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PubMed1983

Rotational refracture of the shaft of the adult tibia.

The incidence and clinical details of refractures of the shaft of the tibia a series of 534 adult patients after conservative primary treatment were analysed. Fracture of the callus is defined as a secondary fracture occurring within twelve months of the primary injury in the area of bone healing by callus. A fracture of the callus was recorded in 13 patients (2.4 per cent), in whom 11 fractures occurred after a primary fracture caused by indirect, rotational violence. The incidence among these was 6.3 per cent. For torsional fractures of the tibial shaft the following factors were associated with appreciably increased frequency of subsequent fracture of the callus: repeated closed reduction; fracture of the fibula at a different level from that of the tibia, and marked initial lateral displacement. When these factors were present simultaneously, the incidence was 18 per cent.

Adolescent↗

PubMed1990

Acute plastic bowing fractures of both the tibia and the fibula in a child.

A case of acute plastic bowing fractures of both the fibula and tibia in a child is presented. This type of fracture has never been reported in the tibia, but has now been reported in all the major bones of the limbs. The clinical picture is described, and the indications for treatment discussed. In case of doubt, radiographs should be taken of the opposite limb, if the clinical picture suggests a bowing fracture.

Bone Development↗

PubMed1992

Mechanical properties of the Pinless external fixator on human tibiae.

UNLABELLED: In the treatment of either acute severe open tibial fractures or their sequelae, a convenient external fixator is desirable. The conventional transosseous fixation with pins entering the medullary cavity is associated with problems such as pin loosening and pin track infection. Due to the bacterial contamination of the medullary space via the pin track the change of treatment from primary external fixation to secondary medullary nailing is an infection risk. In order to minimize these problems an external clamp fixator, the Pinless, was created. Medullary penetration is avoided by substitution of the conventional pins with clamps. The latter are inserted by hand (removable handles) and anchored only in the bone cortex. The medullary cavity stays intact. But is this clamp fixation stable enough for clinical use? MATERIAL AND METHODS: On paired human cadaver tibiae, we compared the mechanical properties of the experimental Pinless, the conventional AO-tubular fixator and the Ultra-X fixator. Clamps differing in size (small/large) and material (steel/titanium) were used and compared to Schanz screws (steel, 5.0 mm diameter). We measured the stiffness of comparable configurations (1 or 2 bars) under axial compression, four-point-bending in two planes, and torsion. The pull-out force of the different clamps in relation to the bone diameter and number of rocking movements during insertion was also determined. RESULTS: The Pinless configurations with small clamps and 1 bar showed stiffness values as follows (as a percentage of the corresponding AO-tubular fixator): 42/36% (steel/titanium clamp) axial stiffness, 61/43% bending stiffness perpendicular to the reference plane, 78/79% bending stiffness parallel to the reference plane, and 90/95% torsional stiffness. The corresponding Ultra-X device was not as stiff as the Pinless. The use of two longitudinal rods increased the relative stiffness only under axial compression. The mean pull-out force on the proximal tibia was 1011 N for the small steel clamp, 717 N for the large steel clamp, 681 N for the small and 777 N for the large titanium clamp. At the lowest tibial diameter the values were reduced by 10 to 43%. The rocking movements doubled the pull-out force, e.g. there was a pull-out force for the large clamp of 600 N with five rocking movements compared to 310 N without. DISCUSSION: The Pinless was not as stiff as the conventional AO-tubular device but stiffer than the clinically used Ultra-X, especially in sagittal bending, the main load on a tibial fracture in the first weeks after trauma.(ABSTRACT TRUNCATED AT 400 WORDS)

Biomechanical Phenomena↗

PubMed1996

Study of the vibrational behaviour of a healing tibia using finite element modelling.

Two finite element models of a fractured tibia with healing callus were developed. In the first model, the callus was modelled at the middle of the diaphysis, while in the second one the callus was located at two-thirds of the length, distal from the knee. From these two models the static torsional stiffness as well as the resonant frequencies and mode shapes of the first four vibration modes were calculated for a series of increasing values of Young's modulus of the callus. Two situations were considered. In the first situation, the geometry of the callus was kept constant, while in the second, the dimensions of the callus were reduced while its Young's modulus was increased. The resonant frequencies were found to increase with increasing stiffness of the callus. The single bending modes were found to be more sensitive when the callus was at the middle of the diaphysis, whereas the double bending modes were more sensitive when the callus was situated distally. Mode shapes were similar to those for the intact tibia when the stiffness of the callus was 5% of the stiffness of the intact bone or higher. A basically linear relation was found between the torsional stiffness and the resonant frequencies. A theoretical relation between resonant frequencies and torsional stiffness was evaluated and found to be valid if the Young's modulus of the callus was equal to or greater than 5% of the Young's modulus of the intact bone. The present results support the quantitative interpretation of vibration analysis measurements for the assessment of tibial fracture healing.

Bony Callus↗

PubMed1996

Biomechanical properties of the human tibia: fracture behavior and morphology.

Standardized biomechanical dynamic load tests were performed to obtain fundamental information on the fracture behavior and morphology of the human tibia. After preparation, the specimens (n = 32) were loaded to breakage by ventral (one side alternately), dorsal, medial or lateral loading on a servo-hydraulic testing machine (Walter und Bai, Löhningen, Switzerland). Primary and secondary fracture lines and fissures were marked differently on the three surfaces of the tibia specimens. They were then videoscanned and digitized on a flatbed scanner to give two-dimensional fracture-line images. Load limits were 2475 to 12,206 Newton. The study revealed both direct fracture patterns with the fracture lines originating from the opposite site of impact, and indirect fracture patterns originating from the distal third of the specimens. Direct fractures occurred in 46% of the specimens after ventral loading, in 80% after medial or lateral loading, and in 100% after dorsal loading. Ventral, medial or lateral loading frequently produced direct wedge fractures of the Messerer type. Dorsal loading resulted in different direct patterns characterized by transverse fractures with longitudinal fissures at the impact site of the loading stamp. Direct transverse fractures also often showed a wedge-shaped pattern due to additional fissures. These were, however, identifiable only after maceration of the specimens and should receive closer attention in forensic practice.

Adolescent↗

PubMed2004

Arthroscopy-assisted reduction and percutaneous fixation for triplane fracture of the distal tibia.

We report a case of triplane fracture of the distal tibia that was treated with arthroscopy-assisted reduction and percutaneous fixation. A 14-year-old boy with a triplane fracture of the distal tibia with 5-mm displacement of the articular surface was treated using a cannulated cancellous screw while viewing the fracture site via an arthroscope. Two months after surgery, the patient was able to walk without discomfort. Three months after surgery, he felt no pain when running and was able to fully participate in athletic activities with an American Orthopaedic Foot and Ankle Society score of 100. In the second-look arthroscopy at one year after surgery, the articular surface of the fracture area was smooth and congruous. We believe that this technique can provide satisfactory clinical results because of an accurate anatomical reduction of the articular cartilage under direct visualization and the minimum invasion with minimum arthrotomy.

Adolescent↗

PubMed2005

Interlocking nails for displaced metaphyseal fractures of the distal tibia.

Metaphyseal fractures of the distal tibia near the ankle joint are difficult to manage. Poor soft tissue coverage and comminution of the fracture complicate open reduction. This prospective study aims to evaluate the practicability of using interlocking nails to treat such fractures. Using the method of closed reduction and internal fixation with a shortened tibial interlocking nail, 20 consecutive cases of distal tibial metaphyseal fractures within 4 cm of the ankle joint line were enrolled from 1997 to 2001. All patients received regular post-operative radiographic check-up and the ankle function was evaluated with the Iowa Ankle-Evaluation rating system. Our result was satisfactory and all of the fractures united solidly with a mean union time of 17.2 weeks. No major complication occurred. We conclude that tibial interlocking nailing is a reliable and safe method for managing metaphyseal fractures of the distal tibia near the ankle joint.

Adult↗

PubMed2006

Medial double-plating for fracture dislocations involving the proximal tibia.

Fracture dislocations of the knee involving the proximal tibia are difficult to treat because of the operative approach that maybe required and the instability of the construct. This paper evaluates the use of a two-incision approach with a medial double-plating technique. The clinical results of a case series of 42 patients collected prospectively are presented. At final follow-up 37 out of 42 (88%) had satisfactory reduction of the articular surface and 41 (98%) had satisfactory alignment. At one year postoperation there was no loss in reduction or alignment. The mean HSS score was 90.9 (s.d. 3.35, range 83 to 97). There were no superficial or deep infections, however four cases (10%) had a sanguinous effusion for more than one week postoperatively. It was concluded that the medial double-plating operation is an effective way of managing fracture dislocations involving the proximal tibia.

Adult↗

PubMed1994

Longitudinal stress fractures of the tibia: MRI features in two cases.

Longitudinal stress fractures of the tibia are a recognized but unusual finding in long distance runners. Two cases are presented in which the diagnosis on plain films and scintigraphy (in one case) was not evident. Both patients were referred for MRI. Coronal short tau inversion recovery (STIR) sequences demonstrated extensive hyperintense longitudinal intramedullary signal changes in the tibia. T1-weighted spin-echo scans showed corresponding but less extensive regions of reduced signal intensity. In one case, enhancement of this area was seen following i.v. dimeglumine-gadopentetate (Gd-DTPA). Adjacent soft-tissue abnormality and periosteal reaction was seen in one case but in neither patient was a fracture line identified. Thin section CT with sagittal reformats demonstrated an irregular intracortical longitudinal lucent fracture line which was distinct from the nutrient foramen, establishing the diagnosis.

Adult↗

PubMed2003

Effect of tenoxicam on fracture healing in rat tibiae.

BACKGROUND: Nonsteroidal anti-inflammatory drugs have been implicated in the development of delayed unions and nonunion after fractures in animal models. Previous investigations have identified two important factors as determinants of delayed fracture healing: early drug administration and a dose-dependent effect. OBJECTIVE: The purpose of this investigation was to study the effect of tenoxicam, a nonsteroidal anti-inflammatory drug, on the fracture healing process in rat tibiae. METHODS: Fifty-eight Wistar rats were randomly divided in four groups (I, II, III, and IV). Group I (control group, n=12) was given 0.1ml saline solution per day intramuscularly. Groups II (n=12), III (n=12), and IV (n=12) were administered 10mg per kg per day of tenoxicam intramuscularly. Administration of substances was begun on a week before to 48h after the fracturing procedure and continued during the entire experiment. Callus formation was studied histologically and histomorphologically, using light microscopy. In addition, a histologic grading based on the morphologic stage of fracture healing was carried out at 4 weeks, according to the criteria proposed by Allen et al. RESULTS: There was a significant difference in treatment effect between Group I (saline solution) and Groups II, III, and IV (tenoxicam) (P=0.07). Histologically and histomorphologically, there were qualitative and quantitative delay in callus formation at all tenoxicam groups. This was more pronounced the earlier the nonsteroidal anti-inflammatory drug was started, although no significant difference could be detected between Groups II, III, and IV (P>(alpha=10%)). Four weeks after fracture, Group I (n=3) showed complete osseous union, Groups II (n=3) and III (n=3), complete cartilaginous union, and Group IV (n=3), incomplete osseous union, according to Allen et al. By using this rating scale, the difference between control and drug-treated groups was statistically significant (P<0.1). CONCLUSION: Under studied conditions, this investigation shows that administration of tenoxicam intramuscularly delays fracture healing process in rat tibiae. These results suggest the hypothesis that early drug administration may delay bone healing after experimental fractures in animals, although it could not be detected statistically significant.

Animals↗

PubMed1997

Minimally invasive plate osteosynthesis of distal fractures of the tibia.

Minimally invasive plate osteosynthesis of distal tibial fractures is technically feasible and may be advantageous in that it minimizes soft tissue compromise and devascularization of the fracture fragments. The technique involves open reduction and internal fixation of the associated fibular fracture when present, followed by temporary external fixation of the tibia until swelling has resolved. Subsequent limited, but open reduction and internal fixation of the articular fragments when displaced followed by minimally invasive plate osteosynthesis of the tibia utilizing precontoured tubular plates and percutaneously placed cortical screws is performed. The semitubular plate was chosen because it adapts more easily to the bone contours than the stiffer small fragment LC-DCP does. Twenty patients (age 25-59 years) with unstable intraarticular or open extraarticular fractures have been treated including 12 A-type, 1 B-type and 7 C-type fractures according to the AO classification. Two fractures were open (both Gustilo Type I). Closed soft tissue injury was graded according to Tscherne with 3 type C0, 7 type C1, 7 type C2 and 1 type C3. All fractures healed without the need for a second operation. Time to full weight-bearing averaged 10.7 weeks (range 8-16 weeks). Two fractures healed with > 5 degrees varus alignment and 2 fractures healed with > 10 degrees recurvatum. No patient had a deep infection. The average range of motion in the ankle for dorsiflexion was 14 degrees (range 0-30 degrees) and plantar flexion averaged 42 degrees (range 20-50 degrees). With longer follow-up and a larger number of patients, the authors feel confident that the minimally invasive technique for plate osteosynthesis for the treatment of distal tibial fractures will prove to be a feasible and worthwhile method of stabilization while avoiding the severe complications associated with the more standard methods of internal or external fixation of those fractures.

Adult↗

PubMed2005

[Tibia nonunion after intramedullar nailing for fracture: decortication and osteosynthesis by medial plating].

PURPOSE OF THE STUDY: Intramedullar nailing is now widely used for fractures of the tibia. Extension of nailing indications to proximal, distal, and comminuted fractures has led to a significant rate of complications. The purpose of this study was to analyze decortication and medial plating for the treatment of tibial nonunion after intramedullary nailing. MATERIAL AND METHODS: Eighteen cases of aseptic tibial nonunion after nailing for fracture were treated in three women and fifteen men, mean age 39 years (19-57). The initial classification was open (n = 8), segmental (n = 3), single-focus (n = 15). The fracture site was inferior (n = 6), middle (n = 7), and superior (n = 2). Primary nailing used reaming in 15 cases (83%), unreamed in 3 (17%) static in 13 and dynamic in 5. Four plaster cabts were also applied. Complications were: infection (n = 1), compartmental syndrome (n = 2), tibial nerve palsy (n = 1), dysesthesia (n = 2), and protrusion of the nail into the knee (n = 1). Dynamization was performed in 11 patients, one with additional bone graft and fibulectomy. Repeated reamed nailing was performed in one patient. Seven nonunions were atrophic and 11 were hypertrophic. There were 13 malpositionings associated with the nonunion. Treatment of the nonunion was performed 300 days on average (90-900) after nailing: cancellous bone graft was associated with decortication in four cases because of bone loss (n = 3) or atrophic nonunion (n = 1). RESULTS: Union rate was 94%. Mean time for union was 108 days (80-180) with no significant difference (Student t-test) between atrophic (119 days) and hypertrophic (103 days) nonunion. Correction of the malposition was incomplete in seven patients, with angular malunion of less than 6 degrees in five patients and greater than 10 degrees in two. One late infection occurred and finally healed after external fixation and antibiotic therapy. No skin necrosis occurred. Five patients had pain on the hardware. Removal was performed in one time and pain resolved. Improvement of knee and ankle stiffness was achieved in all patients. DISCUSSION: This technique has been used in our department since 1967. Different studies have found a union rate ranging from 94% to 100% with this procedure. Intramedullary nailing, sometimes associated with bone graft or decortication, is also used for tibial nonunion with a good rate of union. The main problem of intramedulary nailing for nonunion, as for fracture, is the difficulty in avoiding malunion. Plating a nonunion, as a fracture, enables better reduction. Skin problems can occur with the medial plate if the soft tissues are damaged. This situation is very uncommon in secondary surgery. CONCLUSION: Decortication and medial plating was a safe and efficient treatment for tibia nonunion after failure of intramedullary nailing and allows better reduction and repeated nailing.

Adult↗

PubMed1994

Arthroscopic reduction and fixation of a completely displaced fracture of the intercondylar eminence of the tibia.

A simple method of arthroscopic reduction and fixation of a fracture of the intercondylar eminence of the tibia is described. A 23-year-old man with a completely displaced (Type IIIB) fracture was treated with arthroscopy. A satisfactory reduction was achieved by releasing the medial meniscus, which was entrapped in the fracture site. Link dynamic staples (W. Link, Hamburg, Germany) were used to firmly fix the fracture when the guide tube came downward from the medial mid-patellar portal. The secure fixation of the fragment and the prevention of the need for an arthrotomy facilitated early functional rehabilitation. One year after surgery the patient had a stable, painless joint with a full range of motion. The described method is technically straight-forward and can provide secure fixation of a bone fragment. The Link staples are useful in the fixation of a displaced fracture of the intercondylar eminence of the tibia.

Adult↗

PubMed1998

Sliding performance of unilateral external fixators for tibia.

Some unilateral external fixators have a sliding mechanism to achieve dynamic axial fixation. However, it has been reported that binding of this mechanism occurs during routine ambulation. The Hifixator, a unilateral external fixator, has been developed which has a new type of sliding mechanism. The mechanism of the Hifixator was tested by connecting it to a fractured bone model with pins, and applying dynamic axial loading. The conditions of connection between the pins and bone model were varied to simulate loosening of the pins. Two other external fixators commonly used for tibias, Orthofix and Monotube (blue), were tested for comparison. The amount of sliding motion of the Hifixator was maintained at more than 72% of the motion at the fracture site even when pins were loose and a torque of 4 N m was applied. The sliding mechanism of the Hifixator was shown to be more durable than those of the other fixators tested for conditions found in application to tibias.

Biomechanical Phenomena↗

PubMed1998

Influence of microdamage on fracture toughness of the human femur and tibia.

The relationship between microdamage accumulation and bone fragility is not well understood. Previous work has demonstrated a positive relationship between microdamage and age in human cortical bone. Prior investigations have also demonstrated that fracture toughness decreases with age in the same bone. Based on these findings, the objective of this study was to test the hypothesis that a decrease in fracture toughness can be attributed to an increase in microdamage density. Microdamage parameters (density, surface density, and average crack length) were measured from bone taken from the shaft of the human femur and tibia and correlated with results from fracture toughness tests of the same bone. Results indicated that there was a weak but significant inverse relationship between fracture toughness and microdamage parameters for tension loading of the femur. These findings suggest that in vivo microdamage observable at the transmitted light level (100x) plays a secondary role to other contributory factors to decreased fracture toughness with age. Results also indicate that this relationship depends on bone ductility that apparently differs between the femur and the tibia. This study, in addition to prior investigations, suggests that crack size (microscopic vs. submicroscopic) and crack origin or type (in vivo vs. stress induced de novo) may influence the relationship between microdamage and bone toughness.

Aged↗

PubMed2000

Bending and fracture of compact circumferential and osteonal lamellar bone of the baboon tibia.

Lamellar bone is common among primates, either in the form of extended planar circumferential arrays, or as cylindrically shaped osteons. Osteonal bone generally replaces circumferential lamellar bone with time, and it is therefore of much interest to compare the mechanical properties and fracture behavior of these two forms of lamellar bone. This is, however, difficult as natural specimens of circumferential lamellar bone large enough for standard mechanical tests are not available. We found that as a result of treatment with large doses of alendronate, the lateral sides of the diaphyses of baboon tibia contained fairly extensive regions of circumferential lamellar bone, the structure of which appears to be indistinguishable from untreated lamellar bone. Three-point bending tests were used to determine the elastic and ultimate properties of almost pure circumferential lamellar bone and osteonal bone in four different orientations relative to the tibia long axis. After taking into account the differences in porosity and extent of mineralization of the two bone types, the flexural modulus, bending strength, fracture strain and nominal work-to-fracture properties were similar for the same orientations, with some exceptions. This implies that it is the lamellar structure itself that is mainly responsible for these mechanical properties. The fracture behavior and morphologies of the fracture surfaces varied significantly with orientation in both types of bone. This is related to the microstructure of lamellar bone. Osteonal bone exhibited quite different damage-related behavior during fracture as compared to circumferential lamellar bone. Following fracture the two halves of osteonal bone remained attached whereas in circumferential lamellar bone they separated. These differences could well provide significant adaptive advantages to osteonal bone function.

Journal Article↗

PubMedDate not supplied

A simple technique for arthroscopic suture fixation of displaced fracture of the intercondylar eminence of the tibia using folded surgical steels.

SUMMARY: The purpose of this article is to describe a new and simple technique for arthroscopic suture fixation of avulsion fractures of the intercondylar eminence of the tibia using surgical steels as both suture passers and suture. The looped ends of 2 folded surgical steels being used as suture passers were inserted through 2 tibial drill holes and through the reduced bone fragment into the knee joint cavity and pulled out through the anteromedial portal in front of the knee joint. Outside the knee joint, a third unbent surgical steel to be used as a suture was tied to the 2 small loops of the folded surgical steels very easily. The ends of the folded surgical steels outside the tibia were then retracted back through the tibial drill holes, thereby automatically bringing the third surgical steel through the holes while making a loop over the avulsed fragment. The advantage of this technique is that the suture can be tied to the suture passers outside of the knee joint.

Adult↗

PubMed2007

Free fibula transfer in the treatment of difficult distal tibia fractures.

Management of the high-grade open distal tibia fracture remains problematic. The authors reviewed the charts of 14 cases of distal tibia and tibial plafond fractures reconstructed with a free fibula transfer. Six cases involved a plafond defect, and the fibula was used to arthrodese the tibio-talar joint. Seven cases included a skin paddle. Three of the four patients with osteomyelitis cleared their infection. Twelve patients went on to osseous union, and two were ultimately treated with amputation. Patients who went on to union had an average of 1.1 subsequent procedures, began full weightbearing in an average of 5.8 months, and were weightbearing without any assistive devices by an average of 8.5 months. There was no significant correlation between the time to full weightbearing and either the presence of infection or the length of the original defect. In this series, 86 percent success was obtained when a free fibula transfer was used either to bridge a tibial non-union or to promote arthrodesis of the tibio-talar joint.

Adult↗