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PubMed1990

Tibial fracture with or without fibular fracture--clinical studies.

This report investigated 145 cases of closed tibial fractures treated with closed reduction and cast immobilization, and followed up at least for 2 years, from 1981 to 1984, at Chang Gung Memorial Hospital of Taiwan. The total delayed or nonunion rate was 28.3% (41 patients), and the healing period was 4.6 months on average (range, 3-6 months). Among them, the delayed or nonunion rate in the tibial fractures with fibular fracture group was 33.3% (35/105), but in the tibial fractures without fibular fracture group it was only 15% (6/40). The difference between the groups was statistically significant (P less than 0.05). The severity of soft tissue injury may be a very important prognostic factor for bone healing.

Adolescent↗

PubMed1988

Ankle motion after external fixation of tibial fractures.

Loss of ankle movement is a complication of severe tibial fractures. This can be exacerbated if the foot is allowed to drop into equinus, particularly when an external fixator is employed. The range of ankle motion following external fixation of tibial fractures as compared to the opposite normal ankle was studied in 40 of 55 patients treated over a ten-year period. Nine were excluded due to other causes of ankle stiffness, leaving 31 cases for analysis. The mean follow up was 2 years 7 months (range 1 year to 8 years 3 months), and union had occurred by a mean of 35 weeks (range 9-100 weeks). The mean loss of ankle movement was 8 degrees of plantar-flexion and 12 degrees of dorsiflexion (overall loss 20 degrees), the difference between the two being highly significant (P greater than 0.001, t test). Loss of ankle motion closely paralleled the degree of soft tissue trauma, being 6 degrees for closed fractures and 22 degrees for open fractures (0.05 greater than P greater than 0.02). Ankle function is therefore at risk when a severe tibial fracture is treated by external fixation, and appropriate measures should be taken to preserve movement and prevent an equinus contracture.

Ankle Joint↗

PubMed1989

Early prophylactic bone grafting of high-energy tibial fractures.

Fifty-three high-energy tibial fractures treated with early prophylactic posterolateral bone grafting were retrospectively reviewed. The bone-grafting procedures were performed at a mean of ten weeks following injury and at a mean of eight weeks following soft-tissue coverage. Ninety-six percent of the fractures had associated injuries with a mean injury severity score of 20.9. Seventy-nine percent of the fractures were classified as Grade III open fractures, and 40% had bone loss greater than 50% of the cortical circumference. Ninety-six percent of the fractures healed at a mean time of 43 weeks after injury. Segmental bone loss and soft-tissue injury requiring flap coverage were the best predictors of prolonged time to union. Comparison with a matched historical control group of tibial fractures not receiving early bone grafts revealed a mean reduction in time to union of 11.7 weeks (p = 0.03). The incidence of chronic osteomyelitis was 1.9%. These results are attributed to early and repeated aggressive debridement, immediate rigid external fixation, early soft-tissue coverage, and early posterolateral bone grafting. Recommendations include posterolateral cancellous bone grafting two weeks following wound closure by delayed primary closure, split-thickness skin graft, or local rotational myoplasty. A six-week delay following freely vascularized soft-tissue coverage prior to bone grafting is suggested.

Adolescent↗

PubMed1993

Tibial fractures treated with the AO unreamed tibial nail.

During the last 2 years 20 fractures of the tibial shaft have been treated with the new, 'unreamed' solid AO tibial nail (UTN). There were 13 open fractures, while four of the seven closed fractures had severe soft tissue injuries. There were nine fractures classified as 'complex' or type C according to the AO classification. All UTNs were introduced without reaming but with proximal and distal interlocking. In all, 12 fractures (five of them open) were stabilized primarily by 'unreamed' nailing, whereas the first eight (open) fractures of the series were fixed initially by an external fixator and then nailed after about 14 days. In our series no intraoperative complications occurred, and no major soft tissue problems or infections were observed. The functional results were generally good; however, fracture healing appeared to be delayed in six cases. One patient had a further operation because of non-union. Intramedullary nailing, without reaming, seems to be a reliable and safe treatment for closed and open fractures with severe soft tissue injuries as an alternative to external fixation. The use of a thin, solid nail combined with interlocking allows the stabilization even of complex fractures. Contrary to initial assumptions, the UTN can be used as a definitive implant with no need for further stabilization in the majority of cases.

Adult↗

PubMed2005

Femoral and tibial fractures in a child with myelomeningocele.

Femoral and tibial fractures can occur from accidents, child abuse or pathological causes. It is often very difficult to distinguish the cause among those cases. Radiological diagnosis may be needed for clinicians and medical examiners in order to assist determining the reason of fractures. In this report, we submit a case with femoral and tibial fractures associated with myelomeningocele. This patient was diagnosed as child abuse by clinicians. On review it was decided that her fractures were not because of non-accidental injury. The values of bone mineral density of the upper limb were low and illness caused her fractures.

Bone Density↗

PubMed2002

Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients.

BACKGROUND: The treatment of open fractures of the tibial shaft is often complicated by delayed union and nonunion. The objective of this study was to evaluate the safety and efficacy of the use of recombinant human bone morphogenetic protein-2 (rhBMP-2; dibotermin alfa) to accelerate healing of open tibial shaft fractures and to reduce the need for secondary intervention. METHODS: In a prospective, randomized, controlled, single-blind study, 450 patients with an open tibial fracture were randomized to receive either the standard of care (intramedullary nail fixation and routine soft-tissue management [the control group]), the standard of care and an implant containing 0.75 mg/mL of rhBMP-2 (total dose of 6 mg), or the standard of care and an implant containing 1.50 mg/mL of rhBMP-2 (total dose of 12 mg). The rhBMP-2 implant (rhBMP-2 applied to an absorbable collagen sponge) was placed over the fracture at the time of definitive wound closure. Randomization was stratified by the severity of the open wound. The primary outcome measure was the proportion of patients requiring secondary intervention because of delayed union or nonunion within twelve months postoperatively. RESULTS: Four hundred and twenty-one (94%) of the patients were available for the twelve-month follow-up. The 1.50-mg/mL rhBMP-2 group had a 44% reduction in the risk of failure (i.e., secondary intervention because of delayed union; relative risk = 0.56; 95% confidence interval = 0.40 to 0.78; pairwise p = 0.0005), significantly fewer invasive interventions (e.g., bone-grafting and nail exchange; p = 0.0264), and significantly faster fracture-healing (p = 0.0022) than did the control patients. Significantly more patients treated with 1.50 mg/mL of rhBMP-2 had healing of the fracture at the postoperative visits from ten weeks through twelve months (p = 0.0008). Compared with the control patients, those treated with 1.50 mg/mL of rhBMP-2 also had significantly fewer hardware failures (p = 0.0174), fewer infections (in association with Gustilo-Anderson type-III injuries; p = 0.0219), and faster wound-healing (83% compared with 65% had wound-healing at six weeks; p =0.0010). CONCLUSIONS: The rhBMP-2 implant was safe and, when 1.50 mg/mL was used, significantly superior to the standard of care in reducing the frequency of secondary interventions and the overall invasiveness of the procedures, accelerating fracture and wound-healing, and reducing the infection rate in patients with an open fracture of the tibia.

Adolescent↗

PubMed1995

Skeletal stabilization for tibial fractures associated with acute compartment syndrome.

To determine the possible relationship between outcome and fixation method for tibial fractures associated with compartment syndrome, the authors retrospectively reviewed the records of 96 patients (average age, 31.8 years) with this injury. Seventy-eight patients had multiple injuries (average Injury Severity Score, 22.37). There were 68 closed and 28 open fractures, including 3 gunshot wounds. Compartment syndrome was diagnosed by direct measurement or by clinical findings. The attending surgeon selected the type of fixation based on fracture pattern and associated injuries. Time to healing for the 96 fractures averaged 31.6 weeks. There was no significant difference in healing times between open and closed fractures or between methods of treatment. Healing time for closed fractures was significantly different from that reported for closed fractures not associated with compartment syndrome (30.2 compared with 17.3 weeks, respectively; open fracture healing times were not significantly different (35 compared with 29.3 weeks, respectively). The authors conclude that (1) compartment syndrome significantly lengthens the time to healing for closed tibial fractures but does not significantly affect the time to healing for open tibial fractures; (2) closed tibial fractures with compartment syndrome appear to act as open fractures; and (3) the method of fixation does not appear to affect time to healing for closed or open fractures associated with compartment syndrome.

Adolescent↗

PubMed1985

Open tibial fractures with associated vascular injuries: prognosis for limb salvage.

Open tibial fractures complicated by limb-threatening vascular injuries present an infrequent but difficult management problem. Twenty-three cases were reviewed with an ultimate amputation rate of 61% (22% primary, 39% delayed). Crush injuries, segmental tibial fractures, and revascularization delays of greater than 6 hours were associated with a bad outcome. Guidelines for primary amputation (crushing injuries, delay in revascularization, segmental tibial fractures) are proposed and implications of limb salvage are reviewed.

Accidents, Traffic↗

PubMed1998

The osteogenic potential of free periosteal autografts in tibial fractures with severe soft tissue damage: an experimental study.

The present study was undertaken on 80 adult male New Zealand rabbits to assess the effect of free nonvascularized, autologous, periosteum transplants on bone healing in a rabbit fracture model comparable to a tibial fracture with severe soft tissue damage. Comparison was made between transplantation of free autologous periosteal grafts on the anteromedial side of the tibia and nontransplantation on the contralateral tibia (control). We produced a standardized transverse osteotomy of both tibial diaphyses. The medullary cavity was reamed and nailed ; a 1-cm segment of periosteum was excised from either side of the osteotomy. Periosteal and extraosseous ingrowth was prevented at the osteotomy site by a silastic sheet wrapped around two-thirds of the circumference of the tibia. On the silastic-free bone window, in one group we spanned the osteotomy with a free nonvascularized longitudinally-oriented autologous periosteum sewn to the adjacent periosteum proximally and distally. In the second group, the periosteum was placed transversely with a gap between it and the adjacent periosteum proximally and distally. Revascularization of the graft was determined with the colored microsphere technique. Our data suggest that orthotopically-placed autologous nonvascularized periosteum retains its osteogenic potential in a poorly vascularized environment comparable to a tibial fracture with severe soft tissue damage ; the effect is enhanced if the graft is in contact with intact periosteum. Histologically, callus formation after periosteal grafting resembles endochondral and intramembranous ossification.

Animals↗

PubMed2002

[The adverse effects of smoking on healing of open tibial fractures].

OBJECTIVE: Survey of the influence of smoking on the healing of open tibial fractures. DESIGN: Retrospective. METHOD: During the period 1 January 1994 to 31 December 2000, 168 patients were treated at the Department of Surgery (University Medical Center Utrecht, the Netherlands) due to an open tibial fracture; 118 patients with 125 fractures were included in the study. On the basis of their smoking behaviour, patients were classified as 'non-smokers' or 'smokers'. For all of the patients it was ascertained whether or not complications had occurred during treatment. Whether the fracture had consolidated was determined on the basis of clinical and radiological criteria. RESULTS: Seventy-two (61%) patients were non-smokers and 46 were smokers. The non-smokers had 77 open tibial fractures and the smokers 48. Initial therapy was identical and wound infections occurred with similar incidences in both groups. However, there was a statistically significant difference in the incidence of osteitis between both groups: 7 (9%) times in the non-smokers and 13 (27%) times in smokers (p = 0.04). The mean time to consolidation was 26 weeks for non-smokers and 33 weeks for smokers (p = 0.04). Smokers remained longer in hospital and underwent more re-operations. CONCLUSIONS: Smoking was negatively associated with the healing of open tibial fractures. In smoking patients, the time to consolidation was on average statistically significantly longer and they suffered more from osteitis.

Adult↗

PubMed1995

Factors influencing the outcome of closed tibial fractures treated with functional bracing.

One thousand consecutive closed diaphyseal tibial fractures, treated with prefabricated functional below-knee braces, were analyzed by statistical methods to determine factors predictive of final fracture outcome. Neither the age of the patient nor the location of the fracture influenced the speed of healing. In 95% of the fractures, the final shortening was < or = 12 mm. The mean final shortening was 4.28 mm, compared with mean initial shortening of 4.25 mm. This confirmed the authors' long-held hypothesis, that, in general, for closed, diaphyseal tibial fractures treated with functional bracing and graduated weightbearing ambulation, the final shortening does not increase beyond the initial one. Final angulatory deformity in any plane was < or = 6 degrees in 90% of patients. The presence of an intact fibula was a relative contraindication for functional fracture bracing because angulatory deformity was more likely to develop. The incidence of nonunion was 1.1%. The high union rate and low morbidity associated with functional bracing of closed tibial fractures suggest that the routine use of more expensive surgical treatments is difficult to justify. A clear understanding of the rationale of functional bracing, its indications and contradictions, and its clinical application protocol are essential for the attainment of satisfactory results.

Adolescent↗

PubMed2001

Tosic external fixator in the management of proximal tibial fractures in adults.

This retrospective clinical study assessed proximal tibial fractures managed with the Tosic external fixator. Nineteen patients with 21 proximal tibial fractures treated with the Tosic external fixator between July 1997 and October 1998 comprised the study population. Eleven fractures were graded as 41A2, 3 fractures as 41 A3, 4 fractures as 41C1, and 3 fractures as 41 C2. Fourteen fractures were closed, and 7 fractures were open. Average time to healing was 1 7 weeks. No revision of fixation was needed. There were five cases of pin tract infection. Average range of knee motion was 2 degrees-135 degrees. These results indicate the Tosic external fixator is an efficient and simple way to treat proximal tibial metaphyseal fractures.

Adult↗

PubMed1992

Tibial fractures. The Ilizarov alternative.

Between February 1988 and May 1989, 17 consecutive patients with 18 tibial fractures were treated using the Ilizarov method and apparatus. Injuries included four closed fractures and 14 open fractures. There were three Grade I open, four Grade II open, and seven Grade III open tibial fractures. Indications for application of the Ilizarov frame included fractures that were determined to need surgical management primarily, or fractures that had failed to heal by other treatment methods, either operative or nonoperative. Patients averaged 17.7 months of follow-up treatment. One patient was lost to follow-up treatment after the fracture healed and the device was removed. To date, all fractures are healed. There was one delayed union, which subsequently healed with a second application of the device. Complications included two late wound infections, both in Grade III open fractures. These occurred after removal of the Ilizarov apparatus. The average time from application of the device to complete fracture healing was 5.6 months, with a range of 3.25 to 13 months. This compares favorably with the results described for other treatment modalities. These results indicate that the Ilizarov method is indeed a useful adjunct in the orthopedic armamentarium for the treatment of either open or closed tibial fractures. No practical contraindications to the use of the Ilizarov device in the management of tibial fractures were encountered.

Adolescent↗

PubMed1991

An investigation of the contribution of the extraosseous tissues to the diaphyseal fracture callus using a rabbit tibial fracture model.

The contribution of the extraosseous tissues to diaphyseal fracture healing was investigated using a new fracture model. A transverse osteotomy of the tibial diaphysis of 18 New Zealand White rabbits was reamed and nailed, and a 2-cm length of the periosteum was excised from either side of the osteotomy. Healing was studied by radiography and by haematoxylin/eosin histology at intervals over 2 weeks. None of the osteotomies had united at the end of the observation period. Within days, cellular activity was observed in the remnant of the periosteum, which subsequently resulted in cartilage and bone formation. The repair tissue derived from the periosteum advanced in the direction of the osteotomy site. The extraosseous tissues did not appear to contribute significantly to the fracture callus.

Animals↗

PubMed2000

[Early soft tissue coverage in treatment of severe open tibial fractures].

OBJECTIVE: To study the role of early soft tissue coverage in the treatment of severe open tibial fractures. METHODS: 76 open tibial fractures of type III b were divided into early group (0 - 7 days), subacute group (8 - 30 days), and late group(> 30 days) according to the coverage time of soft tissue. Complications such as infection and nonunion were compared. RESULTS: The infection and nonunion rates of early group were lower than those of the subacute and late groups. The average time to union of the early group was less than that of the subacute and late groups. CONCLUSIONS: Early soft tissue coverage can reduce the complications and the time to union of severe open tibial fractures. The time for "early" coverage should be limited in 1 week. The opportunity of nosocomial infection will increase after 1 week.

Adolescent↗

PubMed1993

Treatment of open tibial fractures with Ender rods.

In a retrospective, nonrandomized study from 1980 until 1988, 43 patients with 46 open tibial fractures were treated with Ender rods. The configuration of each fracture was classified using the Orthopaedic Trauma Association's (OTA) tibial fracture guidelines, and the extent of soft-tissue damage was graded using the Gustilo classification of open fractures. The OTA classification was further divided into stable, unstable, and highly unstable fracture configurations. Ender rods were placed immediately into 90% of fractures; and within one week of initial injury in the remainder. Follow-up evaluation of four patients (six fractures) could not be completed. The average time to union was 22.1 weeks, and there was a low incidence of complications. Otherwise there was a 40% incidence associated with early rod removal. Most complications occurred in those fractures that had extensive soft-tissue damage, and minimal or no inherent axial stability (unstable and highly unstable OTA classes). Except for the above-noted complications, Ender rods provide effective fixation for open tibial fractures with some degree of axial and rotational stability. In fractures with minimal or no inherent axial stability (OTA Classes IIIC, D; IVA, B), and in Grade IIIB or IIIC open tibial fractures, Ender rods have a higher incidence of complications and should be used with caution.

Adult↗

PubMedDate not supplied

Management of the soft tissues in open tibial fractures.

This paper reviews the treatment of 168 open tibial fractures referred to the Northern Ireland Plastic Surgery Service over a 15-year period. Flap reconstruction was carried out in 133 (79%) and split skin graft cover in 22 (13%). There were 18 amputations (11%). There was a high incidence of complications among early post-injury fasciocutaneous flaps and late free flaps. Twenty-five primary free flaps were transferred without complication. The current management of open tibial fractures in this Unit is described.

Adolescent↗

PubMed1990

External fixation for type III open tibial fractures.

An analysis of 51 type III open tibial fractures treated by external skeletal fixation is presented. The fractures are subdivided according to the classification of Gustilo, Mendoza and Williams (1984) into types IIIa, IIIb and IIIc. The different prognoses of these fracture subtypes is examined. The use of the Hoffmann and Hughes external fixators in the management of type III open tibial fractures is presented and it is suggested that the prognosis is independent of the type of fixator used.

Adolescent↗