBIAL MEDULLARY CAVITY AND ITS SIGNIFICANCE

Objective To provide morphological reference for the designing of the intramedullary nail fixation which suitable for Chinese by investigating the morphological characteristics of tibial medullary cavity. Methods The morphological parameters of the 113 normal adult tibiale were measured on the X-ray photographs with the image analysis software. Results The total lengths of tibial medullary cavities were 299.49±11.03 mm(male) and 274.60± 6.77 mm(female), and the lengths of the narrow part were 66.36±3.90 mm(male) and 51.57±3.92mm(female). The end-points of narrow part were about 29.9 mm(male) and 26.09 mm(female)below the midpoints of medullary cavities. The radians of the longitudinal axes of medullary cavities were 2.53±1.27°(male) and 2.57±1.16°(female). The proximal opening K were 9.47±2.71(male) and 8.59±2.46(female). The distal opening K were 8.21± 2.93(male)and 7.65±2.87(female). Conclusion The morphology of tibial medullary cavity, the characteristic variety of radian and the opening K were very important references for designing the Chinese intramedullary nail fixation.

Surgical treatment for a combined anterior cruciate ligament and posterior cruciate ligament avulsion fracture: A case report

BACKGROUND Independent avulsion fractures with anterior cruciate ligament(ACL)or posterior cruciate ligament(PCL)attachment are relatively common among tibial intercondylar eminence fractures,and their postoperative outcomes are generally favorable.Conversely,huge avulsion fractures of the intercondylar eminence containing the attachment site of both the ACL and the PCL are extremely rare,and the reported clinical outcomes are poor.CASE SUMMARY We describe a 30-year-old Japanese male's huge avulsion fracture of the intercondylar eminence of a tibia containing the attachment site of both the ACL and PCL,together with a complete tear of the medial collateral ligament and a partial tear of both the medial and lateral menisci caused by a fall from a high place.All of these injuries were treated surgically,with anatomical reduction and stable fixation.The limb function at 1 year post-surgery was excellent(Lysholm score:100 points).CONCLUSION Although this patient's complete surgical repair was complex,it should be performed in similar cases for an excellent final clinical outcome.

Computer‑aided CT image processing and modeling method for tibia microstructure

We present a method for computed tomography(CT)image processing and modeling for tibia microstructure,achieved by using computer graphics and fractal theory.Given the large-scale image data of tibia species with DICOM standard for clinical applications,we take advantage of algorithms such as image binarization,hot pixel removing and close operation to obtain visually clear image for tibia microstructure.All of these images are based on 20 CT scanning images with 30μm slice thickness and 30μm interval and continuous changes in pores.For each pore,we determine its profile by using an improved algorithm for edge detection.Then,to calculate its three-dimensional fractal dimension,we measure the circumference perimeter and area of the pores of bone microstructure using a line fitting method based on the least squares.Subsequently,we put forward an algorithm for the pore profiles through ellipse fitting.The results show that the pores have significant fractal characteristics because of the good linear correlation between the perimeter and the area parameters in log–log scale coordinates system,and the ratio of the elliptical short axis to the long axis through ellipse fitting tends to 0.6501.Based on support vector machine and structural risk minimization principle,we put forward a mapping database theory of structure parameters among the pores of CT images and fractal dimension,Poisson’s ratios,porosity and equivalent aperture.On this basis,we put forward a new concept for 3D modeling called precision-measuring digital expressing to reconstruct tibia microstructure for human hard tissue.

Ipsilateral femur and tibia fractures in pediatric patients:A systematic review

AIM To better understand how pediatric floating knee injuries are managed after the wide spread use of new orthopaedic technology.METHODS We searched EMBASE, COCHRANE and MEDLINE computerized literature databases from the earliest date available in the databases to February 2017 using the following search term including variants and pleural counterparts: Pediatric floating knee. All studies were thoroughly reviewed by multiple authors. Reference lists from all articles were scrutinized to identify any additional studies of interest. A final database of individual patients was assembled from the literature. Univariate and multivariate statistical tests were applied to the assembled database to assess differences in outcomes.RESULTS The English language literature contains series with a total of 97 pediatric patients who sustained floating knee injuries. Patients averaged 9.3 years of age and were mostly male(73). Approximately 25% of the fractures were open injuries, more tibia(27) than femur(10). Over 75% of the fractures of both the tibia and the femur involved the diaphysis. More than half(52) of the patients were treated non-operatively for both fractures. As a sequela of the injury 32(33%) patients were left with a limb length discrepancy, 24(25%) patients had lengthening of the injured limb at follow up, while 8(8%) had shortening of the affected limb. Infection developed in 9 patients and 3 had premature physeal closure. Younger patients were more likely to be treated non-operatively(P < 0.001) and patients treated with operative intervention had statistically significant shorter hospital length of stays(P = 0.001).CONCLUSION Given the predominance of non-operative managementin published studies, the available literature is not clinically relevant since the popularization of internal fixation for pediatric long-bone

BIOMECHANICAL STUDY ON UNILATERAL SINGLE-PLANE EXTERNAL FIXER

Six tibias removed from 30-40 years old males, who died in an accident for in less than 12 hours, were osteotomized at one-third supra-medium segment. They were fixed by an unilateral adjustable external fixer (UAEF), to be used as a model of external fixation of tibial fracture (MEFTF). The compression. tension, torsion, antero-posterior and lateral bending strength, and the strength for vertically extracting the pins from the tibia were determined in the MEFTF. Within a certain range of load, the correlation of strain to stress was basically a linear relationship. These data provide a theoretical basis of biomechanics for the improvement of UAEF and for early exercises of fracture patients, such as extend-bending of the joint.raising the limb and walking with a walking stick.

Comparative efficacy of ketamine,lidocaine,acetaminophen,and dexmedetomidine combined with morphine patient-controlled analgesia in treating opium-addicted patients undergoing tibia fracture surgery:A randomized clinical trial

Objective:To compare the effect of ketamine,lidocaine,acetaminophen,and dexmedetomidine combined with morphine patient-controlled analgesia for opium addicts after tibial fracture surgery.Methods:This double-blind clinical trial included opium-addicted patients undergoing tibia fracture surgery.Patients were recruited and randomized to four different groups including the ketamine group,the lidocaine group,the acetaminophen group,and the dexmedetomidine group.The hemodynamic parameters such as heart rate(HR),mean arterial pressure,and arterial SaO2,alongside visual analog scale pain scores,sedation assessed by Ramsay score,nausea and vomiting,and opioid use were recorded and compared among the four groups.Results:This study included 140 patients,aged 37(32,41)years,with 92 males and 48 females,and each group had 35 patients.Dexmedetomidine-sedated subjects had the lowest blood pressure from 1 to 24 h after surgery,decreased HR at 12 and 24 h after surgery,and more satisfactory sedation(P<0.05).Notwithstanding no significant difference was noted in the pain scores,or nausea and vomiting among the groups(P>0.05).Conclusions:Dexmedetomidine has a better sedation effect compared to ketamine,lidocaine,and acetaminophen for pain control,but the final choice hinges on the patients’physical condition and the anesthesiologist's preference.Clinical registration:It is registered in Iranian Registry Clinical Trial by code IRCT20141209020258N146.