Abstract This prospective study was undertaken at a regional tertiary referral centre to evaluate the results of treatment of bone defects managed with the induced membrane (IM) technique. Inclusion ...criteria were patients with bone defects secondary to septic non-union, chronic osteomyelitis and acute fracture with bone loss. Pathological fractures with bone loss were excluded. Data collection included patient demographics, pathology, previous surgical intervention, size of bone defect, type of graft implanted, time-to-union and complications/reinterventions. The minimum time of follow up was 12 months. Forty-three patients (32 males) met the inclusion criteria with a mean age of 47.9 years (range 18–80 years). 22 patients had an acute traumatic bone loss associated with open fracture and 21 presented with an infected non-union or underlying osteomyelitis requiring bone excision. The most common microorganisms grown were staphylcoccous aureus and coagulase negative staphylococcous. The mean length of the bone defect area was 4.2 cm (range 2–12 cm). All patients were managed with the two stage technique receiving composited grafting (Autologous bone graft (Iliac crest/RIA), graft expander as required, osteoprogenitor cells, growth factor) during the second stage. There was one failure (humeral infected non-union) in a previous background of bone radiation that necessitated reconstruction with a free fibula vascularized graft. One patient had a fall and sustained implant failure (humeral defect) 3 months after reconstruction and following re-plating progressed to union 4 months later. Two patients required re-grafting due to failure of healing in one of the defect sides. One patient presented with a discharging sinus 2 years after successful healing of a tibial defect that was treated successfully with soft tissue and bone debridement without necessitating further interventions. One patient despite union (distal 1/3 tibia) underwent a below knee amputation due to a dysfunctional ankle/foot (previous foot compartment syndrome-regional pain syndrome). Of those patients, with lower limb injuries, 4 patients had leg length discrepancies of 1 cm, 1.5 cm, 2 cm (two patients) respectively. The mean time to radiological union was 5.4 months (range 2–12 months). The average time of healing of 1 cm bone defect was 1.24 months. Patients with upper limb reconstruction recovered earlier than those with lower limb injuries. At the latest follow up all patients were able to mobilize full weight bearing without residual pain. The induced membrane technique appears to be an alternative good option for the management of large bone defects secondary to acute bone loss or infected non-unions. The incidence of re-interventions was low in this challenging cohort of patients. The technique should be considered in the surgeon's armamentarium as it is effective and is associated with a low rate of complications.
To examine the psychological impact of external fixation for a tibial bone defect due to osteomyelitis, and to compare the Orthofix limb reconstruction system (LRS) with the Ilizarov external ...fixator.
The SCL-90-R questionnaire was administered at four different time points (before surgery, while patients wore the external fixation device, when the device was removed, and two to three months after). The scores at the four time points were compared, as were the two different methods of external fixation (Orthofix LRS vs. Ilizarov).
The patients experienced a significant adverse impact on their mental health, with the worst outcomes at Time 2 (while wearing the external fixator), but with some negative effects still present even several months after removal of the fixation device. Although the Orthofix LRS and Ilizarov groups showed similar mental health scores at Time 1 (preoperatively) and Time 3 (upon removal of the fixation device), the Orthofix LRS was associated with better scores, specifically in the Hostility (Time 2), Phobic Anxiety (Time 2), Psychoticism (Times 2 and 4), and Other (Time 2) sub-scores, as well as the total score (Times 2 and 4).
Although both Ilizarov and Orthofix LRS fixation resolved the bone defects, external fixation had a negative impact on the patients’ mental health, which persisted even after removal of the devices. Although both methods led to negative effects on the patients’ mental, the impact of the Orthofix LRS was less severe.
Open wedge high tibial osteotomy (OWHTO) for medial-compartment osteoarthritis of the knee can be complicated by intra-operative lateral hinge fracture (LHF). We aimed to establish the relationship ...between hinge position and fracture types, and suggest an appropriate hinge position to reduce the risk of this complication.
Consecutive patients undergoing OWHTO were evaluated on coronal multiplanar reconstruction CT images. Hinge positions were divided into five zones in our new classification, by their relationship to the proximal tibiofibular joint (PTFJ). Fractures were classified into types I, II, and III according to the Takeuchi classification.
Among 111 patients undergoing OWHTOs, 22 sustained lateral hinge fractures. Of the 89 patients without fractures, 70 had hinges in the zone within the PTFJ and lateral to the medial margin of the PTFJ (zone WL), just above the PTFJ. Among the five zones, the relative risk of unstable fracture was significantly lower in zone WL (relative risk 0.24, confidence interval 0.17 to 0.34).
Zone WL appears to offer the safest position for the placement of the osteotomy hinge when trying to avoid a fracture at the osteotomy site. Cite this article:
2017;99B10:1313-18.
Abstract Introduction One of the most challenging complications in musculoskeletal trauma surgery is the development of infection after fracture fixation (IAFF). It can delay healing, lead to ...permanent functional loss, or even amputation of the affected limb. The main goal of this study was to investigate the total healthcare costs and length-of-stay (LOS) related to the surgical treatment of tibia fractures and furthermore identify the subset of clinical variables driving these costs within the Belgian healthcare system. The hypothesis was that deep infection would be the most important driver for total healthcare costs. Patients and methods Overall, 358 patients treated operatively for AO/OTA type 41, 42, and 43 tibia fractures between January 1, 2009 and January 1, 2014 were included in this study. A total of 26 clinical and process variables were defined. Calculated costs were limited to hospital care covered by the Belgian healthcare financing system. The five main cost categories studied were: honoraria, materials, hospitalization, day care admission, and pharmaceuticals. Results Multivariate analysis showed that deep infection was the most significant characteristic driving total healthcare costs and LOS related to the surgical treatment of tibia fractures. Furthermore, this complication resulted in the highest overall increase in total healthcare costs and LOS. Treatment costs were approximately 6.5-times higher compared to uninfected patients. Conclusion This study shows the enormous hospital-related healthcare costs associated with IAFF of the tibia. Treatment costs for patients with deep infection are higher than previously mentioned in the literature. Therefore, future research should focus more on prevention rather than treatment strategies, not only to reduce patient morbidity but also to reduce the socio-economic impact.
Infection is common following high-energy open tibial fractures. Understanding the wound bioburden may be critical to infection risk reduction strategies. This study was designed to identify the ...bioburden profile of high-energy open tibial fractures at the time of definitive wound closure or coverage and determine the relationship to subsequent deep infection.
This multicenter prospective study enrolled 646 patients with high-energy open tibial fractures requiring a second debridement surgery and delayed wound closure or coverage. Wound samples were obtained at the time of definitive closure or coverage and were cultured in a central laboratory. Cultures were also subsequently obtained from patients who underwent a fracture-site reoperation.
Two hundred and six (32%) of the wounds had a positive culture at the time of closure or coverage. A single genus was identified in 154 (75%) of these positive cultures and multiple genera, in 52 (25%). Gram-positive cocci (GPCs) were identified in 98 (47%) of the positive cultures. Staphylococci were identified in 64 (31%) of the cultures, and 53 (83%) of these were coagulase-negative (CONS). Enterococci were identified in 26 (13%) of the cultures. Gram-negative rods (GNRs) were identified in 100 (49%) of the cultures; the most frequent GNR genera identified were Enterobacter (39, 19%) and Pseudomonas (21, 10%). Positive cultures were subsequently obtained from 154 (50%) of 310 revision surgeries. A single genus was identified in 85 (55%) of the 154 and multiple genera, in 69. GPCs were identified in 134 (87%) of the 154 positive cultures, staphylococci were identified in 94 (61%), and GNRs were identified in 100 (65%).
The bioburden in high-energy open tibial fractures at delayed closure or coverage was often characterized by pathogens of multiple genera and of genera that are nonresponsive to typically employed antibiotic prophylaxis. Awareness of the final wound bioburden might inform strategies to lower the infection rate.
Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.
Because adolescent distal third tibia fractures pose treatment challenges, we aimed to identify factors predictive of failure among common treatment methods: casting without manipulation, closed ...reduction and casting (CRC) and open treatment. Among displaced fractures, we compared outcomes between CRC versus open treatment. Skeletally immature individuals (10-17 years) with extra-articular distal third tibia fractures at a level 1 trauma center (2011-2017) were retrospectively reviewed. Patient demographics, injury and treatment characteristics and complications were recorded. Radiographs were evaluated for unacceptable alignment (angulation >5°, translation >50%, and shortening >1 cm) and time to union. Of 140 individuals, casting was the most common treatment method (n = 81), followed by CRC under anesthesia/sedation (n = 38), and open treatment (n = 34). For fractures casted without manipulation, increased fracture severity based upon our novel grading system hazard ratio (HR): 10.5, 95% CI, 4.2-27.5, P < 0.0001 was significantly related to treatment failure. Outcomes for a selected group of 47 initially displaced fractures (33 CRC and 14 open treatments) were evaluated. For CRC, 9 (27.3%) healed with malunion and 6 (18.2%) failed initial CRC, resulting in a treatment failure rate of 36.7%. For open treatment, 2 (14.3%) underwent hardware removal, 2 (14.3%) healed with malunion and one developed infection requiring reoperation. No fractures healed with malunion required surgical correction during the study period. The odds of persistent malalignment in CRC was 3.77 95% CI, 0.44-32.60, P = 0.2274 times open treatment. Adolescent minimally displaced distal tibial fractures can undergo successful treatment with casting. However, displaced fractures have a higher chance of short-term failure with CRC. Close monitoring of displaced fractures in the adolescent is essential during conservative management.
Approach to Tibial Shaft Nonunions: Diagnosis and Management Wellings, Elizabeth P; Moran, Steven L; Tande, Aaron J ...
Journal of the American Academy of Orthopaedic Surgeons,
2024-Mar-15, 2024-03-15, 20240315, Letnik:
32, Številka:
6
Journal Article
Recenzirano
The tibia is the most common long bone at risk for nonunion with an annual incidence ranging from 12% to 19%. This topic continues to be an area of research as management techniques constantly ...evolve. A foundational knowledge of the fundamental concepts, etiology, and risk factors for nonunions is crucial for success. Treatment of tibial shaft nonunions often requires a multidisciplinary effort. This article provides guidance based on the most recent literature that can be used to aid the treating provider in the diagnosis, workup, and management of tibial shaft nonunions.
Although epidemiologic studies of tibial plateau fractures have been conducted, none have included geographically defined populations or a validated fracture classification based on computed ...tomography (CT). The goals of this study were to provide up-to-date information on the incidence and basic epidemiology of tibial plateau fractures in a large unselected patient population and to report the mechanisms of injury involved and the distribution of fractures according to a validated CT-based fracture classification. The authors conducted a population-based epidemiologic study of all patients treated for tibial plateau fracture over a 6-year period from 2005 to 2010. The study was based on an average background population of 576,364 citizens. A retrospective review of hospital records was performed. During this time, a total of 355 patients were treated for tibial plateau fracture. This group included 166 men and 189 women, and mean age was 52.6 years (SD, 18.3). The most common fracture type was AO type 41-B3, representing 35% of all tibial plateau fractures. The second most common fracture type was AO type 41-C3, representing 17% of all tibial plateau fractures. The incidence of tibial plateau fractures was 10.3 per 100,000 annually. Compared with women, men younger than 50 years had a higher incidence of fractures. The incidence of fractures increased markedly in women older than 50 years but decreased in men older than 50 years. In both sexes, the highest frequency was between the ages of 40 and 60 years.
Background Computed tomography (CT) is seen as a useful diagnostic modality in preoperative planning for tibial plateau fractures. The purpose of this study was to characterize patterns of tibial ...plateau fractures with use of CT mapping. We hypothesized that CT mapping of fractures of the tibial plateau would reveal recurrent patterns of fragments and fracture lines, including patterns that do not fit into Schatzker’s original classification. Methods One hundred and twenty-seven tibial plateau fractures were retrospectively included in this study. Fracture lines and zones of comminution were graphically superimposed onto an axial template of an intact subarticular tibial plateau to identify major patterns of fracture and comminution. This fracture map of the tibial plateau was subsequently divided into lateral (Schatzker types I, II, and III), medial (Schatzker type IV), and bicondylar (Schatzker types V and VI) fracture maps. Results This study included seventy-three female and fifty-four male patients (average age, forty-seven years range, seventeen to ninety-one years) with a tibial plateau fracture. Sixty-four of the fractures were Schatzker type I, II, or III; fifteen were Schatzker type IV; and forty-eight were Schatzker type V or VI. Analysis of the fracture maps suggested patterns in the Schatzker type-IV, V, and VI fractures beyond those described in Schatzker’s original classification. The maps of the 127 fractures revealed four recurrent major fracture features: the lateral split fragment (A), found in 75%; the posteromedial fragment (B), seen in 43%; the tibial tubercle fragment (C), seen in 16%; and a zone of comminution that included the tibial spine and frequently extended to the lateral condyle (D), seen in 28%. Conclusions Tibial plateau fracture maps show recurrent patterns of fracture lines, revealing four major fracture characteristics. An understanding of these recurrent features of tibial plateau fractures can aid surgeons during diagnosis, preoperative planning, and execution of surgical strategies.
The objective of this study was to examine the morphologic features of spiral tibial shaft as well as concomitant fibular and peri-ankle fractures on multidetector high-resolution CT and to speculate ...about the mechanisms underlying these combined fractures.This is a retrospective cohort study. A total of 197 tibial shaft fractures underwent multidetector high-resolution CT before intramedullary nailing. The presence and location of peri-ankle fractures were recorded using thin-slice axial CT. Tibial shaft fractures were classified as spiral or non-spiral. The morphologies of spiral tibial fractures and concomitant lateral malleolar fractures were delineated using three-dimensional CT.Seventy-five spiral and 122 non-spiral fractures were identified. Peri-ankle fractures excluding lateral malleolar fractures were found in 77.3% of spiral fractures and 18.9% of non-spiral fractures. The most frequent location of peri-ankle fractures in the spiral group was the posterior malleolus, followed by the anterolateral distal tibia, while the medial malleolus was the most frequent site in the non-spiral group. Of 75 spiral fractures, 72 showed a fracture morphology attributed to external rotation force. There were 13 lateral malleolar fractures that were defined as within 6 cm from the distal end of the fibula. No lateral malleolar fractures showed the typical morphology of isolated supination/external rotation-type ankle injuries. The displaced syndesmotic injuries commonly coexisting in pronation/external rotation-type ankle injuries were not observed.Most spiral tibial shaft fractures were caused by external rotation force. However, the morphology of concomitant peri-ankle fractures was inconsistent with typical mechanisms of isolated external rotation ankle injuries.
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