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PubMed2005

Two-stage reconstruction with free vascularized soft tissue transfer and conventional bone graft for infected nonunions of the tibia: 6 patients followed for 1.5 to 5 years.

BACKGROUND: Vascularized soft tissue transfer may give better results of treatment of infected nonunions of the tibia. METHODS: 6 patients with infected nonunion of the tibia and combined soft tissue (70-170 cm(2)) and bony (5-8 cm) defects underwent staged reconstruction. Initial surgery consisted of soft tissue and bone debridement, external fixation, filling of the bony defect with a gentamicin-impregnated cement spacer, and reconstruction of the soft tissue with a free microsurgical muscle flap and skin graft. Second-stage surgery consisted of removal of the cement spacer and osseous reconstruction with nonvascularized bone graft. RESULTS: All patients except 1 achieved full weight-bearing and radiographic consolidation after 7-10 months. This patient required repeated bone grafting and internal plate fixation to heal. There were no cases of recurrence of infection at the latest follow-up, after a mean of 3 (1.5-5) years. INTERPRETATION: Staged reconstruction with free vascularized soft tissue transfer and conventional bone grafting within a cement-induced membrane is a low-risk surgical strategy resulting in a high rate of bone healing.

Adult↗

PubMed1996

Soft-tissue blood flow following reamed versus unreamed locked intramedullary nailing: a fractured sheep tibia model.

A study was performed to compare the effects of reamed versus unreamed locked intramedullary nailing on soft-tissue blood flow in a fractured sheep tibia model. After creation of a standardized short spiral fracture, each tibia was stabilized by insertion of a locked intramedullary nail. Ten animals were randomized into two groups: one that had reaming prior to nail insertion and one that did not. Blood flow was measured in real time, using laser Doppler flowmetry. Skin and muscle perfusion measurements were made at three locations (proximal diaphysis, fracture site, and distal diaphysis) and at five time intervals (postfracture; postnail insertion; and at 2-week, 6-week, and 12-week follow-ups). All animals were sacrificed at 12 weeks postoperatively. Muscle blood flow remained elevated longer in the reamed group than in the unreamed group, following completion of the procedure. Muscle perfusion was significantly greater in the reamed group than in the unreamed group (p < 0.033) and was significantly greater than skin perfusion at 2 weeks (p < 0.024). There was no difference in skin perfusion between the reamed and unreamed groups at any time interval. The study demonstrates that muscle perfusion is altered following reamed and unreamed intramedullary nailing. The findings demonstrate the change in blood flow in the surrounding soft-tissue envelope during the process of revascularization, following devascularization of a segment of tibial cortex by intramedullary nailing.

Animals↗

PubMed1996

Semiextended position of intramedullary nailing of the proximal tibia.

Over a 24 month period, 30 patients with proximal tibia fractures who were reviewed consecutively were treated by nonreamed, statically locked, intramedullary nailing. There were 16 open, 13 segmental, and 7 comminuted fractures (Winquist III, IV). The average distance from the fracture to the proximal locking screws was 24 mm (range, 0-65 mm). All procedures were performed while the patient's affected leg was on a radiolucent table without traction. The last 25 fractures were nailed using a partial (2/3) medial parapatellar incision while the leg was semiextended. This approach allowed the patella to be subluxed laterally availing the trochlear groove for use as a conduit for nail placement. Using only 15 degrees knee flexion eliminated the extension force of the quadriceps on the proximal fragment, which otherwise would have tended to cause anterior angulation at the fracture site. In the first 5 patients, the average anterior angulation was 8 degrees (range, 5 degrees-15 degrees). Of the 25 patients who were treated while in the semiextended position, none had more than 5 degrees anterior angulation and 19 had no anterior angulation. Fractures of 3 of the 25 patients had greater than 5 degrees angulation in the coronal plane, 2 of which were nailed in the semiextended position. This technique greatly facilitates intramedullary nailing of proximal tibia fractures.

Adolescent↗

PubMed1996

Blade plate reconstruction of metaphyseal nonunion of the tibia.

Sixteen patients with nonunion of the metaphyseal region of the proximal or distal tibia after fracture or reconstructive procedures were surgically treated using a fixed angle blade plate and autogenous bone grafting. Eight of these nonunions were complicated by prior sepsis. The average time of followup assessment was 23 months. Fourteen of these 16 nonunions went on to uncomplicated union after the index procedure. Failure of the tibial fracture to unite in 2 patients required further surgical intervention with a ring external fixator. The authors recommend blade plate reconstruction for metaphyseal nonunion of the proximal and distal tibia, especially when complicated by angular deformity, small osteopenic metaphyseal fragments, and stiff adjacent joints.

Adult↗

PubMed1996

Microsurgical treatment of septic nonunion of the tibia. Quality of life results.

The outcome of microsurgical reconstruction of septic nonunion of the tibia was described. The series consisted of 15 patients, with Cierny Stage IVA or IVB septic nonunion of the tibia, who were treated in the microsurgical practice of a major tertiary care hospital. Patients with a documented end point of either union or amputation were eligible for inclusion. Patients were treated with wound excision followed by soft tissue and skeletal reconstruction. The outcome measures of interest included clinical measures (time to union or amputation, surgical complications, wound status) and health related quality of life measures (Short Form-36, Western Ontario and McMaster Universities Osteoarthritis Index, and patient satisfaction questionnaires). The average followup time was 3 years. There was 1 microvascular complication and no failures. Two of 15 patients (both Cierny IVB) required amputation after reconstruction. The time to union after bone grafting was an average of 6.5 months in May et al Type III legs (n = 12), 3 months in May et al Type IV legs (n = 1), and 16 months in May et al Type V legs (n = 2). Nine patients completed the questionnaires; Short Form-36 scores were below normative values for the same age group. Scores on the activity limitation component of the Western Ontario and McMaster Universities Osteoarthritis Index seem to be comparable with those of individual's scores after total knee replacement surgery. Despite relatively low scores on the questionnaires, most patients were either very or completely satisfied with the outcome of surgery. Patients often reported that satisfaction was related to preservation of the limb.

Adolescent↗

PubMed1996

Open fractures of the tibia in children.

Ninety open fractures of the tibia treated at the authors' institution between 1985 and 1994 were retrospectively reviewed. There were 38 Grade I, 35 Grade II, and 17 Grade III fractures. All patients had debridement and lavage of the wound under general anesthesia. Seventeen wounds (19.8%) were closed primarily and 69 (80.2%) were left open. Forty fractures (45.0%) were stabilized in casts, 31 (34.8%) in an external fixator, and 18 (20.2%) with casts and internal fixation. Six patients (7.1%) had superficial infection occur, 2 had vascular injuries, 1 of whom required an amputation, and only 1 had a neurologic injury. The average time to union was 4.5 months (range, 1.2-28.3 months). there were 10 delayed and 7 nonunions. Multiple regression analysis showed that only age of the patient and grade of the fracture were significantly associated with union time. Open fractures of the tibia in children older than 12 years of age have a high risk of developing delayed or nonunion when compared with the same injuries in children younger than 6 years of age.

Adolescent↗

PubMed2001

Effect of shock wave therapy on acute fractures of the tibia: a study in a dog model.

The effect of shock wave therapy on acute fractures of the tibia was studied in eight adult dogs. A fracture with a 3-mm gap was created in both tibias and the fractures were fixed internally with a small metallic plate and screws. Each of the right limbs received 2,000 impulses of shock waves at 14 kV whereas the left limbs were used as controls. The evaluations included the callus formations based on serial radiographic examinations at 1, 4, 8, and 12 weeks and histologic examinations at 12 weeks for tissue distribution including bone tissues. Based on radiographic findings, there was no statistically significant difference in the amount of callus formation between the treated and the control groups at 8 weeks or less. However, the radiographic findings at 12 weeks statistically showed more callus formations in the treated group. In histologic examinations, there was significantly more cortical bone formation in the treated group at 12 weeks and the bone tissues were thicker, denser, and heavier. Shock wave therapy enhanced callus formation and induced cortical bone formation in acute fractures in dogs at 12 weeks. The effect of shock wave therapy seemed to be time-dependent at 3 months.

Animals↗

PubMedDate not supplied

Open fractures of the tibia in children.

We treated 38 patients from 4 to 15 years old and with open growth plates for open fractures of the tibia. The average follow-up was 33 months (range, 9-122). All patients had repeated operative debridement, parenteral antibiotics, and immobilization by cast or fixation. Outcomes were analyzed with respect to age at the time of injury, grade of injury, and type of immobilization. The time to union was prolonged and averaged 21 weeks (range, 6-82). No patients younger than 11 years required bone grafting for union. The deep infection and nonunion rate was 8%, with all of these occurring in patients older than 11 years. Clinically significant leg-length discrepancy or functional limitation was encountered only in patients with an ipsilateral femur fracture or with deep infection requiring osseous debridement. Our data suggest that open tibia fractures in children older than 11 years have nonunion and infection rates that parallel those of adult patients, but that younger children have a more benign course. With aggressive wound care and adequate stabilization, few complications or sequelae should occur in open tibial shaft fractures in younger patients.

Adolescent↗

PubMed1990

Tibia nonunions treated by interlocked nailing: increased risk of infection after previous external fixation.

Eighteen patients, mean age 36 years (range of 22-76 years), with tibia-shaft nonunions were treated with interlocked nailing. There were 12 nonunions originally treated with either cast, lag screws, plate, or Ender nails (nine closed, two open grade I and one grade II injury). The remaining six nonunions, all open fractures (five grade II and one grade III injury) initially received external fixation. After removal of the fixator, 72 days postinjury (range of 58-111 days), there was a delay of 218 days (range of 112-449 days) before the nailing procedure in those patients primarily treated with external fixation. All 12 nonunions not primarily treated with external fixation healed without complications after nailing within 17 weeks (range of 12-24 weeks). All six nonunions primarily treated with external fixation had temporary pin-tract infections, which healed after pin extraction. Two of the nonunions healed without any complication, whereas four developed intramedullary infection with the same bacteria as from the pin-tract site. Although the number of patients is small in this report, there is an apparently high incidence of intramedullary infection in the group originally treated with external fixation. The sequential procedure of external fixation followed by intramedullary nailing is, therefore, not recommended in the treatment of open tibia fractures.

Adult↗

PubMed1994

Limited internal fixation of the tibia with external fixation: an in vivo canine study.

This study reports the results of the healing of canine tibial osteotomies with external fixation alone or in combination with a single lag screw. Twelve dogs had a midshaft tibial osteotomy performed at a 45 degree obliquity. Half of the dogs had a six-pin, unilateral, medial, external half-frame applied after the osteotomy. The remaining six had an identical frame plus a lag screw placed perpendicular to the osteotomy site. When compared with their contralateral controls, the fixator-alone group had a 16.3% (p < 0.05) decrease in bone density, whereas no significant density change was seen in the group with the additional lag screw. Torsional stiffness was 29% higher in the osteotomies treated, and tested, with the lag screw, but this did not achieve statistical significance. Computed tomography scanning revealed that the surface area was increased by an average of 30-40% in both groups, relative to contralateral controls, but there was no difference between the two treatment groups. Three tibias in the group with external fixation alone, and two tibias in the screw group showed primary bone healing without evidence of callus formation. The combination of a semirigid external fixation construct with a lag screw resulted in increased torsional stiffness but healing equal to that seen with external fixation alone.

Animals↗

PubMed1995

Osteomyelitis in grade II and III open tibia fractures with late debridement.

The purpose of this study was to compare the incidence of infection in grade II and III open tibia fractures with respect to early and late debridement. All grade II and III tibia fractures treated between January 1988 and January 1992 were reviewed. Forty-seven fractures (25 grade II and 22 grade III) in 46 patients were eligible for entry into the study. In all grade II and III fractures, one of 15 fractures (7%) debrided in < or = 5 h became infected. Twelve of 32 fractures (38%) debrided > 5 h after injury became infected (p < 0.03). Overt manifestations of infection did not appear until an average of 4.8 months from the time of injury, and the infecting organisms correlated with the initial cultures in only 25% of the cases. Negative postdebridement cultures did not preclude subsequent infection. The Injury Severity Score did not appear to correlate with increased risk of subsequent osteomyelitis.

Adolescent↗

PubMed1996

Biomechanical study of nine different tibia locking nails.

We compared different nail types within the Bone/Implant-Complex to look for differences in stiffness for axial load, bending and torsion of the System. We simulated comminuted mid shaft fractures by a 2-cm defect osteotomy in paired human cadaver tibiae. We fixed tibiae with one of nine different interlocking nails [AO Unreamed Tibial Nail 9 mm (UTN9), AO Unreamed Tibial Nail 8 mm (UTN8), Russell & Taylor Delta Tibial Nail 9 mm (RTD), Russell & Taylor Reconstruction Tibial Nail 11 mm (RTR), Brooker & Wills Tibial Nail 11 mm (B&W), Grosse & Kempf Tibial Nail 11 mm (G&K), AO Universal Tibial Nail 11 mm (AOU), Klemm & Schellmann Tibial Nail 11 mm (K&S), and Börner & Mattheck Tibial Nail 11 mm (B-M)] according to the manufacturer's recommendations. In torque testing the unslotted nails (UTN9, UTN8, RTD, RTR, B&W) showed significantly higher stiffness compared to the slotted nails (G&K, AOU, K&S, B-M). Compared to intact bone, both groups of nails were significantly less stiff. In axial load testing large diameter nails interlocked by large diameter interlocking bolts (G&K, K&S, B-M) showed significantly higher stiffness. For A-P bending no significant differences between implants were found, but isolated bones showed significantly higher A-P bending stiffness. In varus-valgus bending large diameter nails (RTR, G&K, K&S, B-M) showed significantly higher bending stiffness compared to low diameter (UTN8, B&W) implants.

Adult↗

PubMed2000

Treatment of closed tibia shaft fractures: a survey from the 1997 Orthopaedic Trauma Association and Osteosynthesis International--Gerhard Küntscher Kreis meeting.

OBJECTIVE: To identify any consensus of opinion regarding treatment and outcome of a closed mid-shaft tibia fracture among orthopedic surgeons. DESIGN: Survey. SETTING: 1997 combined meeting of the Orthopaedic Trauma Association and Osteosynthesis International-Gerhard Küntscher Kreis. MAIN OUTCOME MEASUREMENT: Percentage of responses to key questions. Proportion test (nonparametric) for statistical significance. RESULTS: There is no consensus of opinion regarding treatment for this fracture type. Wide variation exists between and within the different subgroups of orthopaedic surgeons surveyed. CONCLUSIONS: This brings into focus the spectrum of acceptable care for the management of fractures. More studies must be conducted to identify optimal treatment for closed mid-shaft tibia fractures.

Adult↗

PubMed2001

Soft tissue injuries with the use of safe corridors for transfixion wire placement during external fixation of distal tibia fractures: an anatomic study.

OBJECTIVES: To determine which soft tissue structures are at risk and when joint violation can occur during small wire placement for hybrid external fixation of distal tibial fractures while adhering to published guidelines. DESIGN: Cadaver anatomic experiment. SETTING: University orthopaedic program. SUJBECTS: Five embalmed cadavers. INTERVENTION: Placement of small wire transfixion pins in the distal tibia. MAIN OUTCOME MEASUREMENTS: Dissection and measurements. METHODS: Four orthopaedic surgeons were shown diagrams that have been widely accepted as allowing for placement of transfixion pins in the distal tibia through safe corridors. Each of the orthopaedic surgeons was then asked to place two transfixion pins into each of five cadaver legs in a position that would provide stable external fixation of the metaphysis to the diaphysis with a circular fixator (forty pins total) for a distal tibial fracture within five centimeters of the plafond. The specimens were dissected, and pins impaling neurovascular structures, tendons, or the ankle capsule were recorded. The superior capsular synovial reflections were measured from the anterior joint line and the tip of the medial malleolus. These measurements were also performed on arthrograms of two extremities before their dissection. RESULTS: Fifty-five percent of the pins placed impaled at least one tendon that crosses the ankle joint. Neurovascular structures that were impaled included the saphenous vein (+/-10.5 percent) and the superficial peroneal nerve (+/-7.5 percent). One pin violated the superior capsular synovial reflection, which was an average of thirty-two millimeters (+/-1.58 millimeters) from the tip of the medial malleolus and twenty-one millimeters (+/-1.63 millimeters) from the anteromedial joint line. CONCLUSIONS: This study shows that tendons and neurovascular structures above the ankle are at risk during small transfixion pin placement, even when using safe corridors. Pins placed within two centimeters of the anterior joint line or three centimeters from the medial malleolus may be intracapsular.

Bone Nails↗

PubMed2003

Influence of extensive muscle injury on fracture healing in rat tibia.

OBJECTIVES: The treatment of tibial fractures associated with severe soft tissue injury remains a challenge. The objective of our experiment was to ascertain the influence of standardized muscle injuries on fracture healing in a nailed rat tibial fracture model. We hypothesized that a severe crush injury of leg muscles might not be as deleterious to fracture healing as total loss of a large muscle segment. STUDY DESIGN: A randomized study in male Wistar rats with a diaphyseal osteotomy. METHODS: Three separate, but complementary experiments were done in 51 rats. The first experiment involved 30 rats randomly assigned to three increasingly severe soft tissue interventions in a nailed tibial osteotomy model. The second experiment involved 14 rats divided into two groups to study blood flow measurements of the muscle envelope after soft tissue injury. Seven rats were used in the third experiment to provide biomechanical data and dimensions of the rat tibia. The protocol for the first experiment was intramedullary nailing after a middiaphyseal osteotomy of the left tibia. In group A, the soft tissue injury was minimal, while the muscles in the anterolateral compartment were crushed in group B. Resection of the anterolateral compartment muscles, resulting in only skin coverage at the fracture site, was performed in group C. The fibular nerve was resected in all three groups so that the animals were non-weight bearing on the operated extremity. At 4 weeks, the healing bones in each group were studied clinically, radiographically, and biomechanically. RESULTS: Radiographs in two planes revealed a clearly visible fracture line in the three intervention groups at 4 weeks. The callus area following muscle resection in group C was significantly reduced compared with the minimal soft tissue injury in group A. Biomechanically, resection of the anterolateral compartment muscles in group C reduced maximum bending load and fracture energy compared with fractures with minimal soft tissue injury in group A, while bending rigidity and fracture energy was reduced compared with muscle crush in group B. No difference in mechanical characteristics was detected between the healing bones in groups A and B. CONCLUSION: This animal study indicates that crushing of the leg muscle envelope with reduced blood flow does not influence the quality of bone healing at 4 weeks to a significant degree. Resection of a large muscle segment impairs tibial fracture healing significantly.

Animals↗

PubMed2004

Functional outcome after blade plate reconstruction of distal tibia metaphyseal nonunions: a study of 11 cases.

OBJECTIVES: To present the functional outcome of a cohort of 11 patients prospectively followed before and after blade plate reconstruction of a distal tibia metaphyseal nonunion. DESIGN: Prospective case series. SETTING: University hospital tertiary referral center. PATIENTS: Eleven patients with an average age of 48 years. Average duration of nonunion was 11 months. Patients had undergone an average of 3.1 procedures before the index surgery. Three patients had prior deep infections, and one patient had an active infection. INTERVENTION: A precontoured 4.5-mm cannulated blade plate was applied to the medial tibial surface through a posteromedial approach. Autograft was added in eight patients to fill bone voids. MAIN OUTCOME MEASURES: AOFAS scores were assigned to each patient preoperatively and at most recent follow-up. RESULTS: All patients healed their nonunions after the index surgery. Average time to radiographic union was 16 weeks. Average time to full weight bearing was 12 weeks. AOFAS scores improved in all patients from an average preoperative score of 29 to an average postoperative score of 89. The only complication was a deep infection, which was treated successfully with one irrigation and débridement and 6 weeks of intravenous antibiotics. CONCLUSION: Blade plate reconstruction of distal tibia metaphyseal nonunion is a safe and reliable method that results in a high union and low complication rate.

Adult↗

PubMed2004

Rotational malalignment of the tibia following reamed intramedullary nail fixation.

OBJECTIVE: To determine the incidence and severity of tibial malrotation following reamed intramedullary nail fixation as measured by computerized tomography and to determine the repeatability of computed tomography measurement in the assessment of rotational malreduction. DESIGN: Prospective cohort. SETTINGS: Level 1 trauma center. PARTICIPANTS: Twenty-five consecutive patients with 25 tibial shaft fractures. INTERVENTION: All patients were treated with reamed intramedullary nailing. Appropriate radiographs and a postoperative lower extremity computed tomography scan were obtained for each patient who consented to the study. MAIN OUTCOME MEASURE: Rotational alignment of affected tibia as compared to a version of the normal contralateral limb. Malrotation was defined as an internal/external rotation deformity greater than 10degrees. RESULTS: Malrotation, comparing the fractured limb to normal limb, was determined using a similar measurement method previously described in the literature. Two patients declined inclusion, and in one case, the computed tomography was not acceptable for analysis. Malrotation, comparing the fractured limb to the normal limb, was determined using the measurements from axial computed tomography images. Results revealed a mean absolute rotational difference of 6.7degrees (SD +/-6.3degrees). Rotational malreduction ranged from 15degrees of internal rotation to 22degrees of external rotation. Five of the 22 tibia (22%) were malrotated greater than 10degrees. A larger degree of deformity was seen with certain injury patterns. The intraobserver and interobserver repeatability testing revealed a mean absolute difference between paired malrotation calculations of 3.4degrees and 3.9degrees, respectively, and a repeatability coefficient of 8degrees for both. CONCLUSION: Computed tomography measurement is a repeatable method of assessing tibial torsion and in this study revealed a significantly higher incidence of rotational malreduction than that previously reported in the literature.

Adolescent↗

PubMed2004

Treatment of proximal tibia fractures using the less invasive stabilization system: surgical experience and early clinical results in 77 fractures.

OBJECTIVE: To summarize the surgical experience and clinical results of the first 89 fractures of the proximal tibia treated with the Less Invasive Stabilization System (LISS; Synthes, Paoli, PA). DESIGN: Retrospective analysis of prospectively enrolled patients into a database. SETTING: Academic level I trauma center. SUBJECTS/PARTICIPANTS: Eighty-seven consecutive patients with 89 proximal tibia fractures (AO/OTA type 41 and proximal type 42 fractures) treated by 2 surgeons. Seventy-five patients with 77 fractures were followed until union. The mean follow-up was 14 months (range: 3-35 months). There were 55 closed fractures and 22 open fractures. INTERVENTION: Surgical reduction and fixation of fractures, followed by rehabilitation. MAIN OUTCOME MEASUREMENTS: Perioperative and postoperative complications, postoperative alignment, loss of fixation, time to full weight bearing, radiographic union, and range of motion. RESULTS: Seventy of 77 fractures healed without major complications (91%). There were 2 early losses of proximal fixation, 2 nonunions, 2 deep delayed infections, and 1 deep peroneal nerve palsy. Other complications included a superficial wound infection and 3 seromas. Postoperative malalignment occurred in 7 patients with 6 degrees to 10 degrees of angular deformity (6 flexion/extension and 1 varus/valgus malalignments), and an eighth patient had a 15 degrees flexion deformity. In 4 patients, the hardware was removed at an average of 13 months because of irritation (5%). The mean time for allowance of full weight bearing was 12.6 weeks (range: 6-21 weeks), and the mean range of final knee motion was 1 degrees to 122 degrees . CONCLUSIONS: The LISS provides stable fixation (97%), a high rate of union (97%), and a low (4%) rate of infection for proximal tibial fractures. The technique requires the successful use of new and unfamiliar surgical principles to effect an accurate reduction and acceptable rate of malalignment.

Adolescent↗