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PubMed2004

Staged management of high-energy proximal tibia fractures.

High-energy proximal tibia fractures are complicated by soft tissue compromise and this may result in sub-optimal outcomes. There is a high association of open injuries, compartment syndromes, and vascular injuries with these bony disruptions. Surgical treatment of these injuries has been associated with significant complications such as infection, knee stiffness, malunion, loss of fixation, soft tissue failure, and amputations. The loss of fixation is an issue especially in the elderly, with failure associated with age more than sixty years, premature weight bearing, preoperative displacement, fracture fragmentation, and severe osteoporosis. The use of two-stage reconstruction for the treatment of distal tibia fractures has been successful in decreasing the complication rates, including wound compromise. The two stages involve: 1. stabilization of the injured limb with a bridging external fixator to allow the soft tissues to improve and recover and 2. definitive fixation for reconstruction of the articular surface and meta-diaphyseal fractures. The use of such a protocol has been proposed for high-energy proximal tibia fractures to decrease the high rate of soft tissue compromise associated with traditional open methods of treatment. The choice of definitive fixation may include plates, nails, or non-bridging external fixation.

Adult↗

PubMed2005

Tibialization of the fibula: a viable option to salvage limbs with extensive scarring and gap nonunions of the tibia.

I retrospectively reviewed 21 patients who had tibialization of the fibula for infected nonunions with scarring of soft tissues. Most of the patients had unsuccessfully had other operations to restore continuity of the tibia before this treatment. The prerequisites were adequate vascularity, an intact sensate sole, and intact fibula. Proximal site tibiofibular synostosis was done in all patients. Three patients required a supplementary procedure at the proximal tibiofibular junction because of screws cutting out. Distal tibiofibular synostosis was done as a second-stage procedure in a majority of the patients 3 to 6 weeks after the proximal procedure. Protected weightbearing was recommended for 4 to 8 months. The transplanted fibula hypertrophied and approached the diameter of the tibia (or double the size of original fibula) in 2-3 years. Tibialization of the fibula is a safe, nondestructive, salvage procedure for treating difficult infected nonunions of the tibia. It is a simple technique that can be done in hospitals with a moderate infrastructure. Despite scarring, shortening, and limitation of knee and ankle motion, the patients were satisfied to be able to take part in normal daily activities on their own. After the success of synostosis, all patients engaged in activities of daily living and during the followup of 4-14 years none developed stress fracture of the tibialized fibula.

Adolescent↗

PubMed2006

[Treatment of comminuted fractures at distal femur and proximal tibia with less invasive stabilization systems].

OBJECTIVE: To study the clinical outcome of comminuted fractures at distal femur and proximal tibia treated with AO less invasive stabilization systems (LISS). METHODS: The clinical data of 14 cases of distal femoral fracture and proximal tibial fracture from September 2003 to May 2005 were analyzed retrospectively. The injury was caused by traffic accident in 9 cases, by fall in 3 cases and by slipping in 2 cases. Of 14 cases, there were 5 open fractures and 9 close fractures, including 5 cases of distal femoral comminuted fracture and 9 cases of proximal shaft comminuted fractures. According to AO/OTA classification, the fractures were classified as 33C2 in 3 cases, 33C3 in 2 cases, 41A2 in 2 cases, 41A3 in 2 cases, 41B2 in 3 cases and 41C2 in 2 cases. All patients were treated by the internal fixation with LISS-distal femur or with LISS-proximal tibia. Healing of wounds, the X-ray films before and after operations, and the recovery of joint function were observed. RESULTS: The patients were followed up from 1 month to 20 months (11 months on average). Twelve cases achieved solid osseous unions from 3 months to 5 months postoperatively; 2 cases had a good reduction and recovered smoothly 2-3 months postoperatively. The results were excellent in 10 cases, good in 3 cases and fair in 1 case according to Johner-Wruhs knee scoring. The range of knee flexion-extension was 110-130 degrees in 11 cases, 100 degrees in 2 cases and 80 degrees in 1 case. CONCLUSION: LISS is an effective method of internal fixation for treating comminuted fracture of distal femur or proximal tibia. It has the advantages of less injury, satisfied reduction and reliable fixation.

Adult↗

PubMed1990

[The interlocking nail for long comminuted and compound fractures of the femur and tibia. Technique and results].

Interlocking nailing is presented as an optimal method for the treatment of fractures of femur and tibia, which are complicated because of the length of these bones. Cases from the literature and cases treated by the authors gave a total of 208 fractures of the femur and 158 fractures of the tibia (comminuted fractures and fractures "à deux étages"). There is a low complication rate as a closed procedure was applied whenever possible. In the femur the nail fractured in eight cases (3.9%), while in seven cases infection was observed (3.5%) and in three cases pseudarthrosis. Following interlocking nailing of the tibia we found deviation of the axis by greater than 5 degrees in eight cases (5%) of 158, including 44 open fractures. Fracture of the nail occurred in one case (0.6%), and we observed six cases of infection (3.8%) and one of pseudarthrosis (0.6%).

Adolescent↗

PubMed1989

The value of internal oblique radiographs for posterolateral bone grafting of the tibia.

A 35 degrees internal oblique radiographic view of the tibia was used for the purpose of demonstrating posterolateral tibial bone grafts. This radiograph of the supine patient is made by internally rotating the affected leg 35 degrees obliquely toward the midline. This view eliminates superimposition of both the tibia and fibula on the graft. This method of radiographic evaluation has been found useful in visualization of graft margins intraoperatively and assessing bone graft incorporations in clinical follow-up evaluations. The authors recommend 35 degrees oblique views in preference to anteroposterior and lateral views for patients who have had posterolateral bone grafts of the tibia performed.

Bone Transplantation↗

PubMed1989

Intramedullary nailing with reaming to treat non-union of the tibia.

The records of fifty-one patients who were treated by intramedullary nailing with reaming for non-union of the tibia were retrospectively reviewed. The fractures had been treated initially by closed reduction and immobilization in a cast, external fixation followed by immobilization in a cast, fixation by pins incorporated in a plaster cast, minimum internal fixation and immobilization in a cast, dynamic compression plating, or intramedullary nailing with or without reaming. After the initial treatment had failed, intramedullary nailing with reaming was done to gain union. Although closed nailing of the tibia was preferred, in thirty-three patients, the site of the non-union was opened to improve alignment by performing an osteotomy or to remove failed hardware. Bone grafts from the iliac crest were used in ten patients, and a fibular ostectomy or osteotomy was done in thirty-three. Of thirty-four open fractures (fourteen grade I, seven grade II, and thirteen grade III), eight were infected at the time of intramedullary nailing. The average time of the diagnosis of a non-union was 9.6 months; the average length of follow-up after nailing was twenty months. In forty-nine (96 per cent) of the fifty-one patients, tibial union occurred at an average of seven months postoperatively. Complications included persistent infection (three patients), acquired infection after intramedullary nailing with reaming (three patients), fracture of the nail that necessitated an additional operation (two patients), shortening of more than one centimeter (two patients), malrotation of more than 15 degrees (one patient), peroneal palsy (one patient), and amputation (one patient). When used to treat non-union of the tibia, intramedullary nailing with reaming can produce union as effectively as other alternatives, while enabling the patient to function more normally without external immobilization or walking aids.

Adolescent↗

PubMed1988

Treatment of infected non-unions and segmental defects of the tibia with staged microvascular muscle transplantation and bone-grafting.

Fourteen patients who had an infected non-union or segmental defect of the tibia were treated with débridement and microvascular transplantation of muscle. Successful free muscle transplantation and control of the infection were achieved in all patients. The prognosis was, in general, related to the severity of the underlying osseous problems, which were categorized into types A (a tibial defect and non-union without significant segmental loss), B (a tibial defect that is more than three centimeters long and an intact fibula), and C (a tibial defect that is more than three centimeters long, involving both the tibia and the fibula). All of the six type-A patients healed without needing bone-grafting. Of the four type-B patients, all of whom had subsequent bone-grafting, reactivation of the infection occurred in two, and both ultimately had a below-the-knee amputation; the third patient had a non-union between the fibular graft and the tibia; and the fourth patient was fully weight-bearing. All of the four type-C patients also required subsequent bone-grafting; all finally healed and were able to walk with a brace. The results in the present series indicate that, in patients who have an infected tibial defect or non-union, including those that are so severe that an amputation might be considered, this method of treatment is a valid option for salvage of the limb.

Adolescent↗

PubMed1986

Effects of vitamin D deprivation and 1,25-dihydroxyvitamin D3 treatment on ion release from rat tibiae in vitro.

Skeletal effects of dietary vitamin D and of 1,25-dihydroxyvitamin D3[1,25(OH)2D3] in vivo and in vitro were investigated using bones from vitamin D-deficient suckling rats. Tibiae from 19- to 21-day-old pups were incubated for up to 8 h in a defined medium and the net releases of Ca, inorganic phosphate (Pi) and Mg into and from the bones were determined. The pups were delivered and nursed by mothers fed either a diet containing vitamin D3 (+D) or a D-free diet (-D) starting on the sixth day of pregnancy. Effects of metabolic inhibition with iodoacetic acid (IAA, 1 mM); of elevated medium Pi concentration (2 mM); and of 1,25(OH)2D3 in vitro (2 and 10 ng/ml of medium) or in vivo (500 ng/mother ip, 2x) were evaluated. Although no effects of vitamin D on glucose metabolism or net Pi release were seen, tibiae from -D pups showed a marked decrease in net Ca release (up to 70%), while net Mg release was increased by 27%. IAA completely inhibited net Ca release in this system, had no effect on net Pi release, and reduced lactate production and net Mg release by 86 and 33%, respectively. Elevating the medium Pi concentration from 1 to 2 mM did not affect the differences between +D and -D bones. Treatment with 1,25(OH)2D3 in vitro and in vivo returned ion releases by the -D tibiae partly or completely to the +D levels. The results support the following conclusions: (1) vitamin D deficiency during suckling reduces net Ca release and increases net Mg release from bone which may contribute to the changes in circulating concentrations of these ions seen in D deficiency; (2) these effects on bone appear to be specific for Ca and Mg, since the vitamin has little or no effect on net Pi release; (3) net Ca and Mg release from rat bone in vitro presumably are energy-dependent processes, while net Pi release is not; and (4) 1,25(OH)2D3 can affect net Ca and Mg release from -D bones by a direct action.

Animals↗

PubMedDate not supplied

The operative treatment of intra-articular fractures of the lower end of the tibia.

Intra-articular fractures of the lower end of the tibia are an interesting challenge. The best functional results in the past series were observed in patients treated according to the following 4 sequential principles: (1) reconstruction of the correct length of the fibula; (2) anatomical reconstruction of the articular surface of the tibia; (3) insertion of a cancellous autograft to fill gaps left by impaction and comminution; (4) stable internal fixation of the fragments by a plate placed on the medial aspect of the tibia. Seventy-five cases had a good or excellent late result (on average 6 years postoperatively) in 70% as compared to 43% to 55% in cases treated by closed and/or open methods.

Adult↗

PubMed1986

Interlocking nailing of complex fractures of the femur and tibia.

The interlocking nail widens the range of indications for medullary osteosynthesis of femoral and tibial shaft fractures. Stability is achieved by transverse threaded bolts in prefabricated holes in the nail, which anchor the implant directly to cortical bone, thereby controlling length, alignment, and rotation of the limb. Two hundred eighty-three femoral and 401 tibial fractures were treated with an interlocking nail and followed for an average of 20 months. Overall, 97% of the femurs and 94.3% of the tibias were judged to have an excellent or good result, based on both clinical and radiographic parameters. Delayed union or nonunion requiring bone grafts occurred in 2% of the femurs and 0.7% of the tibias following interlocking nailing. Deep infection developed in 2.4% of the femurs and 2.2% of the tibias. All of these patients eventually healed their fractures without evidence of chronic osteomyelitis. The main advantage of interlocking nails is that surgery can be performed using closed nailing techniques, allowing early protected weight-bearing and joint motion. The rates of nonunion and infection are very low, and there is little risk of refracture after implant removal.

Bone Nails↗

PubMed1984

Prognostic factors in nonunion of the tibia: an evaluation of 185 cases treated with constant direct current.

The present series represents a retrospective clinical study of 185 cases of nonunion of the tibia. The severity of the injury was important in the development of the nonunion. Primary closure of open injuries was noted to be dangerous and resulted in high incidence of infection, 27 of 37 cases. The distal third of the tibia was the most frequent site of the nonunion. One of the most striking findings in this study was a high incidence (92.4%) of patients presenting with initial delay to weight bearing of greater than 6 weeks. The authors feel that this is a definite contributory factor in the development of nonunion of the tibia.

Adult↗

PubMed1982

Congenital pseudarthrosis of the tibia. A long-term follow-up study.

A review of 36 cases of congenital pseudarthrosis of the tibia revealed that at long-term follow-up, patients tended to fall into three groups: (1) those who show the typical radiographic and physical findings of congenital pseudarthrosis of the tibia, fracture before eight years of age and progress of pseudarthrosis; these cases tended to proceed to a poor end-result, regardless of the form of treatment; (2) those who did not show the typical prefracture stage but fractured after the eight years of age responded well to grafting procedures and had minimal shortening and satisfactory results at long-term follow-up; and (3) those patients who presented with a prefracture stage tibia but were braced and never fractured, and had a satisfactory end-result.

Adolescent↗

PubMed1982

Ipsilateral fractures of the femur and tibia.

14 cases of ipsilateral fractures of the femur and tibia were reviewed from the hospital records. The two commonest patterns were fractures of the shafts of the femur and tibia and fractures of the shaft of the femur and the tibial condyle. Rigid internal fixation of both the femur and the tibia in case of fracture through the shaft of both bones gave satisfactory functional end result. For those in whom the femoral shaft fracture was associated with tibial condylar fracture, rigid fixation of the femoral fracture and conservative management of the tibial condylar fracture with traction was found to be more satisfactory. Initial resuscitation of these severe injuries is very important and significant morbidity from this combination of injury can be expected. Associated vascular and knee ligamentous injury in these cases may be overlooked at the initial presentation and must be looked for carefully.

Adolescent↗

PubMed1982

Multidirectional in vivo strain analysis of the equine radius and tibia during dynamic loading with and without a cast.

Rosette strain gauges were applied to the equine radius and tibia. Three sites were examined on each bone on separate occasions (proximal metaphysis, middiaphysis, and distal metaphysis). At each site, 4 rosette gauges were applied around the bone (ie, cranial, caudal, medial, and lateral). Strain recordings were made while walking the horse with and without a full-limb plaster cast. The principal axis of tensile strain was on the craniolateral aspect of the radius. Distally, on the radius, the largest strains were torsional. The cast changed the principal axis of tensile strain on the radius from the craniolateral surface to the caudal surface. The principal tensile strain of the tibia was just to the lateral side of cranial in the proximal and diaphyseal regions. Distally, the principal axis of tensile strain was craniolateral; however, the largest strains measured here were torsional. The cast changed the principal axis of tensile strain on the distal metaphysis of the tibia, but it did not reduce the magnitude of the strains measured. Casts may not aid stabilization of radial or tibial fractures repaired with internal fixation and may in fact place additional stress on the fracture site.

Animals↗

PubMed1981

Superior dislocation of the fibular head associated with a tibia fracture.

Superior dislocation of the fibular head associated with a fractured tibia occurred in four cases with a direct, severe trauma to the tibia. In one case there was permanent peroneal nerve damage. This injury is somewhat analogous to the fracture-dislocation of the Monteggia type in the forearm. To diagnose secondary dislocations of the fibula and treat the condition early, the knee joint should be carefully examined before and after X-ray of all fractures of the tibia.

Adolescent↗

PubMed1994

[Current status of surgical technique for unreamed nailing of tibial shaft fractures with the UTN (unreamed tibia nail)].

Nailing technique has changed in recent years in some important aspects which are not limited to the omitted reaming procedure. These changes concern patient positioning, reduction technique, the use of temporary stabilizers such as the 'Pinless', and determination of implant length and diameter. Approach and exposure techniques have been modified to new, less invasive procedures, in order to fulfill technical, functional and aesthetic requirements. Techniques and tricks have been developed for avoidance of fragment diastasis and axial and torsional malalignment. Finally, simple algorithms are described for the management of large bone defects, bilateral tibia shaft or ipsilateral femoral shaft fractures, number and location of locking bolts, the 'when and how' of patient mobilization and load bearing, and primary and secondary dynamization. These algorithms, techniques and procedures were developed in a series of 152 tibia shafts, which were stabilized with the AO unreamed tibia nail (UTN) in a prospective study between March 1989 and June 1994. Of these, 75 cases with a mean follow-up of 19.4 +/- 6.3 (range 11-37) months after trauma were reviewed. Fractures were classified according to Müller (1990): 14 type A, 37 type B and 24 type C. Closed soft tissue damage was categorized according to our classification: C0/1, n = 5; C2, n = 12; C3, n = 9 (Tscherne 1982). Among 49 open fractures 8 were OI, 18 OII, 10 OIIIA and 13 OIIIB (Gustilo 1976). The main minor intraoperative complication was drill bit breakage (n = 10), most frequently at the proximal locking holes. The main postoperative complication was breakage of locking bolts (n = 16), mainly between weeks 6 and 20. Minor secondary reinterventions were, in most cases, secondary dynamization under local anaesthesia. Major reintervention were: soft tissue reconstructions (n = 5), isolated cancellous bone graft (n = 6), and change of treatment (n = 12). There were nine changes to a reamed nail, two changes, in very proximal fractures, to plate osteosyntheses. There were three deep infections. Mean time to union was 23.9 weeks (range 10-48 weeks, n = 73); in two cases non-union was observed. The overall result was judged with the Karlström-Olerud score, which was applicable in 66 of 75 cases; excellent, n = 2; good, n = 22; satisfactory, n = 24; fair, n = 9; poor, n = 9. In the remaining nine cases no scoring was attempted because of severe injuries around the knee or ankle.

Adolescent↗

PubMed1994

[Longitudinal stress fractures of the tibia. Apropos of 3 cases].

Longitudinal stress fractures of the tibia are rare: only 16 cases have been published. We report three cases, in two men aged 54 and 70 years and in one women aged 73. The patients had pain when bearing weight on the affected limb. The pain increased over a few weeks. A diagnosis of arthritis of the ankle joint was entertained in 2 cases. Among the three patients, one was suffering from rheumatoid arthritis and had had Ender nails due to fracture of the femoral neck of the same limb. The longest delay for diagnosis was six months. Plain radiographs were normal in two cases. A technetium 99m MDP bone scan showed increased uptake of the whole shaft of the tibia in one patient, on the lower end of the tibia in two others. Computed tomography was performed in two cases and showed the stress fracture. Diagnosis was often delayed because clear changes at plain X-ray examination, periostal reaction often being delayed. Technetium 99m bone scan early showed increased uptake. CT scan showed callus formation and sometimes the fracture itself. MRI has been studied little.

Aged↗

PubMed1993

Open tibia fractures.

Open tibia fractures can be very challenging fractures to care for. Good results should be expected, however, if a thorough irrigation and debridement is performed, repeated as necessary, and appropriate antibiotics utilized. Soft tissue coverage is extremely important in open tibia fractures to decrease the rate of infection and to facilitate fracture healing. Bony stabilization can be achieved in a variety of ways. In the past, the gold standard has been external fixation. In the future, however, small, unreamed, locked intramedullary nails may be utilized more frequently, especially with Types I, II and IIIA open tibia fractures.

Adolescent↗