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Open fracture is a risk factor for nonunion of diaphyseal tibia fractures. Compared with closed injuries, there is a relative lack of scientific knowledge regarding the healing of open tibia fractures. The objective of this study was to investigate which patient, injury, and surgeon-related factors predict nonunion in open tibial shaft fractures. A cohort of 98 patients with 104 extra-articular open tibial shaft fractures (OTA/AO 41A2-3, 42A-C, and 43A) were treated surgically between 2007 and 2018 at a single level 1 trauma center and were retrospectively reviewed. Patients underwent irrigation and debridement followed by definitive intramedullary nailing or plate fixation. Patient, injury, and perioperative prognostic factors were analyzed as predictors of nonunion based on anteroposterior and lateral radiographs. The nonunion rate was 27.9% (n=29). There were 12 occurrences of deep infection (11.5%). The median follow-up was 14 months. High-energy mechanism of injury (hazard ratio [HR], 5.76), Gustilo-Anderson class IIIA injury (HR, 3.66), postoperative cortical continuity of 0% to 25% (HR, 2.90), early postoperative complication (HR, 4.20), and deep infection (HR, 2.25) were significant predictors of nonunion on univariable analysis ( P <.05). On multivariable assessment, only high-energy mechanism of injury, Gustilo-Anderson class IIIA injury, and early postoperative complication reached significance as predictors of nonunion. These data also indicate that lack of cortical continuity is a significant univariable radiographic predictor of nonunion. This is potentially modifiable, may guide surgeons in selecting patients for early bone grafting procedures, and should be assessed carefully in this high-risk population. [ Orthopedics . 2021;44(3):142-147.].

Objectives: We report on the largest series to date of minimally invasive medial plate osteosynthesis of high-energy tibia fractures in skeletally immature patients., Design: Retrospective., Setting: Level 1 trauma center., Patients: Skeletally immature patients with high-energy tibia fractures treated with minimally invasive medial plate osteosynthesis between 2006 and 2017. We identified 28 fractures in 26 patients., Main Outcome Measure: We reviewed the record for patient, injury, and treatment factors as well as for complications and reoperation. We assessed the relationships between age, implant selection, and implant removal using χ and t test analyses., Results: Mean age was 12 years (4-15) with OTA/AO classifications including 42A (18), 42B (6), and 42C (4). There were 10 open fractures (1 type I, 2 type II, and 7 type III). Mean follow-up was 37.6 months (minimum 7). Mean time to full weight-bearing and union was 2 and 3 months, respectively. Plate stock (2.7, 3.5, and 4.5 mm) and length (6-20 holes) varied independent of age, P = 0.19. There were 2 superficial infections, one 15 mm leg length discrepancy, and one case of fasciotomy at the time of plate fixation for trauma-related compartment syndrome. Implant removal was more likely in younger patients (10.9 vs. 13.2 years, P = 0.04) and not associated with plate stock, P = 0.97. There were no neurovascular injuries, losses of reduction, or rotational deformities. Angulation was universally <5 degrees in the coronal plane and <10 degrees in the sagittal plane., Conclusions: Minimally invasive medial plate osteosynthesis of high-energy pediatric tibia fractures may be performed with a low rate of complications and should be considered in this select patient population with multiple injuries, high-energy mechanisms, and significant soft-tissue trauma., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To assess the relationship between the distal nail target and postoperative alignment for distal tibia fractures treated with intramedullary nailing., Design: Retrospective cohort study., Setting: A single level 1 trauma center., Patients/participants: One hundred thirty distal tibia fractures treated with intramedullary nailing over a 10-year period., Main Outcome Measurements: Malalignment >5 degrees., Results: Thirty-eight cases (29.2%) of malalignment >5 degrees included valgus (19 cases, 14.6%), procurvatum (13 cases, 10.0%), recurvatum (1 case, 0.8%), and combined valgus with procurvatum (5 cases, 3.8%). Medially directed nails demonstrated relative valgus (mean lateral distal tibia angle 86.4 vs. 89.4 degrees, P < 0.01) and more frequent coronal malalignment (24 of 78, 30.8% vs. 0 of 52, 0%, P < 0.01). Anteriorly directed nails demonstrated relative procurvatum (mean anterior distal tibia angle 82.8 vs. 80.9 degrees, P < 0.01) and more frequent sagittal malalignment (15 of 78, 19.2% vs. 3 of 52, 5.8%, P = 0.03). Malalignment was less common for nails targeting the central or slightly posterolateral plafond (0 of 30, 0% vs. 38 of 100, 38%), P < 0.01. Multivariate analysis demonstrated the distal nail target (P = 0.03), fracture within 5 cm of the plafond (P = 0.01), as well as night and weekend surgery (P = 0.03) were all independently associated with malalignment., Conclusions: Alignment of distal tibia fractures is sensitive to both injury and treatment factors. Nails should be targeted centrally or slightly posterolaterally to minimize malalignment., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Peri- and intra-articular fractures about the knee are frequently managed with joint-spanning external fixation before definitive treatment. With a systematic approach, a near-anatomic reduction with respect to length, alignment, and rotation can be obtained., Methods: This video highlights 2 clinical cases: a bicondylar tibial plateau fracture-dislocation and a distal femur fracture, both of which were treated with temporizing, knee-spanning external fixation., Results: The indications, principles, and biomechanics of knee-spanning external fixation are presented. In addition, we demonstrate a systematic approach to applying knee-spanning external fixation., Conclusions: Temporizing, joint-spanning external fixation is a critical treatment modality in the orthopaedic armamentarium for managing fractures about the knee. With a systematic approach, it is possible to obtain a near-anatomic reduction with respect to length, alignment, and rotation.