Aims. This study aimed to demonstrate the promoting effect of elastic fixation on fracture, and further explore its mechanism at the gene and protein expression levels. Methods. A closed tibial fracture model was established using 12 male Japanese white rabbits, and divided into elastic and stiff fixation groups based on different fixation methods. Two weeks after the operation, a radiograph and pathological examination of callus tissue were used to evaluate fracture healing. Then, the differentially expressed proteins (DEPs) were examined in the callus using proteomics. Finally, in vitro cell experiments were conducted to investigate hub proteins involved in this process. Results. Mean callus volume was larger in the elastic fixation group (1,755 mm. 3. (standard error of the mean (SEM) 297)) than in the stiff fixation group (258 mm. 3. (SEM 65)). Pathological observation found that the expression levels of osterix (OSX), collagen, type I, alpha 1 (COL1α1), and alkaline phosphatase (ALP) in the callus of the elastic fixation group were higher than those of the stiff fixation group. The protein sequence of the callus revealed 199 DEPs, 124 of which were highly expressed in the elastic fixation group. In the in vitro study, it was observed that a stress of 200 g led to upregulation of thrombospondin 1 (THBS1) and osteoglycin (OGN) expression in bone marrow mesenchymal stem cells (BMSCs). Additionally, these genes were found to be upregulated during the osteogenic differentiation process of the BMSCs. Conclusion. Elastic fixation can promote fracture healing and osteoblast differentiation in callus, and the ability of elastic fixation to promote osteogenic differentiation of BMSCs may be achieved by upregulating genes such as THBS1 and OGN. Cite this article: Bone Joint Res 2024;13(10):559–572

Aims. Compartment syndrome (CS) is a well-recognised, serious complication of long bone fractures. The association between CS and tibial shaft fractures is well documented in adult patients and in children with open or high velocity trauma. There is, however, little literature on the risk of developing CS in children with closed tibial fractures. In a number of units these children are routinely admitted for elevation and monitoring for CS. We audited our experience of managing paediatric tibial fractures to ascertain whether it may be safe to discharge a sub-group of these children. Methods. We audited all children up to the age of 12 years admitted to our hospital over a 5 year period. We reviewed radiographs and clinical notes to determine fracture pattern, modality of treatment, and complications. Results. We audited 159 tibial fractures. The mean age was 5.8 years (1–12 years), 95 boys, 64 girls. 105 (66%) closed fractures were conservatively managed: 87 of these were diaphyseal and 20 involved both tibia and fibula. Of the conservatively managed fractures, 89 (85%) were minimally displaced (< 5 degrees varus/valgus/anterior angulation, < 5 degrees rotation, < 5mm shortening, no posterior angulation). In the conservatively managed group there were 3 cases of angulation in cast, managed with wedging. There were no other complications and no cases of compartment syndrome. Conclusion. Of the 105 closed tibial fractures we managed conservatively, most were minimally displaced, diaphyseal, tibia-only fractures. No patient developed compartment syndrome. Based on our experience we suggest that children with closed, minimally displaced tibial fractures do not require admission for monitoring of CS and may go home in a plaster-slab with early fracture clinic follow-up providing suitable supervision is in place, pain is controlled, and they are able to mobilise safely

Introduction. We retrospectively evaluated our five years' experience in using Expandable Fixion nail system in tibial diaphyseal fractures. Materials/Methods. Eighteen cases with closed tibial diaphyseal fracture were identified between January 2006 and January 2011, all treated successfully with Fixion intramedullary nail as a primary osteosynthesis device. Results. All patients were followed-up in our department until clinical and radiological fusion was achieved with a mean follow-up of 13 months (range 6–20 months). There was one asymptomatic delayed union at 13 months, treated with regular observation until fusion was achieved. There was no incidence of infection, compartment syndrome or non-union in this group. Conclusion. We conclude from our experience that Expandable Fixion Nail is as effective as traditional locking intramedullary nail system in treating closed tibial shaft fracture with the advantages of shorter theatre time and less radiation exposure

Introduction. Management of complex fractures poses a significant challenge. Evolving research and changes to national guidelines suggest better outcomes are achieved by transfer to specialist centres. The development of Major Trauma Networks was accompanied by relevant financial arrangements. These do not apply to patients with closed fractures referred for specialist treatment by similar pathways. Despite a surge in cases transferred for care, there is little information available regarding the financial impact on receiving institutions. Materials & Methods. This retrospective study examines data from a Level 1 trauma centre. Patients were identified from our electronic referral system, used for all referrals. Transferred adult patients, undergoing definitive treatment of acute isolated closed tibial fractures, were included for a 2-year period. Data was collected using our clinical and Patient Level Information and Costing (PLICS) systems including coding, demographics, treatment, length of stay (LOS), total operative time, number of operations, direct healthcare costs, and NHS reimbursements. Results. 104 patients were identified, 23 patients were treated by internal fixation and 81 with circular frames. Patients required a median of 190 minutes of total operative time and 6 days of hospital stay at a median cost of £16,233 each, median reimbursement was £10,625. The total cost of treatment for all 104 patients was £2,205,611 and total reimbursement was £1,391463, the median deficit per patient being £5825. The overall deficit over the 2 years was £814,148. Conclusions. This study reveals a considerable economic burden associated with treating complex tibial fractures. It should be emphasised that these do not include patients referred for fracture-related infection or non-union, who may also incur similar deficits in recovered costs. These findings emphasise the importance of understanding and addressing the financial implications of managing tertiary referral orthopaedic trauma patients to ensure efficient and sustainable resource allocation

BACKGROUND. Most closed tibial fractures in children can be treated conservatively. On the occasions that surgical intervention is required, there are various options available to stabilise the fracture. We would like to present our experience of using monolateral external fixators in the management of closed tibial fractures. Aim. We sought to assess the time to healing, limb alignment, and complications observed in a cohort of tibial fractures treated with external fixation. METHODS. Our limb reconstruction database was used to identify patients who underwent monolateral external fixation for a closed tibial fracture between January 2008 and December 2016. Radiographs of all patients were assessed to determine the original fracture pattern. Time to union was assessed as the time when the fixator was removed and the patient allowed to mobilise independently without any further support of the limb. The presence or absence of residual deformity was assessed on final follow-up radiographs. RESULTS. 22 patients fulfilled the inclusion criteria. 78% of patients had both tibial and fibular fracture. The mean age at injury was 12 years. The mean time taken for the fracture to heal was 18 weeks. The total duration of follow-up averaged 9 months. The mean Valgus deformity at the final follow up was 4 degrees and the mean Varus deformity was 4 degrees. The mean procurvatum was 4.2 degrees and the mean recurvatum was 6 degrees. 50% of patients had pin site infection. Two patients had tibio fibular synostosis. None of them had leg length discrepancy or refractures. There were no episodes of osteomyelitis. CONCLUSIONS. Five degree of coronal plane deformity and ten degree of sagittal deformity were considered as acceptable in children due to their potential for remodeling. All our patients had acceptable levels of residual deformity. In our opinion monolateral external fixation represents a safe and effective option

Aim of this study: The aim of this prospective study was the evaluation of the results of intramedullary nailing with mild reaming for the treatment of closed tibial fractures. Patients and Method: During the period 2001–2003 a total of 22 closed tibial fractures were managed. Fractures were classified according to the AO system. The method of treatment was determined by the degree of comminution at the fracture site as well as of the presence or not of intact fibula. Dynamic nailing was performed for the treatment of 9 fractures type A, static nailing following dynamization in 4–6 weeks with the presence of radiological callus formation was performed for the treatment of 5 fractures type B with > 50% comminution and dynamic nailing was performed for the treatment of 8 fractures type B with < 50% comminution. In 2 cases with intact fibula (A31, B21) osteotomy of the fibula performed at the same time. The mean size of the reaming was 11mm for the total of cases. Results: The mean union time was 16 weeks, no infection or mechanical failure was recorded. Two cases of non-union were recorded (patient under anti-depression therapy and fracture type B23 in a patient with bilateral tibial fracture). Revision nailing were performed for these two cases (union in 14 and 16 weeks respectively). Conclusion: Intramedullary nailing with limited reaming is a valuable method for the management of closed tibial fractures, especially in high energy fractures. Osteotomy of the tibia improves the mechanical environment at the fracture site

Māori consistently have poorer health outcomes compared to non-Māori within Aotearoa. Numerous worldwide studies demonstrate that ethnic minorities receive less analgesia for acute pain management. We aimed to compare analgesic management of a common orthopaedic injury, tibial shaft fracture, between Māori and non-Māori. A retrospective cohort study from January 1. st. , 2015, to December 31. st. 2020 inclusive. Eligible patients were 16–65 years old and had isolated closed tibial shaft fractures. 104 patients were included in the study, 48 Māori and 56 Non-Māori. Baseline demographics were similar between the 2 cohorts. The primary outcome measure was type of analgesia charted on the ward. Secondary outcome measures were pre-hospital medications given, pain scores on arrival to the emergency department (ED) and the ward, time to analgesia in ED and type of analgesia given in ED. Statistics were calculated using Fisher's exact test, Pearson's chi-squared test or Wilcoxson's rank sum test as appropriate. No statistically significant differences were found in opiates or synthetics charted to Māori vs Non-Māori (83% vs 89% and 77% vs 88% respectively), opiates given in ED, time to analgesia in ED or ED and ward arrival pain scores. Of statistical significance is that Māori were less likely to receive pre-hospital medication compared to Non-Māori (54% vs 80% respectively, p=0.004). Māori were significantly less likely to receive pre-hospital pain medication compared to Non-Māori. However no other statistically significant findings were found when comparing pain scores, time to analgesia or type of pain relief charted for Māori vs non-Māori. The reasons for Māori receiving significantly less prehospital medication were not explored in this study and further investigation is required to reduce the bias that exists in this area

Aims. The aim of this study was to establish a reliable method for producing 3D reconstruction of sonographic callus. Methods. A cohort of ten closed tibial shaft fractures managed with intramedullary nailing underwent ultrasound scanning at two, six, and 12 weeks post-surgery. Ultrasound capture was performed using infrared tracking technology to map each image to a 3D lattice. Using echo intensity, semi-automated mapping was performed to produce an anatomical 3D representation of the fracture site. Two reviewers independently performed 3D reconstructions and kappa coefficient was used to determine agreement. A further validation study was undertaken with ten reviewers to estimate the clinical application of this imaging technique using the intraclass correlation coefficient (ICC). Results. Nine of the ten patients achieved union at six months. At six weeks, seven patients had bridging callus of ≥ one cortex on the 3D reconstruction and when present all achieved union. Compared to six-week radiographs, no bridging callus was present in any patient. Of the three patients lacking sonographic bridging callus, one went onto a nonunion (77.8% sensitive and 100% specific to predict union). At 12 weeks, nine patients had bridging callus at ≥ one cortex on 3D reconstruction (100%-sensitive and 100%-specific to predict union). Presence of sonographic bridging callus on 3D reconstruction demonstrated excellent reviewer agreement on ICC at 0.87 (95% confidence interval 0.74 to 0.96). Conclusion. 3D fracture reconstruction can be created using multiple ultrasound images in order to evaluate the presence of bridging callus. This imaging modality has the potential to enhance the usability and accuracy of identification of early fracture healing. Cite this article: Bone Joint Res 2021;10(12):759–766

Purpose. Using utilities and other outcome data collected prospectively on all SPRINT patients and cost data collected from a sample of SPRINT patients, we compared reamed and unreamed intramedullary nailing using a cost-utility analysis. Method. Participants completed the Health Utility Index 3 (HUI) questionnaire at two weeks after hospital discharge, and three, six, and 12 months post-surgery. We calculated quality adjusted life years (QALYs) for each patient for the first 12 months following intramedullary nailing. A convenience sample of 235 SPRINT patients with similar baseline characteristics provided data on healthcare resource utilization. Costs associated with the healthcare resource utilization were obtained from the 2008 Physicians Schedule of Benefits and a Case Costing System. Results. We found small, non-significant differences in QALYs for patients treated with reamed compared with unreamed intramedullary nails in both closed and open fractures: −0.017 (95% CI −0.021, 0.058) and −0.002 (95% CI −0.060, 0.062) respectively. The incremental costs for reamed compared with unreamed intramedullary nailing were $51 CAN (95% CI −$2,298, $2,400) in closed tibial fractures and $2,546 CAN (95% CI −$1,773, $6,864) in open tibial fractures. Conclusion. Considering point estimates only, reamed intramedullary nailing was less effective and more costly when compared to unreamed intramedullary nailing for both closed and open tibial fractures. Bootstrap simulations revealed that unreamed nailing was more likely to be cost-effective for both open and closed tibial fractures at all decision-making thresholds. Confidence intervals around both cost and utility estimates were wide and neither approached conventional levels of statistical significance

Unreamed, small diameter nails with interlocking capability have become the preferred treatment for most unstable tibial fractures, but have been shown to have a high rate of hardware breakage and frequently require secondary procedures to obtain union. Reamed nailing may offer advantages for fracture healing due to the use of larger implants and increased stability, but may cause higher rates of infection and compartment syndrome. In order to determine if there is a difference in healing or complications in open and closed tibial fractures treated with reamed or unreamed intramedullary nailing, we performed a prospective, surgeon-randomized comparative study. Ninety-four closed and open, unstable tibial shaft fractures (excluding Gustilo Types IIIB and C) treated with intramedullary nailing were studied. Our findings support the use of reamed nailing in closed tibial fractures, which led to earlier time to union without increased complications. In addition, reaming did not increase the risk of complications in open tibial fractures

Introduction. Pain after trauma has received relatively little research attention compared with surgical techniques and functional outcomes, but is important to patients. We aimed to describe nerve dysfunction and pain characteristics using tibial fractures as a model. We hypothesized that early nerve dysfunction was associated with neuropathic and chronic pain. Materials and Methods. Adult patients with isolated open or closed tibial diaphyseal fractures were prospectively observed for 1-year in 5 Major Trauma Centres. Nerve dysfunction was assessed using Semmes-Weinstein monofilaments, acute pain with the visual numerical rating scale (VNRS), neuropathic pain with the doleur neuropathique-4 score and quality of life (QOL) using the EQ-5D score. Results. Of 77 included patients, twenty-six (33.8%) had Gustilo-Anderson grade II or worse injuries. Forty-six (63.0%) had operative repair; 0 operation notes reported nerve injury. Mean VNRS pain scores one week post-injury were 4.6/10 (SD 2.4). Seventeen patients (23.3%) presented with impaired sensation, persisting in 11 (15.1%) at 3-months. Neuropathic pain affected 16 (20.8%) patients one week post-injury; a further 20 (26.0%) had >2 symptoms of nerve pain. Only four (11.1%) received anti-neuropathic drugs. At 6-months, twenty-three (31.5%) reported mobility problems, 21 (28.8%) difficulty completing normal activities, 25 (34.2%) pain and 15 (20.5%) anxiety and depression. Conclusions. Nerve dysfunction and neuropathic pain are common early features in patients with tibial fractures, but are poorly recognised and inadequately treated. Pain has long-term effects on patients’ QOL. Future work should aim to improve identification and management of neuropathic pain

Fractures of the tibia should be reduced as accurately as possible. Fractures opened for internal fixation can be reduced accurately under direct vision, but unstable closed fractures treated by external fixation must be reduced by indirect means. Most surgeons reduce the fracture by manipulation, insert the bone-screws, apply the fixator and then manipulate the fracture again to improve the reduction before locking the fixator. Using this technique it is difficult to obtain a perfect reduction. A poor reduction can prolong healing time and may lead to malunion causing long-term impairment of function. A good reduction lessens the loading imposed on the bone-screws and fixator. We describe a device with which closed tibial fractures can be reduced with a predictable high degree of precision prior to external fixation. A reduction device, the Staffordshire Orthopaedic Reduction Machine (STORM), was developed. Externally fixed unstable closed tibial fractures reduced by conventional methods (n=37) were compared with those reduced using the STORM (n=41). In the STORM group, the holes for the fixator pins were only drilled once the fracture had been perfectly reduced and no further manipulation was undertaken after the fixator had been applied. Reductions were assessed by measurements of radiographs taken at, and 4 weeks after, fixator removal. All cases were treated with monolateral external fixation. The STORM significantly improves the precision of reduction of unstable tibial fractures without increasing operating time. Its use obviates the need for reduction joints on external fixators for the tibia

Per definition we distinguish between shaft fractures of the tibia and fibula (lower leg), proximal tibial fractures, distal tibial fractures and isolated tibial shaft fractures. There are different criteria to classify a tibial fracture: 1. age, 2. soft tissue damage. Not only the terms, “open” and, “closed” but also coexistent neurovascular damage and the presence of a compartment syndrome have to be mentioned. 3. Furthermore there are well known anatomical classifications of tibial fractures (AO, OTA). Special conditions, as osteoporosis, osteopenia, pathological fractures and osteogenesis imperfecta have to be recognized. The optimal treatment concept depends on the correct diagnosis, the manifestation of priorities, calculation of risks, management of complications and rehabilitation. The treatment options of severe tibial fractures are: The interlocking nail in reamed or unreamed technique, the external fixator and in very rare cases plating or screw fixation. The following principles in the treatment of severe tibial fractures should be mentioned:. The method of choice in closed and I° open tibial fractures is the reamed intramedullary nailing. If there is a coexistent fibular fracture at the same level as the tibial fracture, plating of the fibula should be performed. The preferred method in closed tibial fractures with moderate soft tissue damage and in II° open tibial fractures is the unreamed interlocking nailing. The closed tibial fracture with severe soft tissue damage as well as the III° open fracture are preferable treated by external fixation. The changing to intamedullary stabilization should be included in the therapeutic plan, primarily, or should be indicated later on. Plating (ORIF) of severe tibial fractures has become a very rare performed procedure and is presently done just in some special exemptions. A complementary osteo-synthesis, including nailing and plating, is not included in our therapeutic concept. Proximal and distal tibial fractures involving the joint surface are not included in this consideration. The indication for fasciotomy must not be too restrictive. A compartment syndrome should not prevent intramedullary nailing and a standardized protocol for second look procedures to protect bone and soft tissue has to be made. In children the method of choice in severe tibial fractures is the external fixation The own experiences, during a three year period (1999–2001), including 208 tibial/ fibular shaft fractures are presented. We had 77% closed and 23% open fractures. Overall 90% were treated by intramedullary nailing. In the open fractures, we fixed all I° open fractures by nailing and 56% of the II° open fractures. 67% of III°a fractures, 90% of III°b and all III°c fractures were initially stabilized by external fixation

We would like to present this case series of 10 adolescent patients with displaced, closed diaphyseal tibial fractures managed using the Taylor Spatial Frame. Management options for these injuries include non-operative treatment, antegrade nailing, flexible nailing systems, plating and external circular fixation. External circular fixation allows anatomical reduction avoiding potential complications such as growth arrest associated with antegrade nailing and retained metal work with plating. Flexible nailing system and cast immobilisation are unreliable for precise anatomical reduction. With limited evidence as to the extent of post-traumatic deformity that is acceptable, combined with the limited remodeling potential that this patient group possess, the precision of percutaneous fixation with the Taylor Spatial Frame system has clear advantages. This is a retrospective analysis of 10 adolescent patients with a mean age of 14.5 years (range 13 to 16 years). Data collected includes fracture configuration, deformity both pre and post operatively compared to post frame removal, length of time in frame and complications. The data was gathered using the patient case notes and the Picture Archiving and Communications System. The mean time in frame was 15.5 weeks (range 11 to 22 weeks). One non-union in a cigarette smoker was successfully managed with a second Taylor Spatial Frame episode. Our conclusion was that with careful patient selection the Taylor Spatial Frame allows successful treatment of closed tibial fractures in adolescents, avoiding complications such as growth arrest and post-traumatic deformity as well as avoiding retained metalwork

A single centre, prospective study of 196 closed tibial diaphyseal fractures treated by monolateral external fixation. Surgical management of all patients followed a protocol of the senior author (PBMT), with regard to technique and fracture reduction. Operations were performed by several different surgeons including the senior author. A definitive fixator was used as a reduction tool in 34 cases, and a separate fracture reduction device was used in 162 patients. Follow-up was in a dedicated external fixator clinic by the senior author until one year post-fracture healing. Fracture healing was determined by fracture stiffness measurements. 196 tibial fractures in 196 patients, average age 29 (range 12-80). 111 right sided and 85 left sided. 166 male and 30 female. 116 fractures due to low energy and 80 due to high energy. Mechanism of injury. football 75, fall 52, RTA 49, others 20. 33 patients had an additional 74 injuries: 38 fractures/dislocations (3 open), 7 compartment syndromes, 7 head injuries, 16 chest injuries, 9 soft tissue injuries. According to AO classification system: 33 A1, 47 A2, 42 A3, 15 B1, 46 B2, 7 B3. Time to fracture healing was 19 weeks on average (range 9-87). 15 patients had coronal deformity >5 degrees and 1 also had saggital deformity >10 degrees. One osteotomy for correction of malunion. 279 pin site infections requiring antibiotics in 35 patients. 7 fixators removed early due to pin site infection. One established osteomyelitis-lautenbach. 7 refractures, all healed (5 with pop, 2 with further fixator). Non-union: 5 hypertrophic, 2 atrophic-all healed with further external fixation. Our results show that external fixation of closed tibial fracture is a viable alternative to other treatment methods with regard to healing time and angular deformity. Our study also uses a well validated end point to define fracture healing and does not rely on the difficulty of defining union on clinical and radiological grounds

Abstract. Objectives. Three-dimensional visualisation of sonographic callus has the potential to improve the accuracy and accessibility of ultrasound evaluation of fracture healing. The aim of this study was to establish a reliable method for producing three-dimensional reconstruction of sonographic callus. Methods. A prospective cohort of ten patients with a closed tibial shaft fracture managed with intramedullary nailing were recruited and underwent ultrasound scanning at 2-, 6- and 12-weeks post-surgery. Ultrasound B-mode capture was performed using infrared tracking technology to map each image to a three-dimensional lattice. Using echo intensity, semi-automated mapping was performed by two independent reviewers to produce an anatomic three-dimensional representation of the fracture. Agreement on the presence of sonographic bridging callus on three-dimensional reconstructions was assessed using the kappa coefficient. Results. Nine of the ten patients achieved union at six months. At six weeks, seven patients had bridging callus at ≥1 cortex on the three-dimensional reconstruction; when present all united. Compared to radiographs, no bridging callus was present in any patient. Of the three patients lacking sonographic bridging callus, one went onto a nonunion (77.8%-sensitive and 100%-specific to predict union). At twelve weeks, nine patients had bridging callus at ≥1 cortex on three-dimensional reconstruction and all united (100%-sensitive and 100%-specific to predict union). Compared to radiographs, seven of the nine patients that united had bridging callus. Three-dimensional reconstruction of the anteromedial and anterolateral tibial surface was achieved in all patients, and detection of sonographic bridging callus on the three-dimensional reconstruction demonstrated substantial inter-observer agreement (kappa=0.78, 95% confidence interval 0.29–1.0, p=0.011). Conclusions. Three-dimensional fracture reconstruction can be created using multiple ultrasound images in order to evaluate the presence of bridging callus. This imaging modality has the potential to identify impaired healing at an early stage in fracture management. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Objective. To compare the clinical and radiological outcome between less invasive stabilization system (LISS, Synthes, Paoli, PA.) and open reduction with internal fixation (ORIF) for the treatment of extraarticular proximal tibia fractures through the lateral approach. Background. Proximal tibial fractures present a difficult treatment challenge with historically high complication rates. ORIF has been in vogue for long time with good outcome. But these are associated with problems especially overlying skin conditions, delayed recovery and rehabilitation with limited functional outcome. LISS is an emerging procedure for the treatment of proximal tibial fractures. It preserves soft tissue and the periosteal circulation, which promotes fracture healing. Patients and methods. Thirty patients with closed proximal tibial fractures were included in this study. They were randomly divided into 2 groups. Group I (n=15) patients were treated by LISS and group II (n=15) by ORIF. Major characteristics of the two groups were similar in terms of age, sex, mode of injury, fracture location, and associated injuries. All patients were followed up at least 6 months. Results. In each group, 12 patients were united, 2 patients were non- united and one patient showed delayed union. The mean operative time in LISS patients was 79.3 min, while in ORIF patients; it was 122 min. All patients of LISS group were exposed to radiation, while only 40% of ORIF group were exposed. The mean time of union of LISS patients was 10.87weeks. While in ORIF patients, the mean time of union was 21.13 weeks. There was no significant difference between both groups regarding the postoperative complications. Functional outcome was satisfactory in both groups. Conclusion. LISS achieves comparable results with ORIF in extraarticular fractures of the proximal tibia. Although LISS potentially has the radiation hazard, it reduces the perioperative complications with a shortened operation time and minimal soft tissue dissection. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

A prospective study of 196 closed tibial diaphyseal fractures treated by a monolateral external fixator is presented. The patients were managed by a group of Surgeons including the senior author (PBMT), a definitive fixator being used in 34 patients, and a fracture reduction device in 162 patients. All the patients were followed up in an external fixator clinic by the senior author, and follow up continued for 1 year after the fractures had healed. Fracture healing was determined clinically. There were 196 tibial fractures, with an average age of 29 years (range 12–80 years). 111 Fractures involved the right tibia, and 85 the left. There were 166 males and 30 females. 116 Fractures were deemed due to a low energy accident, and 80 due to a high energy injury. The most common mechanism of injury was football (75), a fall (52), a road vehicle accident (49), direct trauma (7), assault (4), and rugby (3). According to the AO classification system 33 were A1 fractures, 47 A2, 42 A3, 15 B1, 46 B2, and 7 B3. Time to fracture healing was 19 weeks on average (with a range from 9–87 weeks). 15 Fractures united with a deformity of more than 5. 0. in the coronal plane. One patient required a corrective osteotomy for a mal-united fracture. There were 279 pin track infections that required antibiotic treatment in 85 patients. 33 Pins had to be removed due to persistent infection. Of these patients 15 developed 32 ring sequestrae, but infection was settled by debridement under GA. 7 External fixators had to be removed early because of pin site infection. One patient developed a full blown osteomyelitis, which was treated with the Lautenbach irrigation and settled. There were 7 re-fractures, but all healed after further treatment. 5 Were treated in a POP cast and 2 were re-treated with another external fixator. There were 7 non-unions, but all eventually healed with further treatment with an external fixator. The authors conclude that treating a closed tibial fracture with an external fixator is a viable alternative method of treatment

Aims. Using tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery. Methods. The Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trial examined adults with an open or closed tibial shaft fracture who were treated with either reamed or unreamed intramedullary nails. HRQoL was assessed at hospital discharge (for pre-injury level) and at 12 months post-fracture using the Short Musculoskeletal Functional Assessment (SMFA) Dysfunction, SMFA Bother, 36-Item Short Form 36 (SF-36) Physical, and SF-36 Mental Component scores. We used multiple linear regression analysis to determine if baseline and surgical factors, as well as post-intervention procedures within one year of fracture, were associated with these HRQoL outcomes. Significance was set at p < 0.01. We hypothesize that, irrespective of the four measures used, prognosis is guided by both modifiable and non-modifiable factors and that patients do not return to their pre-injury level of function, nor HRQoL. Results. For patient and surgical factors, only pre-injury quality of life and isolated fracture showed a statistical effect on all four HRQoL outcomes, while high-energy injury mechanism, smoking, and race or ethnicity, demonstrated statistical significance for three of the four HRQoL outcomes. Patients who did not require reoperation in response to infection, the need for bone grafts, and/or the need for implant exchanges had statistically superior HRQoL outcomes than those who did require intervention within one year after initial tibial fracture nailing. Conclusion. We identified several baseline patient factors, surgical factors, and post-intervention procedures within one year after intramedullary nailing of a tibial shaft fracture that may influence a patient’s HRQoL. Cite this article: Bone Jt Open 2021;2(1):22–32

Single centre prospective study of 196 closed tibial diaphyseal fractures treated by monolateral external fixation. Methods: Surgical management of all patients followed protocol of senior author (PBMT), with regard to technique and fracture reduction. Operations performed by several different surgeons including senior author. Definitive fixator used as a reduction tool in 34 cases, fracture reduction device used in 162 patients – ST.O.R.M. Followed up in a dedicated external fixator clinic by the senior author until one year post fracture healing. Fracture healing was determined by fracture stiffness measurements. Results: 196 tibial fractures in 196 patients, average age 29 (range 12–80). 111 right sided and 85 left sided. 166 male and 30 female. 116 fractures due to low energy and 80 due to high energy. Mechanism of injury: football 75, fall 52, RTA 49, direct blow 7, assault 4, rugby 3, crush 2, dancing 2, bowling 1, roller skating 1. 33 patients had an additional 74 injuries: 35 fractures (3 open), 7 compartment syndromes, 3 dislocations, 7 head injuries, 16 chest injuries, 9 soft tissue injuries. According to AO classification system: 33 A1, 47 A2, 42 A3, 15 B1, 46 B2, 7 B3. Time to # healing was 19 weeks on average (range 9–87). X ray data: 15 patients had deformity > 5 degrees in the coronal plane and 1 of these also had deformity > 10 degrees in the saggital plane. One patient underwent osteotomy for correction of malunion. 85 patients had a total of 279 pin site infections requiring Abx (6 with 14 pin infections requiring iv abx), and 33 pins were removed due to persistent infection. 15 patients had 32 ring sequestra which settled with debridement under GA. 7 fixators removed early due to pin site infection. 1 established osteomyelitis-lautenbach. 7 refractures, all healed(5 with pop, 2 with further fixator). Non-union: 5 hypertrophic, 2 atrophic-all healed with further external fixation. Malunion: 1. Conclusion: Our results show that external fixation of closed tibial fractures is a viable alternative to other treatment methods with regard to healing time and angular deformity. Our study also uses a well validated end point to define fracture healing and does not rely on the difficulty of defining healing on clinical or radiological grounds which is known to be unreliable. This is the first time this highly repeatable methodology has been used for such fractures