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Objectives To report the progression of radiographic healing after intramedullary nailing of tibial shaft fractures using the Radiographic Union Score for Tibial fractures (RUST) and determine the ideal timing of early post-operative radiographs. Design Retrospective case series. Setting Urban academic Level 1 trauma center. Patients/participants 303 acute tibial shaft fractures underwent intramedullary nailing between 2006-2013, met inclusion criteria, and had at least three months of radiographic follow-up. Intervention Baseline demographic, injury, and surgical data were recorded for each patient. Each set of post-operative radiographs were scored using RUST and evaluated for implant failure. Main outcome measurements Post-operative time distribution for each RUST score, RUST score distribution for four common follow-up time points, and the presence and timing of implant failure. Results The 5th percentile and median times, respectively for reaching: "any radiographic healing" (RUST= 5) was 4.0 weeks and 8.4 weeks, "radiographically healed" (RUST=9) was 12.1 and 20.9 weeks, and "healed and remodeled" (RUST=12) was 23.5 weeks and 47.7 weeks. At six weeks, 84% of radiographs were scored as RUST≤6 (two or fewer cortices with callus). No implant failure occurred within the first eight weeks after surgery and the indication for all seven reoperations within this period was apparent on physical examination or immediate post-operative radiographs. Conclusions The median time to radiographic union (RUST=9) after tibial nailing was approximately twenty weeks and little radiographic healing occurred within the first eight weeks after surgery. Routine radiographs in this time period may offer little additional information in the absence of clinical concerns such as new trauma, malalignment, or infection. Level of evidence Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To evaluate the outcomes of patients who underwent soft tissue flap coverage during treatment of a tibia fracture nonunion. DESIGN Retrospective analysis on prospectively collected data. SETTING Academic medical center. PATIENTS/PARTICIPANTS One hundred fifty-seven patients were treated for a fracture nonunion after a tibia fracture over a 15-year period. Sixty-six patients had sustained an open tibial fracture initially and 25 of these patients underwent soft tissue flaps for their open tibia fracture nonunion. INTERVENTION Manipulation of soft tissue flaps, either placement or elevation for graft placement in ununited previously open tibial fractures. MAIN OUTCOME MEASUREMENTS Bony healing, time to union, ultimate soft tissue status, postoperative complications, and functional outcome scores using the Short Musculoskeletal Functional Assessment (SMFA). This group was compared with a group of open tibial fracture nonunions that did not undergo soft tissue transfer. RESULTS Bony healing was achieved in 24 of 25 patients (96.0%) who received flaps at a mean time to union of 8.7 ± 3.3 months compared with 39 of 41 patients (95.1%) at a mean 7.5 ± 3.2 months (P > 0.05) in the noncoverage group. Healing rate and time to union did not differ between groups. At latest follow-up, the flap coverage group reported a mean SMFA index of 17.1 compared with an SMFA index of 27.7 for the noncoverage group (P = 0.037). CONCLUSIONS Utilization of soft tissue flaps in the setting of open tibia shaft nonunion repair surgery are associated with a high union rate (>90%). Coverage with or manipulation of soft tissue flaps did not result in improved bony healing rate or time to union compared with those who did not require flaps. However, soft tissue flap coverage was associated with higher functional scores at long-term follow-up. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To identify a group of ballistic tibia fractures, report the outcomes of these fractures, and compare them with both closed and open tibia fractures sustained by blunt mechanisms. We hypothesized that ballistic tibia fractures and blunt open fractures would have similar outcomes. DESIGN Retrospective cohort study. SETTING A single Level-1 trauma center. PATIENTS/PARTICIPANTS Adult patients presenting with ballistic (44), blunt closed (179), or blunt open (179) tibia fractures. INTERVENTION Intramedullary stabilization of tibia fracture. MAIN OUTCOMES Unplanned reoperation, soft tissue reconstruction, nonunion, compartment syndrome, and fracture-related infection. RESULTS Compared with the blunt closed group, the ballistic fracture group required more operations (P < 0.01), had a higher occurrence of soft tissue reconstruction (P < 0.01), and higher incidence of compartment syndrome (P = 0.02). Ballistic and blunt closed groups did not significantly differ in rates of unplanned reoperation (P = 0.67), nonunion (11.4% vs. 4.5%, P = 0.08), or deep infection (9.1% vs. 5.6%, P = 0.49). In comparison to the blunt open group, the ballistic group required a similar number of operations (P = 0.12), had similar rates of unplanned reoperation (P = 0.10), soft tissue reconstruction (P = 0.56), nonunion (11.4% vs. 17.9%, P = 0.49), and fracture-related infection (9.1% vs. 10.1%, P = 1.0) but a higher incidence of compartment syndrome (15.9% vs. 5.0%, P = 0.02). CONCLUSIONS Ballistic tibia fractures require more surgeries and have higher rates of soft tissue reconstruction than blunt closed fractures and seem to have outcomes similar to lower severity open fractures. We found a significantly higher rate of compartment syndrome in ballistic tibia fractures than both open and closed blunt fractures. When treating ballistic tibia fractures, surgeons should maintain a high level of suspicion for the development of compartment syndrome and counsel patients that ballistic tibia fractures seem to behave like an intermediate category between closed and open fractures sustained through blunt mechanisms. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives To investigate the complication rates after use of retained adjunctive plate (RAP) fixation with intramedullary nailing of Gustilo-Anderson type IIIB open tibia fractures, as part of a 2-stage orthoplastic approach. Design Consecutive cohort study. Patients/participants One hundred and thirty-seven consecutive patients with a Gustilo-Anderson type IIIB open diaphyseal tibia fracture (OTA/AO 42) treated between May 2014 and January 2018. Ninety-eight patients (RAP = 67; non-RAP = 31) met the inclusion criteria and underwent 2-stage reconstruction. All patients were treated using a small fragment adjunctive plate to hold the fracture reduced before intramedullary nailing. Intervention At stage 2, the temporary small fragment (in-fix) plate was removed and the site further thoroughly debrided. After this, the fracture is reduced and held with a new small fragment plate to facilitate the definitive intramedullary nailing. This new plate was either retained (RAP) as part of the definitive fixation at second stage or removed before wound coverage. Main outcome measurement The main outcome measures were reoperation rate, deep infection, nonunion, and flap-related complication. Results Six patients (6/98, 6.1%) proceeded to nonunion (RAP 5/67, non-RAP 1/31). This was not significant (P = 0.416). Two hundred twelve operations were undertaken, and the median was 2. Sixteen (16/212, 7.5%) complication-related reoperations were undertaken, affecting 8 patients (8/67, 11.9%) in the RAP group. Eight patients (8/98, 8.2%) developed a deep infection (RAP 6/67, non-RAP 2/31). This was not significant (P = 0.674). Conclusions In the context of an orthoplastic approach, the use of a RAP with definitive intramedullary nailing does not seem to significantly increase the rate of deep infection or nonunion in patients with type IIIB open tibial shaft fractures. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE To assess the outcomes of patients who sustained blunt trauma tibia fractures compared with tibia fractures from civilian gunshot injuries when treated with intramedullary fixation. DESIGN Retrospective chart review. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Two hundred and seven patients underwent intramedullary nailing for 211 tibia fractures. METHODS A retrospective review of tibia fracture(s) treated with intramedullary fixation with comparison of closed, open, and gunshot wound (GSW) fracture outcomes. MAIN OUTCOME MEASUREMENTS Outcomes included infection and nonunion. RESULTS The infection rate in closed and GSW tibia fractures was significantly lower compared with the infection rate of open fractures (1% vs. 9% vs. 20%; P = 0.00005). Significantly lower rates of nonunion in closed fractures compared with open fractures and GSW fractures were appreciated (8% vs. 20% vs. 30%; P = 0.003). There was no difference in infection or nonunion between GSW fractures with small wounds, no exposed bone, and minimal comminution and closed injuries (P = 0.24, P = 0.60). Conversely, there was a significantly higher nonunion rate in GSW fractures with large wounds, exposed tibia, and comminution compared with blunt injuries (P = 0.0014). CONCLUSIONS This study suggests that tibia fractures from civilian GSWs are heterogeneous injuries, and outcomes are dependent on the extent of soft-tissue injury, bone exposure, and bone loss. There are comparable infection rates in all fractures due to civilian GSWs and closed fractures, which are lower than high-grade open fractures. Tibia GSW fractures with exposed bone and comminution have higher complication rates and should be treated accordingly. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives To evaluate the reliability, sensitivity, and specificity of the Squat and Smile (S&S) test, a clinical photographic follow-up, in determination of fracture healing and to assess the extent of continued fracture healing beyond 1-year postoperation. Design Retrospective review of the Surgical Implant Generation Network (SIGN) database. Setting The S&S test is utilized in low-resource settings where the SIGN intramedullary nail is used due to unavailability of intraoperative fluoroscopy. Patients/participants One hundred fifty patients undergoing fracture fixation utilizing SIGN intramedullary nails with data available at least 1 year (9-16 months) after surgery. Intervention None. Main outcome measures We extracted clinical data and calculated scores for the S&S photographs and radiographs at the 1-year (9-16 month postoperative) follow-up and last follow-up available beyond that. We analyzed the sensitivity of S&S scoring, using Radiographic Union Scale for Tibia fracture scores as the gold standard for fracture union. Results Of the 126 patients analyzed, 21% were found to have incomplete healing at 1 year, whereas 17% of the 64 patients with further follow-up past 1 year had incomplete healing. We found that both S&S and radiographic fracture healing scores had good interrater reliability (k = 0.73-0.78 for S&S and 0.94 for radiographs). The S&S test had poor sensitivity (0.11) and specificity (0.85) in determining fracture healing at the 1-year follow-up. Conclusions The S&S scoring method was reliable but neither sensitive nor specific for determining fracture healing at 1 year. Fractures deemed incompletely healed by radiographic evaluation at 1 year after SIGN implant may still have the potential to heal over time. Level of evidence Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES: To evaluate inter-rater reliability of the modified Radiographic Union Score for Tibial (mRUST) fractures among patients with open, diaphyseal tibia fractures with a bone defect treated with intramedullary nails (IMNs), plates, or definitive external fixation (ex-fix). DESIGN: Retrospective cohort study. SETTING: 15 level one civilian trauma centers; 2 military treatment facilities. PATIENTS/PARTICIPANTS: Patients ≥18-years-old with open, diaphyseal tibia fractures with a bone defect ≥1 centimeter surgically treated between 2007 and 2012. INTERVENTION: Three of six orthopaedic traumatologists reviewed and applied mRUST scoring criteria to radiographs from the last clinical visit within 13 months of injury. MAIN OUTCOME MEASUREMENTS: Inter-rater reliability was assessed using Krippendorff’s Alpha (KA) statistic; Intraclass correlation coefficient (ICC) is presented for comparison to previous publications. RESULTS: 213 patients met inclusion criteria including 115 IMNs, 24 plates, 29 ex-fixes, and 45 cases that no longer had instrumentation at evaluation. All reviewers agreed on the pattern of scoreable cortices for 90.4% of IMNs, 88.9% of those without instrumentation, 44.8% of rings, and 20.8% of plates. Thirty-one (15%) cases, primarily plates and ex-fixes, did not contribute to KA and ICC estimates because

The use of percutaneous clamps is often a helpful tool to aid reduction and intramedullary nailing of distal tibial spiral diaphyseal fractures. However, the anterior and posterior neurovascular bundles are at risk without careful clamp placement. We describe our preferred technique of percutaneous clamp reduction for distal spiral tibial fractures with a distal posterolateral fracture spike, with care to protect the adjacent neurovascular structures. We also investigated the relationship between these neurovascular structures and the site of common percutaneous clamp placement. Preoperative computed tomography images of surgically managed patients who sustained this specific common fracture pattern (distal third spiral diaphyseal tibia fracture with a posterolateral fragment) were retrospectively reviewed. On computed tomography, we extrapolated the ideal virtual clamp site on the posterolateral fracture fragment to facilitate reduction. The average distance of this clamp position from the anterior neurovascular bundle was 14 mm (SD = 7.6), with a range of 6-32 mm. The average distance of the clamp site from the posterior neurovascular bundle was 19 mm (SD = 6.1), with a range of 11-30 mm. In 31% of patients, the distal fragment's apex extended anterior to the interosseous membrane, and in 69% of patients, the apex was posterior to the interosseous membrane. We also describe our preferred surgical technique with percutaneous clamping and tibial nailing, which involves sliding the posterolateral tine of the percutaneous clamp along the lateral tibial cortex to prevent neurovascular bundle injury.

Pediatric phalangeal fractures are extremely common, especially among toddlers and older children/adolescents involved in sporting activities. The physical examination must include an assessment for deviation and malrotation. In addition, concomitant injuries must be assessed for such as tendon and/or neurovascular injuries. Plain radiographs are typically sufficient to make the diagnosis and determine the treatment. The majority of pediatric and adolescent phalangeal fractures can be treated with immobilization. Substantial deviation and malrotation must be addressed with closed reduction techniques with or without percutaneous pinning. Open reduction is reserved for cases with concomitant injuries, open fractures, older adolescents, and patients in whom an adequate closed reduction cannot be obtained. When diagnosed and treated appropriately, pediatric and adolescent phalangeal fractures typically result in excellent outcomes.

OBJECTIVE To develop a clinically useful prediction model of success at the time of surgery to promote bone healing for established tibial nonunion or traumatic bone defects. DESIGN Retrospective case controlled. SETTING Level 1 trauma center. PATIENTS Adult patients treated with surgery for established tibia fracture nonunion or traumatic bone defects from 2007 to 2016. Two hundred three patients met the inclusion criteria and were available for final analysis. INTERVENTION Surgery to promote bone healing of established tibia fracture nonunion or segmental defect with plate and screw construct, intramedullary nail fixation, or multiplanar external fixation. MAIN OUTCOME MEASURES Failure of the surgery to promote bone healing that was defined as unplanned revision surgery for lack of bone healing or deep infection. No patients were excluded who had a primary outcome event. RESULTS Multivariate logistic modeling identified 5 significant (P < 0.05) risk factors for failure of the surgery to promote bone healing: (1) mechanism of injury, (2) Increasing body mass index, (3) cortical defect size (mm), (4) flap size (cm), and (5) insurance status. A prediction model was created based on these factors and awarded 0 points for fall, 17 points for high energy blunt trauma (OR = 17; 95% CI, 1-286, P = 0.05), 22 points for industrial/other (OR = 22; 95% CI, 1-4, P = 0.04), and 28 points for ballistic injuries (OR = 28; 95% CI, 1-605, P = 0.04). One point is given for every 10 cm of flap size (OR = 1; 95% CI, 1-1.1, P < 0.001), 10 mm of mean cortical gap distance (OR = 1; 95% CI, 1-2, P = 0.004), and 10 units BMI, respectively (OR = 1.5; 95% CI, 1-3, P = 0.16). Two points are awarded for Medicaid or no insurance (OR = 2; 95% CI, 1-5, P = 0.035) and 3 points for Medicare (3; 95% CI, 1-9, P = 0.033). Each 1-point increase in risk score was associated with a 6% increased chance of requiring at least 1 revision surgery (P < 0.001). CONCLUSIONS This study presents a clinical score that predicts the likelihood of success after surgery for tibia fracture nonunions or traumatic bone defects and may help clinicians better determine which patients are likely to fail these procedures and require further surgery.

Objective To compare the magnitude of knee pain between the suprapatellar (SP) and infrapatellar (IP) approach for tibial nailing in patients who are more than 1 year after injury. Design Retrospective cohort study. Setting Academic Level I trauma center. Patients/participants All tibia fracture patients 18-80 years of age treated with an intramedullary tibial nail during a 5-year period were retrospectively reviewed for inclusion. The surgical approach was determined by surgeon preference, with 3 of the 9 surgeons routinely using the SP approach. The primary outcome was knee pain during kneeling, with secondary assessments comparing knee pain during resting, walking, and the past 24 hours. Intervention Intramedullary nailing of a tibia fracture with either the SP or IP approach. Main outcome measurements Knee pain assessed with the Numeric Rating Scale between 0 and 10. A difference of >1.0 was considered to be clinically meaningful. Results The study group consisted of 262 patients (SP, n = 91; IP, n = 171) with a mean age of 41.4 years (SD = 16.6). The median follow-up was 3.8 years (range: 1.5-7.0). No difference in knee pain during kneeling was detected between the surgical approaches (IP: 3.9, SP 3.8; P = 0.90; mean difference: -0.06, 95% confidence interval, -1 to 0.9). Similarly, no differences were detected in average knee pain scores at rest (IP: 2.0, SP: 2.0; P = 1.00), walking (IP: 2.7, SP 3.0; P = 0.51), or the last 24 hours (IP: 2.6, SP 2.9; P = 0.45). Conclusions In contrast to a study conducted by Sun et al, in which there was a statistical difference in knee pain between the SP and IP surgical approaches, we did not detect any statistical or clinical differences in knee pain between the SP and IP surgical approaches among patients with greater than 12 months of follow-up. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective To evaluate the efficacy of intramedullary nailing of distal tibia fractures using modern techniques, without fibula fixation, in obtaining and maintaining alignment. Design Retrospective case review. Setting Level-I academic trauma center. Patients One hundred thirty-two consecutive patients with distal tibia fractures. Intervention Intramedullary nail of distal tibia fracture, without fibula fixation, was performed in consecutive patients using modern reduction techniques. Main outcome measures Malalignment and malunion were defined as >5 degrees of varus/valgus angulation or anterior/posterior angulation on the initial postoperative or final anteroposterior and lateral x-rays. Results There were 122 consecutive patients (86 men and 36 women) 16-93 years of age (average, 43 years) with 36 (30%) open and 85 (70%) closed fractures with complete follow-up. Mechanism of injury did not predict the presence or level of fibula fracture. Upon presentation, varus/valgus and procurvatum/recurvatum angulation was greatest when the fibula was fractured at the level of the tibia fracture (P = 0.001 and 0.028). The most common intraoperative reduction aids were nailing in relative extension, transfixion external fixation, and clamps at the fracture site. The OTA fracture type or level/presence of fibula fracture did not influence malalignment (P = 0.86 and 0.66), malunion (P = 0.81 and 0.79), or the change in alignment during union, which averaged 0.9 degrees. Conclusions We found an overall low rate of both malalignment (2%) and malunion (3%) after intramedullary nailing of distal tibial shaft fracture without fibula fixation. We conclude that when modern nailing techniques are used, which allow for confirmation of reduction by visualization in fluoroscopy, from nail placement to distal interlocking, fibula fixation is not necessary to obtain or maintain alignment. Furthermore, standard 2 medial to lateral screws distally afford adequate stability to hold the reduction during union with a 0.9-degree difference in the initial postoperative and final united films. Level of evidence Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives To quantify the impact of compartment syndrome in the setting of tibial shaft fracture on hospital length of stay (LOS) and total hospital charges. Design Retrospective case-control study. Setting All New York State hospital admissions from 2001 to 2011, as recorded by the New York Statewide Planning and Research Cooperative System database. Patients Thirty three thousand six hundred twenty-nine inpatients with isolated open or closed fractures of the tibia and/or fibula (AO/OTA 41-43). Six hundred ninety-two patients developed a compartment syndrome in the setting of tibia fracture. All patients were filtered to ensure none had other complications or medical comorbidities that would increase LOS or total hospital charges. Intervention Fasciotomy and delayed closure in patients who developed a compartment syndrome. Main outcome measure Hospital LOS (days) and total inflation-adjusted hospital charges. Results A total of 33,629 patients with tibial shaft fracture were included in the study. There were 32,937 patients who did not develop a compartment syndrome. For this group, the mean LOS was 6 days, and the mean inflation-adjusted hospital charges were $34,000. Patients who developed compartment syndrome remained in-house for an average of 14 days with average charges totaling $79,000. These differences were highly significant for both lengths of stay and hospital charges (P Conclusions Besides the obvious physical detriment experienced by patients with compartment syndrome, there is also a significant economic impact to the healthcare system. Compartment syndrome after a tibial fracture more than doubles LOS and total hospital charges. These findings highlight the need for a standardized care algorithm aimed toward efficiently and adequately treating acute compartment syndrome. Such an algorithm would optimize cost of care and presumably decrease LOS. Level of evidence Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

To determine the correlation between the OTA/AO classification of tibia fractures and the development of acute compartment syndrome (ACS).Retrospective review of prospectively collected database.Single Level 1 academic trauma center.All patients with a tibia fracture from 2006 to 2016 were reviewed for this study. Three thousand six hundred six fractures were initially identified. Skeletally mature patients with plate or intramedullary fixation managed from initial injury through definitive fixation at our institution were included, leaving 2885 fractures in 2778 patients.After database and chart review, univariate analyses were conducted using independent t tests for continuous data and χ tests of independence for categorical data. A simultaneous multivariate binary logistic regression was developed to identify variables significantly associated with ACS.ACS occurred in 136 limbs (4.7%). The average age was 36.2 years versus 43.3 years in those without (P0.001). Men were 1.7 times more likely to progress to ACS than women (P = 0.012). Patients who underwent external fixation were 1.9 times more likely to develop ACS (P = 0.003). OTA/AO 43 injuries were at least 4.0 times less likely to foster ACS versus OTA/AO 41 or 42 injuries (P0.007). OTA/AO 41-C injuries were 5.5 times more likely to advance to ACS compared with OTA/AO 41-A (P = 0.03). There was a significantly higher rate of ACS in OTA/AO 42-B (P = 0.005) and OTA/AO 42-C (P = 0.002) fractures when compared with OTA/AO 42-A fractures. In the distal segment, fracture type did not predict the risk of ACS (P0.15). Group 1 fractures had a lower rate of ACS compared with group 2 (P = 0.03) and group 3 (P = 0.003) fractures in the middle segment only. Bilateral tibia fractures had a 2.7 times lower rate of ACS (P = 0.04). Open injury, multiple segment injury, fixation type, and concurrent pelvic or femoral fractures did not predict ACS.In this large cohort of tibia fractures, we found that the age, sex, and OTA/AO classification were highly predictive for the development of ACS.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

© Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved. Objective: To study the activity and incidence of knee pain after sustaining an isolated tibia fracture treated with an infrapatellar intramedullary nail at 1 year. Design: Retrospective review of prospective cohort. Setting: Multicenter Academic and Community hospitals. Patients: Four hundred thirty-seven patients with an isolated tibia fracture completed a 12-month assessment on pain and self-reported activity. Intervention: Infrapatellar intramedullary nail. Outcomes: Demographic information, comorbid conditions, injury characteristics, and surgical technique were recorded. Knee pain was defined on a 1-7 scale with 1 being "no pain" and 7 being a "very great deal of pain." Knee pain >4 was considered clinically significant. Patients reported if they were "able," "able with difficulty," or "unable" to perform the following activities: kneel, run, climb stairs, and walk prolonged. Variables were tested in multilevel multivariable regression analyses. Results: In knee pain, 11% of patients reported a "good deal" to a "very great deal" of pain (>4), and 52% of patients reported "no" or "very little" pain at 12 months. In activity at 12 months, 26% and 29% of patients were unable to kneel or run, respectively, and 31% and 35% of patients, respectively, stated they were able with difficulty or unable to use stairs or walk. Conclusions: Clinically significant knee pain (>4/7) was present in 11% of patients 1 year after a tibia fracture. Of note, 31%-71% of patients had difficulty performing or were unable to perform routine daily activities of kneeling, running, and stair climbing, or walking prolonged distances.

OBJECTIVES To quantify the radiographic tibia and fibula shaft fracture characteristics that are associated with a concomitant ipsilateral ankle injury. DESIGN Retrospective case-control study. SETTING Academic level I trauma center. PATIENTS Seventy-one adult patients with an operatively treated tibial shaft fracture met the inclusion/exclusion criteria. INTERVENTION Preoperative radiographs were categorized according to tibia and fibula fracture pattern, location and spatial relationship to each other. Preoperative computed tomographic scans were then evaluated to assess for the presence of an articular ankle injury. MAIN OUTCOME MEASUREMENTS (1) incidence of concomitant tibial shaft fracture and ipsilateral ankle injury; and (2) statistical association between tibia and fibula fracture characteristics in patients with and without an ipsilateral ankle fracture. RESULTS Thirty-five of 71 (49.3%) tibial shaft fracture patients had a concomitant ipsilateral ankle injury. Of these, 31 (88.6%) ankle injuries occurred in patients with a spiral pattern tibia fracture of the distal third diaphysis (P < 0.001). A spiral pattern tibia fracture, a distal one-third tibial shaft fracture location, or a spiral pattern fibula fracture all were significantly associated with the presence of an ipsilateral ankle injury (P ≤ 0.001; P = 0.001; and P = 0.002, respectively). Patients with either a transverse pattern or absent fibula fracture, a nonspiral pattern tibia fracture, or a midshaft diaphyseal tibia fracture location were significantly less likely to have an associated ankle injury (P ≤ 0.001; P ≤ 0.001; and P = 0.012, respectively). CONCLUSIONS Ipsilateral ankle fractures are commonly associated with tibial shaft fractures, specifically distal one-third spiral type injuries. Recognition of an associated ankle injury is important as it can alter operative and postoperative management. Clinical studies are needed to examine patient outcomes with or without ipsilateral ankle injury to determine the clinical significance of this entity. LEVEL OF EVIDENCE Prognostic level IV. See instructions for authors for a complete description of levels of evidence.

BACKGROUND The Masquelet technique is a relatively new option in the management of bone defects. It consists of 2-stage surgery. At first surgery, a cement spacer is placed to fill the bone defect. After a waiting period of 6-8 weeks, a pseudo-synovial membrane is formed around the cement. The induced membrane is rich in vascularity and osteogenic activity. At second surgery, the cement is replaced with an autologous bone graft and the graft is packed in the membrane. To harvest large quantities of bone graft, the reamer irrigator aspirator (RIA) is utilized. We report a case in which low-intensity pulsed ultrasound (LIPUS) was applied to bone reconstruction by the Masquelet technique using RIA. CASE The patient was a 44-year-old man. He suffered a tibia fracture involving the proximal part and the shaft. Open reduction and internal fixation was performed at the previous hospital. However, MRSE infection was found at 6 months postoperatively and surgery to eradicate the infection was performed. Two months after surgery, pseudoarthrosis surgery was performed; however no progression in bone union was observed for 5 months. Therefore, the patient was referred to our hospital. At the first surgery in our hospital, plates and screws were removed, and the avascular bone was debrided. Vancomycin-impregnated cement was placed to fill the bone defect and an Ilizarov external fixator was applied. Eight weeks later, the cement was replaced with the autologous bone graft and the graft was packed in the induced membrane. Bone graft was harvested from the ipsilateral femur using RIA. We applied LIPUS to the affected site postoperatively. Now, 4 months after the second surgery, bone union is progressing and the patient can walk without pain. DISCUSSION LIPUS may be used as an adjuvant therapy for a patient treated by the Masquelet technique using RIA.

© Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved. Objectives: To determine the extent to which knowledge from clinical trial protocols is transferred to nonparticipating patients. Design: Retrospective review of prospectively collected data from a large clinical trial. Setting: Six level-1 international trauma centers. Methods: We compared rates and timing of reoperation in a subset of patients enrolled in the Study to Prospectively evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) to concurrent patients who were eligible but not enrolled. This was a retrospective review of prospectively collected trial data. The records of 6 of the original SPRINT centers were searched for non-SPRINT patients who underwent intramedullary nailing of a closed tibial fracture. The rate and timing of reoperation were compared. A P < 0.05 was considered significant. Results: One hundred fourteen non-SPRINT patients were compared with 328 patients enrolled in SPRINT from those same sites. There were 7 reoperations (6.1%) in non-SPRINT patients versus 18 (5.2%) in SPRINT patients [odds ratio (OR) 1.19, 95% confidence interval (CI) 0.41 to 3.13; P 0.811]. There was no difference in the time to reoperation between the SPRINT and non-SPRINT patients (6.2 vs. 6.8 months, 95% CI of the difference -3.8 to 2.6; P 0.685) or in the proportion of patients who underwent reoperation before 6 months (29% vs. 43%; OR 1.75; 95% CI 0.18 to 15.41; P 0.647). Conclusions: Patients not enrolled in SPRINT had similarly low rates of reoperation for nonunion, and the average time to reoperation for both groups was longer than 6 months. A 6-month waiting period may have allowed slow-to-heal fractures adequate time to heal, thereby reducing the rate of diagnosis of nonunion. As such, this waiting period could contribute to lower-than-expected reoperation rates for nonunion. It is possible that clinical trials may beneficially influence the care of nonenrolled patients.

Tibia fractures are the most common long bone fracture. Criteria for closed and open reduction are based on the amount of fracture shortening, angulation, and rotation, with high success rates achieved if acceptable alignment is maintained. However, there exists limited data available regarding the long-term consequences of specific deformation patterns.The tibiae of 2898 cadaveric skeletons were manually inspected for evidence of fracture. Specimens with midshaft fractures were identified as candidates for study; intraarticular fractures were excluded. Fracture shortening, location, angulation, rotation (torsion), and translation were measured using previously described techniques. Degenerative joint disease of the knee and hip was graded from 0 to 3 in fracture specimens using a previously published system. Correlations between fracture characteristic and osteoarthritis were evaluated.Thirty-seven tibia fractures were present in 36 skeletons. In patients with tibia fractures, ipsilateral knee arthritis was greater than that of the contralateral side (P0.001). Knee arthritis was greater in fractures with coronal plane deformity greater than 5 degrees (P = 0.006) and with rotational deformity greater than 10 degrees (P = 0.004). There were no differences in knee arthritis based on laterality, shortening, sagittal deformity, fracture type, or translation in any plane (P0.05 for all). There were no differences in hip arthritis on the ipsilateral side compared with the contralateral side (P = 0.149). However, tibiae that were shortened by more than 10 mm had higher grades of ipsilateral hip arthritis (P = 0.009).The results of this study suggest that coronal and axial plane malalignment and shortening are of the greatest consequence following tibia fracture. These conclusions strengthen the recommendations of authors who have emphasized restoring tibial length following fracture, and providing anatomic restoration in the coronal and axial planes.

WOS: 000378093200010 PubMed: 26978131 Objectives: The objective was to compare the rates of union and infection in patients treated with and without fasciotomy for acute compartment syndrome (ACS) in operatively managed tibia fractures. Design: This was a retrospective review. Setting: The study was conducted at both a Level 1 and Level II trauma center. Patients/Participants: Patients operated for tibial plateau fractures (group 1) and tibial shaft fractures (group 3) with ACS requiring fasciotomy were matched to patients without ACS (plateau: group 2, shaft: group 4) in a 1: 3 ratio for age, sex, fracture pattern, and open/closed injury. Intervention: Surgical treatment was provided with plates/screws (plateau fractures) or intramedullary rod (shaft fractures). Patients with ACS were treated with a 2-incision 4-compartment fasciotomy. Main Outcome Measurements: Time to union and incidence of deep infection, nonunion, and delayed union. Results: One hundred eighty-four patients were included-group 1: 23 patients, group 2: 69 patients, group 3: 23 patients, and group 4: 69 patients. Time to union averaged 26.8 weeks for groups 1 and 3 and 21.5 weeks for groups 2 and 4 (P > 0.05). Nonunion occurred in 20% for groups 1 and 3 and in 5% for groups 2 and 4 (P = 0.003). Deep infection developed in 20% for groups 1 and 3 and in 4% for groups 2 and 4 (P = 0.001). There was a significant increase in infection in group 1 versus group 2 and nonunion in group 3 versus group 4. There were significantly more smokers for those with fasciotomies (46%) than without (20%, P, 0.001), though all statistical results remained similar after a binary regression analysis. Conclusion: Four-compartment fasciotomies in patients with tibial shaft or plateau fractures is associated with a significant increase in infection and nonunion.

OBJECTIVES Surgical treatment of displaced distal tibia fractures yields reliable results with either plate or nail fixation. Comparative studies suggest more malalignment and nonunions with nails. Some studies have reported knee pain after tibial nailing. However, plates may be associated with soft tissue complications, such as infections or wound-healing problems. The purpose of this study was to assess functional outcomes after distal tibia shaft fractures treated with a plate or a nail. We hypothesized that tibial nails would be associated with more knee pain and that plates would be associated with pain from implant prominence, each of which would adversely affect functional outcome scores. DESIGN Randomized prospective study. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS One hundred four patients with extra-articular distal tibia shaft fractures (OTA 42), mean age of 38 years (range, 18-95), and mean Injury Severity Score of 14.3 (range, 9-50). INTERVENTION Patients were randomized to treatment with a reamed intramedullary nail (n = 56) or standard large fragment medial plate (n = 48). MAIN OUTCOME MEASUREMENTS Ability to work was evaluated after a minimum of 12 months, with mean of 22 months. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were completed. RESULTS Mean MFA was 27.5, and mean total FFI was 0.26; P < 0.0001 versus an uninjured reference population. Sixty-one of 64 patients (95%) employed at the time of injury had returned to work, although 31% had modified their work duties because of injury. Three patients were unable to find work. None reported unemployment secondary to their tibial fracture. Forty percent of all patients described some persistent ankle pain, and 31% had knee pain after nailing, versus 32% and 22%, respectively after plating. Both knee and ankle pain were present in 27% with nails and 15% with plates (P = 0.08), and rates of implant removal were similar after nails versus plates. Patients with malunion ≥5 degrees were more likely to report knee or ankle pain (36% vs 20%, P < 0.05). Except 1 patient with knee pain when kneeling, none reported modifying activity because of persistent knee or ankle pain, although knee and ankle pain were more frequent in the unemployed (P = 0.03). Unemployed patients requested implant removal more frequently (24% vs 9.2%, P = 0.07) and continued to report pain afterward. Although FFI and MFA scores were not related to plate or nail fixation, open fracture, fracture pattern, multiple injuries, Injury Severity Score, or age, both MFA and FFI scores were worse when knee pain or ankle pain was present (all Ps < 0.004) and in patients who remained unemployed (P < 0.0001). All 4 patients with work-related injuries had returned to employment but had worse FFI scores (P = 0.01). CONCLUSIONS Mean MFA and FFI scores suggest substantial residual dysfunction after distal tibia fractures when compared with an uninjured population. Mild ankle or knee pain was reported frequently after plate or nail fixation but was not limiting to activity in most. Angular malunion was associated with both knee and ankle pain, and there was a trend toward more patients with knee and ankle pain after tibial nailing. No patients reported unemployment because of their tibia fracture, but unemployed people described knee and ankle pain more frequently and had the worst functional outcome scores.

Objective To determine if 1) angularly stable devices created by compressing ("locking") proximal locking screws to intramedullary nails using end caps or compression screws or 2) increasing the number of proximal screws from two to three increases the stiffness of intramedullary constructs that stabilize proximal third tibia fractures in a nonosteopenic bone model. Methods Four proximal locking screw configurations were examined in a synthetic composite tibia model with a 2-cm gap simulating a comminuted proximal third tibia fracture with no bony contact: 1) two proximal screws not compressed to the nail; 2) one of two proximal screws compressed to the nail; 3) two proximal screws compressed to the nail; and 4) three proximal screws with only the most proximal screw compressed to the nail. An 11-mm tibial nail with two distal locking screws was used. Stiffness was measured in axial and torsional loading. An analysis of variance was performed to compare results of the screw configurations for each testing mode. Results Compressing two screws to the nail produced 22% to 39% greater (P ≤ 0.01) axial and 16% to 29% greater (P ≤ 0.03) torsional stiffness than securing neither or only one of the screws. Adding a third proximal transverse locking screw increased the axial stiffness by 28% (P = 0.005) and the torsional stiffness by 15% to 28% (P ≤ 0.04) compared with using two oblique proximal screws. Conclusions "Locking" two proximal locking screws to the nail through compression or adding a third proximal screw increases the axial and torsional stiffness of intramedullary nails used to fix unstable proximal third tibia fractures.

Posttraumatic osteomyelitis of the tibia represents a major therapeutic challenge and continues to be associated with poor outcomes. In this article, we report on the successful management of a rare case of a Nocardia osteomyelitis of the tibial shaft secondary to intramedullary nailing of a closed fracture in a 19-year-old immunocompetent patient. In addition, we provide a review of the literature in the field and discuss optimized treatment strategies.

To compare the fixation stability of intramedullary nails to that of locked plates for the treatment of distal metaphyseal tibia and fibula fractures.A simulated, distal metaphyseal tibia fracture was created in 8 pairs of cadaveric tibia-fibula specimens. One of each pair was treated using an intramedullary nail (Trigen IM Nail System; SN Richards, Memphis, TN) and the other with a locked plate (Peri-Loc Periarticular Locked Plating System; SN Richards). Each specimen was vertically loaded to 250 N in central, anterior, posterior, medial, and lateral locations; loaded to 250 N in cantilever bending in anterior to posterior and posterior to anterior directions; and loaded to 250 N mm in torsion. Load-displacement curves were generated to determine the construct stiffness for each loading scenario, with comparisons made between the 2 treatment groups. Each specimen was then cyclically loaded with 750 N vertical loads applied for 10, 100, 1000, and 10,000 cycles. Measurements of fracture displacements were made and compared between treatment groups. A fibular osteotomy was then created in each specimen at the same level as the tibia fracture to simulate a same-level tibia-fibular fracture. Torsional stiffness assessment and cyclic vertical loading for 10, 100, 1000, and 10,000 cycles were repeated and fracture displacement measurements were again obtained.The locked plate construct was stiffer than the intramedullary nail construct for central, anterior, and posterior loading scenarios (P0.005, P0.03, and P0.02, respectively). The intramedullary nail construct was stiffer than the locked plate construct for both anterior to posterior and posterior to anterior cantilever bending (P0.03 and P0.02, respectively). No statistically significant difference in stiffness was noted between treatment groups for medial and lateral vertical loading or for torsional loading (P = 0.09, P = 0.32, and P = 0.84, respectively). There was no significant difference between treatment groups with respect to fracture displacement after cyclic vertical loading. After creation of the fibular osteotomy fracture, construct displacements after 1000 and 10,000 cycles significantly increased and torsional stiffness significantly decreased for both treatment groups. The locked plate constructs had significantly less displacement after cyclic loading of 1000 and 10,000 than the locked nail constructs (P0.001 and P0.0001, respectively). Locked plate constructs were stiffer in torsion after osteotomy than the intramedullary nail constructs (P0.05).This study demonstrated that, in the treatment of distal metaphyseal tibia fractures, locked plates provided more stable fixation than intramedullary nails in vertical loading but were less effective in cantilever bending. An intact fibula in the presence of a distal tibia fracture improved the fracture fixation stability for both treatment methods. In fracture patterns in which the fibula cannot be effectively stabilized, locked plates offer improved mechanical stability when compared with locked intramedullary nails.

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.

Objective To examine the danger to the superficial peroneal nerve during percutaneous screw placement in the distal holes of the 13-hole proximal tibia Less Invasive Stabilization System plate in a cadaver. Design Anatomic study. Setting Medical school anatomy laboratory. Interventions Fourteen adult cadaveric lower extremities were used. A 13-hole proximal tibia Less Invasive Stabilization System plate was placed as described by the manufacturer. Dissection of the superficial peroneal nerve was performed following localization of screw holes 7 through 13 using insertion sleeves, centering sleeves, and 2.0-mm Kirschner wires passed through the insertion guide. Results The average distance from the superficial peroneal nerve to the center of holes 11, 12, and 13 was 10.0 mm (range 0-21, standard deviation 5.6), 6.8 mm (range 0-16, standard deviation 4.3), and 2.7 mm (0-11, standard deviation 3.7), respectively. In 12 of 14 legs (86%), the superficial peroneal nerve was 5.0 mm or less from the center of hole 13. The nerve was touching the guide wire at hole 11 in 1 specimen (7%), at hole 12 in 2 specimens (14%), and at hole 13 in 6 specimens (43%). In 1 specimen (7%), the guide wire pierced the superficial peroneal nerve at hole 13. Conclusion These findings suggest that the superficial peroneal nerve is at significant risk during percutaneous screw placement in holes 11 through 13 of the 13-hole proximal tibia Less Invasive Stabilization System plate. Use of a larger incision and careful dissection down to the plate in this region may minimize the risk of damage to the nerve.

This case report describes a Gustilo Anderson type IIIB tibia fracture associated with extensive segmental bone loss at the proximal meta-diaphyseal junction associated with a tibial plateau fracture and an avulsion of the tibial tubercle. After the tibial plateau fracture was stabilized using cannulated lag screws, the shaft fracture was stabilized using a statically locked intramedullary nail in combination with a cylindrical titanium mesh cage and cancellous bone graft. The soft tissue defect was covered with local flaps. Immediate full weight bearing was initiated, and early functional recovery was achieved. At the final follow-up, plain radiographs demonstrated excellent limb alignment, and bony healing with computed tomography examination revealed bony ingrowth through the cage. This technique may be a reasonable alternative in the treatment of segmental bone loss of long bones.

Objectives: To compare hospital charges and length of stay in a series of adult patients with isolated, otherwise uncomplicated tibia fractures with and without acute compartment syndrome (ACS). Design: Retrospective case―control study. Setting: Urban Level I trauma center. Patients: Forty-six previously healthy adults with isolated tibia fractures (open or closed), with or without ACS but without other complication, associated injury, or social circumstance that influenced hospital stay or charges. Intervention: Intramedullary nailing in all patients with immediate fasciotomy and delayed fasciotomy closure in the subset of patients who developed ACS. Main Outcome Measure: Hospital length of stay in days and hospital charges. Results: Forty-six otherwise uncomplicated patients with isolated tibial shaft fractures were identified. Twelve fractures were open. ACS occurred in five patients, all with closed fractures. In 41 patients without ACS (12 open fractures, 29 closed fractures), the mean hospital stay was 3.0 days and mean hospital charges were $23,800. The five patients with ACS underwent a mean of 1.6 additional surgeries to treat the fasciotomy wound, were hospitalized for a mean of 9.0 days, and the mean hospital charges were $49,700. These differences were highly significant for hospital stay (P < 0.005) and charges (P < 0.00004). In contrast, there were no differences in length of stay or hospital charges in patients with closed or open fractures, respectively. Conclusion: The cost of ACS is significant, resulting in hospital stays that are increased threefold and hospital charges that are more than doubled in this cohort of patients. The impact of compartment syndrome on these factors was more important than whether the fracture was open or closed. In addition to the obvious benefit to the patient, methods that decrease the incidence of compartment syndrome and need for fasciotomy such as improved diagnosis to prevent unnecessary fasciotomy and methods to reduce intramuscular pressure and avoid fasciotomy in cases of incipient ACS would also be of value in reducing medical costs.

Fat emboli syndrome is a well-recognized complication of displaced long bone fractures, often times requiring internal fixation. Treatment is generally supportive and is most successful with early diagnosis. This article describes a case of fat emboli syndrome resulting from a nondisplaced tibia fracture treated with long leg casting. This case demonstrates that fat emboli should be considered as a potential complication of any long bone fracture and should be part of the differential diagnosis for any patient unconscious or in respiratory distress that has sustained a recent long bone fracture.

Objective To evaluate the changes in the articular cartilage and subchondral bone after an osteotomy designed to simulate an articular fracture. Design The contribution of the cartilage and subchondral bone was evaluated twelve weeks after creating a 1.0-millimeter step-off in the medial plateau of the tibia of twelve adult domestic sheep. All animals surviving were labeled with fluorescent markers for bone production, oxytetracycline (fifty milligrams per kilogram), and calcein (twelve milligrams per kilogram) nine and 11.5 weeks after surgery. The knees were loaded in compression using an Instron materials tester with pressure-sensitive film to record joint contact pressures above and below the medial meniscus. Setting The studies were performed in the research laboratories of the Orthopaedic Laboratory at Harborview Medical Center in Seattle, Washington and the Madigan Army Medical Center in Tacoma, Washington. Animals Twelve adult domestic sheep. Intervention An intraarticular osteotomy of the medial tibial plateau with 1.0 millimeter of displacement was performed. The osteotomy was stabilized with 3.5-millimeter lag screws. Main Outcome Measures The contact pressures of the knee joint and articular histology were evaluated twelve weeks after surgery. Samples of the articular cartilage were analyzed by light microscopy and electron microscopy to evaluate the response of the articular cartilage and subchondral bone of the differential joint loading because of the irregularity in the articular surface caused by the osteotomy. Results The knees with an intraarticular step-off had two major contact areas with an intervening zone of reduced load corresponding to the edge of the depressed fragment. Coronal histologic sections through the articular surface showed the presence of thinning and fibrillation on the high side of the step-off and some compensatory hypertrophy of the cartilage. The subchondral bone was not responsible for restoring articular congruity because the rate of bone production was similar between the low side of the articular fracture (1.85 micrometers per day) and the high side of the fracture (1.67 micrometers per day). Scanning electron microscopy showed partial cartilage remodeling by deformation of the high side cartilage with bending of the vertical collagen fibrils, even in the unloaded state. Conclusions In this model with a small fracture displacement (1.0 millimeter), which was less than the thickness of the articular cartilage (1.5 millimeters), the contour of the joint improved despite residual articular surface incongruency after the fracture healing.

Treatment goals in the operative management of talus fractures include prompt, anatomic, open reduction with rigid internal fixation; functional outcome is measured by degree of arthrosis, pain, range of motion, limb length, cosmesis, and return to premorbid activities. If restoration of the articular surfaces is precluded secondary to comminution, immediate and/or staged reconstructive salvage procedures must be considered. This report describes an immediate reconstructive procedure for salvage after a comminuted talus fracture with an ipsilateral tibia fracture. A standard antegrade tibial nail extending into the calcaneus was selected to stabilize both fracture sites. The technique of tibiocalcaneal arthrodesis using interposition fibular autograft and intramedullary fixation is presented as a unique treatment option.

Objective: To compare the elastic stiffness, in several loading modes, of commercially available hybrid external fixation systems. Design: Laboratory investigation using a polyvinylchloride pipe periarticular tibia fracture model. Setting: Simulated periarticular fractures were created in an in vitro tibia fracture model. Instrumented specimens and intact controls were elastically tested in a biomaterials testing system. Intervention: Groups of simulated periarticular tibia fractures were stabilized with one of six different hybrid external fixator designs. Main Outcome Measurements: Elastic stiffness of each specimen was measured in compression, torsion, flexion bending, extension bending, and varus/valgus bending. Results: Fixators with multiple levels of fixation in the periarticular fragment, regardless of design, were stiffer than those with one level. Specifically, the EBI Ring Connector fixator was stiffer than all others in all modes of testing. The Ace, Synthes, Smith & Nephew Richards, and Howmedica fixators were mechanically similar. The Zimmer Torus fixator was the least stiff fixator tested. Conclusions: Fixators with multiple levels of fixation in the periarticular fragment, regardless of design, were stiffer than those with one level. The choice of which hybrid external fixator to use should be made based not only on stiffness but also on ease of clinical application, patient comfort, customer support from the manufacturer, and cost. Clinical investigation of the efficacy of each of these devices is warranted.

We present a case illustrating the extraction of a distal segment of a broken cannulated tibial nail. Using minimal soft tissue dissection, a ball-tipped guidewire is inserted through the medial malleolus. It is then threaded through the distal aspect of the broken nail. The guide wire is advanced further proximally out the standard knee incision. When the ball tip engages the end of the broken nail, it can be removed easily.

© Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved. Objectives: We sought to determine the effect of reaming on 1-year 36-item short-form general health survey (SF-36) and short musculoskeletal function assessment (SMFA) scores from the Study to Prospectively Evaluate Reamed Intramedullary Nails in patients with Tibial Fractures. Design: Prospective randomized controlled trial.1319 patients were randomized to reamed or unreamed nails. Fractures were categorized as open or closed. Setting: Twenty-nine academic and community health centers across the US, Canada, and the Netherlands. Patients/Participants: One thousand three hundred and nineteen skeletally mature patients with closed and open diaphyseal tibia fractures. Intervention: Reamed versus unreamed tibial nails. Main Outcome Measurements: SF-36 and the SMFA. Outcomes were obtained during the initial hospitalization to reflect preinjury status, and again at the 2-week, 3-month, 6-month, and 1-year follow-up. Repeated measures analyses were performed with P < 0.05 considered significant. Results: There were no differences between the reamed and unreamed groups at 12 months for either the SF-36 physical component score [42.9 vs. 43.4, P 0.54, 95% Confidence Interval for the difference (CI) -2.1 to 1.1] or the SMFA dysfunction index (18.0 vs. 17.6, P 0.79. 95% CI, -2.2 to 2.9). At one year, functional outcomes were significantly below baseline for the SF-36 physical componentf score, SMFA dysfunction index, and SMFA bothersome index (P < 0.001). Time and fracture type were significantly associated with functional outcome. Conclusions: Reaming does not affect functional outcomes after intramedullary nailing for tibial shaft fractures. Patients with open fractures have worse functional outcomes than those with a closed injury. Patients do not reach their baseline function by 1 year after surgery.

Introduction: Despite the high incidence of battlefield orthopaedic injuries, long term outcomes and return to duty (RTD) status have rarely been studied. Our purpose was to determine the RTD rate for soldiers who sustained Type III open tibia fractures in active combat. Methods: One hundred fifteen soldiers who sustained battle related Type III open tibia fractures were retrospectively reviewed. The Army Physical Evaluation Board database was reviewed to determine which soldiers were able to RTD and the disability ratings of those not able to RTD. Results: The overall RTD rate was 18%, isolated open fractures had a RTD rate of 22%, salvaged extremities had a RTD rate of 20.5%, and amputees had a RTD rate of 12.5%. Older age and higher rank were both significant factors in increasing the likelihood of RTD and amputees had significantly higher disability ratings than those with salvaged extremities. Conclusion: Despite the severe nature of combat extremity wounds, 20% of patients with salvaged Type III open tibia fractures and 22% with isolated injuries were able to return to active duty. These rates are similar to those reported for civilian amputees. Amputees in our cohort were less likely to RTD.

Standard techniques for immobilization of a tibia shaft fracture in the emergency department in a long-leg splint can be cumbersome, technically difficult, and often requires the use of an assistant. We have developed a novel technique for the reduction and splinting of tibial shaft fractures, which uses a "hammock" constructed of stockinette, which allows a single consulting orthopaedic physician to rapidly reduce and place a long-leg plaster splint or cast on a patient. This technique was performed on 12 consecutive patients with a total of 12 tibial shaft fractures. Translation, angulation, and shortening of the fracture were documented in anteroposterior and lateral views of the injured tibia and these parameters were compared against values measured after the hammock technique was used to reduce and splint the fracture. Pre-"hammock" average values for fracture displacement in the anteroposterior plane for translation, angulation, and shortening were 10.5 mm (53.1 %), 12.0°, and 9.4 mm, respectively. Post-"hammock" average values for fracture displacement in the anteroposterior plane for the same parameters were 8.7 mm (44.4%), 4.2°, and 7.9 mm, respectively. Pre-"hammock" average values for fracture displacement in the lateral plane for translation and angulation were 4.9 mm and 8.7°. Post-"hammock" average values for fracture displacement in the lateral plane for the same parameters were 4.9 mm and 2.0°, respectively. These results show that this technique is able to achieve the goals of fracture reduction and immobilization in a rapid fashion when help is not available.

Fractures involving the posterior malleolus of the tibia can be difficult to manage. Failure to address these fractures can lead to posterior ankle instability and altered ankle reaction forces. The posterolateral approach to the posterior ankle provides access to both the lateral and posterior malleoli. Displaced fractures of the posterior malleolus can be reduced and fixed under direct visualization through a posterolateral incision. We have had excellent results using this technique for management of displaced posterior malleolar fractures with few complications. Surgeons should be aware of the effectiveness of this technique for managing displaced fractures of the posterior malleolus.

Intramedullary nailing is a widely accepted technique for the stabilization of unstable diaphyseal tibia fractures. When this method of stabilization is applied to proximal and distal metadiaphyseal fractures, achieving and maintaining fracture reduction is more difficult. The intramedullary nailing of proximal metadiaphyseal fractures in semiextension has been advocated to make stabilization less difficult. The intra-articular nature of this technique makes it less appealing. We present a nailing technique that facilitates extra-articular semiextended tibial nailing. The technique simplifies intraoperative imaging, fracture reduction, and maintenance of reduction during nail insertion and locking.

We reviewed cases of 75 battered children with fractures over a 2-year period. The average age was 16 months; 57% were boys. There were 154 fractures (2.0 per child); 77% were acute and 23% were old. The most common fracture occurred in the skull (32%) and the most common long bone fracture occurred in the tibia (16%). The most common long bone fracture pattern was transverse (41%); corner fractures accounted for 28% of long bone fractures. An isolated acute fracture was the orthopaedic injury in 65% of the children, whereas multiple fractures in various stages of healing were present in only 13% of children. Language: en

We conducted a study to evaluate the long-term functional outcomes of patients with an isolated tibial shaft fracture treated with locked intramedullary nailing.Prospective cohort and retrospective clinical and radiographic assessment.A level 1 trauma and tertiary referral center.We identified 250 eligible patients with isolated tibia fractures from the Center's prospectively enrolled orthopaedic trauma database between 1987 and 1992. A total of 56 patients agreed to participate. We had a median follow-up of 14 years, with a range from 12 to 17 years.All enrolled patients were initially acutely treated with locked intramedullary nailing of their tibia.All enrolled patients were evaluated with the SF-36 and Short Musculoskeletal Functional Assessment functional questionnaires and an injury-specific questionnaire focusing on knee pain and symptoms of venous insufficiency. A subgroup of patients were evaluated radiographically and by physical examination.The mean normalized SF-36 scores (physical composite score-PCS 48.9, mental composite score-MCS 51.8) and the mean normalized Short Musculoskeletal Functional Assessment scores (50.7) (bothersome index, functional index) were not statistically different (P0.05) from reference population norms. Of the questionnaire group (n = 56), only 15 (26.7%) denied knee pain with any activity whereas 41 patients (73.2%) had at least moderate knee pain. With respect to swelling, 19 (33.9%) reported asymmetrical swelling affecting the injured limb. However, of the 33 physically examined patients, only 6 (18.2%) had objective evidence of venous stasis. Knee range of motion was equivalent to the unaffected side in all but two patients (93.9%) whereas 14 (42.4%) had a restricted range of motion of the ankle. Nine patients (27.3%) had persistent quadriceps atrophy, and the same rate was observed for calf atrophy. Twenty-five patients (75.8%) had no tenderness to anterior knee palpation. Of the 31 radiographically examined patients, 11 patients (35.4%) showed evidence of arthritis despite the absence of radiographic malalignment. Five patients (16.1%) had at least mild osteoarthritis of at least one knee compartment, 5 (16.1%) had at least mild osteoarthritis of the tibio-talar joint, and 1 (3.2%) had osteoarthritis of both, despite the absence of malunion. Self-reported knee pain was not correlated with the presence of a tibial nail or radiographic nail prominence. Similarly, knee tenderness on examination was not correlated with these factors.At a median 14 years after tibial nailing of isolated tibial fractures, patients' function is comparable to population norms, but objective and subjective evaluation shows persistent sequelae which are not insignificant. This study is the first to describe the long-term functional outcomes after tibial shaft fractures treated with intramedullary nailing nails. It may allow surgeons to better inform patients on the expected long-term function after intramedullary nailing of a tibia fracture. It may also prove useful when comparing intramedullary nailing nailing to other treatment techniques.

Detection of tibial fractures in which a concomitant ankle injury may exist.Prospective study.Department of Trauma Surgery, University Hospital.43 (20.1%) of 214 patients with a tibial fracture were found to have an associated injury of the ankle joint.Analysis of all patients with tibial fractures regarding typical mechanisms of injuries and typical radiographic criteria for concomitant injuries of the ankle joint.Primary x-rays were analyzed looking for spiral fractures of the tibia or proximal fibular fractures or an intact fibula, typically associated with syndesmotic injury. The assessment of patients was based on radiological findings and functional recovery.45 ankle injuries in 43 patients were found. There were distal fibular fractures in 14, Maisonneuve fractures in 13, isolated ruptures of the syndesmosis in 3, fractures of the posterior malleolus in 8, and fractures of the medial malleolus in 7 of the cases. In 38 of the 43 patients, the distal tibiofibular syndesmosis was ruptured, and 88.4% of the tibia injuries were spiral fractures located in the distal third. Of the 38 patients who could be followed, 31 were categorized according to the Phillip's Score as very good, 3 as good, 2 as satisfactory, and 2 as unsatisfactory after an average of 19.8 months (12-26).Due to the obvious injury of the tibia, the potential instability of the ankle joint is often overlooked, and the risk of development of secondary osteoarthritis is often consequently underestimated. Added attention should be paid to the ankle in the following tibial fracture cases: pronation-eversion trauma, spiral fracture of the tibia, proximal fibular fracture, or intact fibula. Using these markers, we were able to diagnose 20.1% of combined injuries compared to our retrospective study in 1999, in which only 13.6% of these injuries could be detected (Pearson r=0.1305, not significant).

A case is presented of a fifty-three-year-old man with a displaced tibia-fibula fracture that was treated with an intramedullary nail. The morning after surgery pulses were absent and did not improve after fasciotomies. The patient was transferred to our institution, where an arteriogram showed tapering of the anterior tibial and peroneal vessels in the mid-calf and occlusion of the posterior tibial artery at the level of the ankle. Vascular status did not improve after heparinization and arteriogram thrombolysis. The patient ultimately underwent below-the-knee amputation and subsequent revision to above-the-knee amputation.

Objective To report the results of using the expandable nailing system in the treatment of femoral and tibial shaft fractures. Design Prospective, cohort series. Setting Two level-1 university trauma centers. Participants Forty-eight patients with acute, traumatic diaphyseal fractures of the tibia or femur. Intervention Internal fixation of lower extremity long bone fractures using expandable intramedullary nailing. Main Outcome Measurements Perioperative complications and time to healing. Results Forty-nine long bone fractures were treated: 22 femoral fractures (OTA classification: 4 type A1, 6 A2, 7 A3, 1 B1, and 4 B2) and 27 tibial fractures (OTA classification: 4 type A1, 11 A2, 9 A3, 0 B1, and 3 B2). There were 13 open fractures and 37 closed fractures. Healing occurred in 37 (75%) fractures without additional interventions. There were 2 tibial delayed unions and 1 femoral and 1 tibial nonunion. Five tibial shaft fractures and 6 femoral fractures shortened by 1.0 cm or more postoperatively. In 3 tibias and 4 femurs, shortening occurred after fractures judged to be length-stable became unstable because of fracture propagation during nail expansion. Five tibias and 3 femurs were converted to standard locked nails because of shortening. The average time to healing, excluding nonunion, was 15 weeks in the tibia and 16 weeks in the femur. The expandable nail resulted in an unplanned reoperation in 12 cases (25%). Conclusion We found a high complication rate because of shortening, which was independent of fracture classification. Consequently, we cannot recommend the use of an unlocked, expandable nail in diaphyseal fractures of the femur or tibia.

Intramedullary nailing of tibial shaft fractures is the preferred treatment of most displaced, unstable tibial shaft fractures. In open tibia fractures, direct exposure of the fracture segments for irrigation and debridement is required prior to fracture stabilization. We propose a method of provisional stabilization using commonly available implants placed through the associated traumatic open wound prior to intramedullary nailing. This technique, particularly helpful to surgeons operating with limited assistance, employs a temporarily applied 3.5-mm dynamic compression plate or limited contact dynamic compression plate implant secured with unicortical screws, allowing reaming and intramedullary nailing of a reduced, stabilized tibia fracture.

Current data show smoking is associated with a number of complications of the fracture healing process. A concern, however, is the potential confounding effect of covariates associated with smoking. The present study is the first to prospectively examine time to union, as well as major complications of the fracture healing process, while adjusting for potential confounders.Eight Level I trauma centers.Patients with unilateral open tibia fractures were divided into 3 baseline smoking categories: never smoked (n = 81), previous smoker (n = 82), and current smoker (n = 105).Time to fracture healing, diagnosis of infection, and osteomyelitis.Survival and logistic analyses were used to study differences in time to fracture healing and the likelihood of developing complications, respectively. Multivariate models were used to adjust for injury severity, treatment variations, and patient characteristics.After adjusting for covariates, current and previous smokers were 37% (P = 0.01) and 32% (P = 0.04) less likely to achieve union than nonsmokers, respectively. Current smokers were more than twice as likely to develop an infection (P = 0.05) and 3.7 times as likely to develop osteomyelitis (P = 0.01). Previous smokers were 2.8 times as likely to develop osteomyelitis (P = 0.07), but were at no greater risk for other types of infection.Smoking places the patient at risk for increased time to union and complications. Previous smoking history also appears to increase the risk of osteomyelitis and increased time to union. The results highlight the need for orthopaedic surgeons to encourage their patients to enter a smoking cessation programs.

Objectives: To determine whether long bone fractures cause bacterial translocation and to investigate the effect of concomitant head trauma on this process. Design: An in vivo animal model. Setting: Animal Laboratory, University of Mersin School of Medicine, Mersin, Turkey. Subjects: Male Sprague-Dawley rats (n = 60). Intervention: Sixty male Sprague-Dawley rats were divided into five groups: (1) anesthesia only (control group, n = 12); (2) anesthesia and tibia fracture (n = 12); (3) anesthesia, tibia fracture, and femur fracture (n = 12); (4) anesthesia, tibia fracture, femur fracture, and moderate head trauma (n = 12); and (5) moderate head trauma only (n = 12). After 24 hours, mesenteric lymph nodes, liver, spleen, ileum, and systemic blood samples were quantitatively cultured for aerobic organisms. Main Outcome Measurements: Colony-forming unit per gram for bacteria count. Results: The incidence of bacterial translocation was higher in groups that had fractures (4/12 in group 2; 5/12 in group 3) than in the control group (2/12); however, this did not reach statistical significance. There was a significant increase in the number of subjects with bacterial translocation in group 4 (9/12) compared with the control group and group 5 (3/12) (P = 0.0123, P = 0.0391). Conclusions: Multiple fractures of long bones associated with head injury promote bacterial translocation.

Objectives The purpose of this study was to assess effects of hemorrhagic shock on fracture healing in a large animal closed fracture model. Design Prospective randomized trial. Setting University Medical Center. Study Subjects Eight skeletally mature neutered male goats. Intervention Standardized bilateral closed midshaft tibia fractures were created in all the goats. The goats were randomized to a hemorrhage, shock and resuscitation group (shock group), or a control group. Hemorrhagic shock was induced in the four goats in the shock group. The shock state was maintained for thirty minutes. The remaining four goats were used as a control group. All fractures were stabilized with a standardized external fixator. Outcome Measures Swan-Ganz catheters were used to record cardiac output (CO). Arterial blood was sampled to determine base deficit values for the goats after hemorrhage. Radiographs were obtained weekly. After four weeks the tibias were harvested and nondestructively tested in torsion. Immediately after mechanical testing, the tibias were processed for histologic analysis. Standard histomorphologic indices, including total bone volume (TV/BV%), osteoblast surfaces (Ob/BS%), and osteoid surface (OS/BS%), were measured. Results One goat in the shock group became agitated upon emergence from anesthesia and dislodged two of his external fixator pins. This animal was killed and was not included in the analysis of results. One goat that would have been entered into the control group was then switched to the shock group, leaving four goats in the shock group and three in the control group. One goat in the shock group developed a nonunion of his left tibia fracture. This nonunion occurred because of loosening of pin fixation in the distal tibia. The nonunited bone was not included in the analysis of results. The animal's right tibia healed uneventfully. Hemorrhage uniformly resulted in shock. In the shock group goats, average CO on induction of anesthesia was 3.7 l/min. Average CO dropped to 0.7 after hemorrhage and rose to 6.6 after fluid resuscitation. The average base deficit for the shock group animals was −9.9. The control group animals had minor drops in average CO, from 4.5 on induction of anesthesia to 4.3 on emergence from anesthesia. Radiographic analysis showed no apparent differences in healing between groups when comparing callus area and density. With the exception of the nonunion, all tibiae were considered to be healing normally radiographically. Biomechanical testing showed no statistical difference between the shock and control groups in maximum torque (p = 0.95), stiffness (p = 0.64), and energy absorbed at failure (p = 0.91). Histomorphologic results indicated there were no differences between groups. Shock did not appear to influence bone formation rate or callus remodeling compared with controls (p = 0.6). No evidence of osteocyte necrosis was observed. Conclusions In this study no significant difference was found between the shock and control groups in any of the parameters measured. Transient hemorrhagic shock does not appear to adversely affect closed tibia fracture healing in a goat model.

Objectives: To locate the proper insertion point for a tibial intramedullary nail in the coronal plane. Design: Fifty-seven cadaveric lower legs were disarticulated at the knee and ankle and stripped of their soft tissue. Each tibia was nailed in a retrograde fashion through the center of the tibial plafond with a seven-millimeter sharp-tipped rod through the proximal tibia. The exit point of the nail was measured in the coronal plane in relation to the tibial tubercle. Results: Except for one tibia, the intramedullary nail exit point was always located medial to the center of the tibial tubercle with the average being eight millimeters ± six millimeters medial to the center of the tibial tubercle. Forty-six percent of the nails exited medial to the whole tibial tubercle. Conclusions: The insertion point of a tibial nail should be over the medial aspect of the tibial tubercle in the coronal plane. Our data supports using a medial or patellar splitting approach for nail insertion. Insertion sites lateral to the tibial tubercle should be avoided.

Objective: To determine the structural stiffness and reducibility of various external fixators placed in malalignment and malrotation. Design: Uniform testing of all external fixator configurations. Setting: Orthopaedic biomechanical laboratory. Methods: Thirteen external fixators from different manufacturers, in a total of fifteen configurations, were studied. All external fixators were applied to a malreduction jig initially, and a subsequent anatomic reduction was then attempted. If an anatomic reduction was possible, the structural stiffness of those fixators was determined. If anatomic reduction was not possible, the external fixator was removed and reapplied to an anatomically reduced model, and then structural stiffness was determined. Results: Six of the thirteen external fixator configurations allowed an anatomic reduction after placement on a malreduction model. The other nine external fixator configurations would not allow for an anatomic reduction. All the external fixator configurations were biomechanically tested in anteroposterior bending, lateral bending, axial load, and torsion. Each fixator had its own structural stiffness and is reported. Conclusions: Some external fixators will not allow for an anatomic reduction once placed in malalignment and malrotation without repositioning of the fixator pins. External fixator configurations (i.e., single-pin, dual-pin, and multipin barclamps) affect structural stiffness. Structural stiffness widely varied among the external fixators. Proper external fixator selection will enable early fracture immobilization in malalignment and malrotation in suboptimal conditions (e.g., wartime conditions or a civilian disaster), with subsequent external fixator adjustment for an anatomic reduction.