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.

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.

Locking plates for distal fibula fractures in young and elderly patients:A retrospective study

BACKGROUND Ankle fractures are common injuries in the young and elderly populations.To prevent post-traumatic arthritis,an anatomic reconstruction of the ankle structure is mandatory.Open reduction and internal fixation is the treatment of choice among orthopaedics.Conventional plates allow stability of the fracture if bone quality is present.Locking plates might offer an advantage for the treatment of lateral malleolar fracture in patients with comminution,severe instability,distal fractures,or osteoporotic bone.Our hospital introduced a new locking plate for fracture of the distal fibula.AIM To evaluate locking plates in terms of outcomes and complications in young and elderly patients.METHODS We retrospectively reviewed a total of 67 patients treated for displaced distal fibula fractures.Demographic data,number of comorbidities,use of inter fragmentary screw,complication,time of fracture healing,partial or full weight bearing,and reoperation were recorded for all patients.Clinical outcome was assessed by the American Orthopedic Foot and Ankle Society clinical scoring system.Radiographs were obtained at 4,8,12,16,20,and 24 wk until radiographic union was obtained.RESULTS All patients displayed complete bony union on radiographic assessment,and no patients developed any serious complications.We observed two superficial infections,one delayed wound healing,and two plate intolerances.Significant differences were observed between the two age groups in terms of radiographic healing(11.9 wk in younger patients vs 13.7 wk in older patients;P=0.011)and in the American Orthopedic Foot and Ankle Society score at 6 mo after surgery(88.2 in younger patients vs 86.0 in older patients;P=0.001)and at 12 mo after surgery(92.6 in younger patients vs 90.0 in older patients;P=0.000).CONCLUSION Locking plates provide a stable and rigid fixation in multifragmentary and comminuted fractures or in the presence of poor bone quality.

Treatment of Children’s Shaft Fracture of Tibia and Fibula with ESIN Fixation

The Objective is to evaluate Elastic Stable Intrame-dullary Nailing (ESIN) fixation through the treat-ment of children’s shaft fracture of tibia and fibula. From January 2007 to January 2009, 16 cases of children’s shaft fracture of tibia and fibula had been treated by ESIN. 15 cases were followed up after the surgery and the follow-up time was 4 - 12 months (4.5 in average). The results turn out that all the patients’ fractures have got healed by Phase I and the healing time is 10 weeks in average. The near joints’ activity and affected extremity completely return to normal. This group of cases doesn’t show any sign of infection, bone nonunion, malunion or epiphysis injury. And six patients have had their intramedullary nails taken out after six months. It can be concluded that ESIN is good for treating children’s long diaphysis fracture which has difficulty in closed diaplasis and is suitable for children aged 6 - 13. ESIN has the advantages of small incision, slight injury of soft tissue, short sur-gery time, rapid recovery and few complications.

Relationship between serum adhesion molecules, trace elements and delayed union of tibial and fibula fractures

Objective:To investigate the relationship between serum adhesion molecules, trace elements and delayed union of tibial and fibula fractures.Methods:A total of 46 patients with delayed union of tibial and fibula fractures in our hospital from May 2014 to June 2016 were selected as the observation group, 46 patients with normal healing of tibial and fibula fractures were selected as the control group, then the serum adhesion molecules and trace elements levels of two groups at forth, eighth and sixteenth week after the surgery were compared.Results:The serum dhesion molecules levels of observation group at forth, eighth and sixteenth week after the surgery were all higher than those of control group, the serum trace elements levels were all lower than those of control group, and the serum adhesion molecules levels of two groups at eighth week after the surgery were all higher than those at other time, the trace elements levels were all lower than those at other time (allP<0.05).Conclusions:The serum adhesion molecules and trace elements of patients with delayed union of tibial and fibula fractures show obviously abnormal state, so those indexes of those patients should be paid to more monitoring and improvement.

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.

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.

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.

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

Fibula fractures management

Isolated distal fibula fractures represent the majority of ankle fractures.These fractures are often the result of a low-energy trauma with external rotation and supination mechanism.Diagnosis is based on clinical signs and radiographic exam.Stress X-rays have a role in detecting associated mortise instability.Management depends on fracture type,displacement and associated ankle instability.For simple,minimally displaced fractures without ankle instability,conservative treatment leads to excellent results.Conservative treatment must also be considered in overaged unhealthy patients,even in unstable fractures.Surgical treatment is indicated when fracture or ankle instability are present,with several techniques described.Outcome is excellent in most cases.Complications regarding wound healing are frequent,especially with plate fixation,whereas other complications are uncommon.

Numerical Stress Analysis of the Plates Used to Treat the Tibia Bone Fracture

Tibial fractures are one of the most frequent bone fractures caused by accidents or falls because of the tibia’s slender shape. In the tibial fractures close to the joint surface, a plate and screws may be the ideal method of fixation. While using the plate and the screws the estimation of the stress on the plate and screw gains importance before beginning the treatment. In this study, it is aimed to conduct a numerical simulation which uses finite element methodology, to estimate the von Mises stress subjected to the plate and screw which is used in tibia fracture treatment. A titanium plate and 4 screws on it are used for treatment of the fracture. The fracture angle varies as 0&deg;, 15&deg;, 30&deg;, and 45&deg;. The compressive force affected on the plate is estimated to be 750 N. Moreover, the bone is simulated 3D, by using commercial software, ANSYS Structural.

Open Fracture Tibia Treated by Unreamed Interlocking Nail. Long Experience in El-Bakry General Hospital

Background: Internal splintage of open tibial fractures had gained acceptance as a preferred method of early stabilization of such injuries. Patients and Methods: Fifty-five patients had been operated upon. They were followed from July 2008 to March 2013 (56 months) with an average time of 39 months. The final results had been evaluated through a scheme including 7 parameters: pain, union, malunion, infection, range motions of nearby joints, implant and technical failure and activity and returning to the same work. Results: According to previous parameters, union was achieved in 52 cases (94.5%) at an average time of 20 weeks (16 - 52 weeks) with 5.5% incidence of nonunion. Excellent and good ranges of knee and ankle motions were achieved at final follow-up visit in 49 cases (89.09%). The incidence of complication was acceptable mainly malunion 7.3%, deep infection 12.7%, implant and technical failure 9.1% full activity and returning to the same work achieved in 89.1%. The overall net results of our series are as follows: excellent—19 cases (34.5%), good—27 cases (49.1%), fair—6 cases (10.9%) and poor—3 cases (5.5%). Conclusion: Utilizing unreamed interlocking nail for open tibial fractures is a good method of treatment particularly those of grade (II), and (IIIA).

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.

Strategies and outcomes in severe open tibial shaft fractures at a major trauma center: A large retrospective case-series

BACKGROUND Severe open tibia fractures are challenging to treat with a lack of published clear management strategies.Our aim was to provide an overview of the largest singlecenter experience in the literature,with minimum 1-year follow-up,of adult type 3 open tibial shaft fractures at Cambridge University Hospitals(a United Kingdom major trauma center).We sought to define patient characteristics and our main outcome measures were infection,union and re-fracture.AIM To retrospectively define patient and injury characteristics,present our surgical methods and analyze our outcomes–namely infection,union and re-fracture rates.METHODS Consecutive series of 74 patients with 75 open tibial fractures treated between 2014 and 2020(26 classified as Gustilo-Anderson 3A,47 were 3B and two were 3C).Nine patients underwent intramedullary nailing(IMN),61 underwent Taylor spatial frame(TSF)fixation and 5 were treated with Masquelet technique(IMN and subsequent bone grafting).RESULTS Mean follow-up was 16 mo(IMN)and 25 mo(TSF).We had an infection rate of 6.7%(5),non-union rate of 4%(3)and re-fracture rate of 2.7%(2).Average time to union was 22 wk for IMN and 38.6 wk for TSF.Thirty-three cases had a bone defect with a mean of 5.4 cm(2-11).Patient age,sex,diabetes,smoking status or injury severity did not have a significant effect on union time with either fixation method.Our limb salvage rate was 98.7%.CONCLUSION Grade 1 to 3A injuries can effectively be treated with reamed or unreamed IMN.Grade 3B/C injuries are best treated by circular external fixators as they provide good,reproducible outcomes and allow large bone defects to be addressed via distraction osteogenesis.

Ankle Arthrodesis Nail Combined with Locking Compression Plate to Stabilize Two-Level Pathologic Tibial Fractures

Treatment of fragility fractures of the distal tibia in the elderly is demanding because of osteopenic bone quality, the delicate soft tissue cuff and frequent critical circulation. We report the case of two-level tibial pseudarthroses in an 83- year-old woman caused by multiple myeloma successfully stabilized by a long ankle arthrodesis nail combined with locking compression plate osteosynthesis. This case is unique, as to our best knowledge, herein diaphyseal fractures were treated for the first time using a technique reported hitherto primarily for fragility ankle and pilon fractures.

Distal Tibial Stress Fracture Secondary to Severe Osteoarthritis Knee

Stress fractures of the tibia are commonly seen in young athletes or military recruits due to repetitive micro trauma. These are rare in elderly patients. Osteoarthritis knee with varus deformity leading to stress fracture is rare but has been reported in literature. Stress fracture in osteoarthritis more commonly occurs in upper third tibia. We report a patient who had stress fractures of distal tibial shaft secondary to advanced osteoarthritis of knee with varus deformity.

Osteosynthesis Results of Tibia Plateau Fractures at the Yalgado Ouedraogo University Hospital Center

The sophistication of the implants allows the extension of the surgical indications for tibia plateau fractures. These fractures, which are often comminuted, are caused by a high velocity trauma, making treatment difficult. Objective: The aim of this study was to determine the indications for osteosynthesis of tibia plateau fractures in the orthopaedic-traumatology department of the Yalgado Ouédraogo University Hospital, in order to evaluate the results for their better management. Patients and Methods: it was a 5-year retrospective study of the records of patients with tibia plateau fracture operated and hospitalized in our department. The anatomical-clinical and therapeutic aspects collected from the complete files were analysed. A cortico-cancellous graft was performed in 67.4% of cases. The results were evaluated according to the criteria of Merle d’Aubigné and Mazas [1]. Road traffic accidents (97.4%) were the predominant etiology, involving mainly motorcycles (97.8%). Results: Spino-tuberository and uni-tuberository fractures were the most common. The average consolidation time was 12.5 weeks. One urinary infection, 3 superficial suppurations, 3 vicious calluses and 2 equipment dismantlings were the main complications. Our results were excellent and good in 91.3% and fair in 6.5%. Osteosynthesis of tibial plateau fractures provides excellent results and remains the most appropriate procedure to treat these fractures. Conclusion: reduce the operating time, modernize the technical platform, will allow stable osteosynthesis and early functional rehabilitation to optimize their results.

Stress Fracture of Bilateral Distal Tibia Provoked by Stair Climbing

Background: Stress fractures are fatigue-induced, very small cracks in the bone caused by repetitive application of force and most often seen in the weight-bearing bones of the lower extremities of athletes or military recruits. Case Report: A 47-year-old postmenopausal and heavy smoker woman complained of localized sensitivity on the distal-anterior and medial surfaces of both tibiae, which had been ongoing for 1 month. She moved to a flat at 5th-floor without an elevator a year ago. Bilateral stress fractures were diagnosed by radiographs and confirmed by Magnetic Resonance Imaging (MRI). She was suggested to restrict activities and to use crutches until the symptoms subsided. Bilateral ankle joint pneumatic brace with full heel support was applied. The patient was followed one year after diagnosis. At the 2-month follow-up examination, the patient was pain free and planning to move to a new house. Conclusions: Several risk factors have been defined in the pathogenesis of stress fracture. In the present case, the acute phase had passed and diagnosis could be made from the direct radiographs. Although extremely rarely seen, tibia distal stress fracture should be kept in mind in the differential diagnosis of patients with the relevant risk factors who present with tibia distal localized pain.

Correlative Factors Research of Tibial Shaft Fracture with Ipsilateral Posterior Malleolar Crack Fractures

Background:Missed diagnosis rate of spiral tibia shaft fracture with posterior malleolus crack fracture(PMCF)is high in the clinical.However,the mechanism and related factors of fracture are still unclear.Moreover,PMCF has been observed in other types of tibial shaft fractures.Objective:To explore the correlative factors of tibial shaft fracture with ipsilateral PMCF,decrease the rate of clinical missed diagnosis,strengthen the effective fixation of PMCF,and reduce the incidence of traumatic arthritis.Methods:From September 2014 to May 2019,we collected 137 tibiofibular fracture.Only 68 cases involved in ankle joint CT examination and were retrospectively analyzed.The patients were divided into posterior malleolus group(30 cases)and non-posterior malleolus group(38 cases)according to whether come up PMCF or not.The posterior malleolus group contained 24 males and 6 females,27-77(47.57±11.79)years old,the non-posterior malleolus group contained 23 males and 15 females,18-85(48.71±13.84)years old.The gender,age,location,fibula fracture and tibial shaft fracture classification were observed for univariate and multivariate analysis.Results:The probability of PMCF was higher with right tibial shaft fracture(OR=3.6995%CI:1.13-12.08 P<0.05);the probability of PMCF following distal fibular fracture was higher than that without fibular fracture(OR=11.3695%CI:1.72-75.05 P<0.05);the probability of PMCF with type A tibial shaft fracture was higher than type C(OR=4.8295%CI:1.19-19.58 P<0.05).Conclusion:Right type A tibial shaft fracture accompanied by distal fibular fracture are very important factors related to PMCF,which needs highly attention to avoid clinical missed diagnosis.