Orthopaedic injuries in the knee are often associated with vascular injury. When these vascular injuries are missed devastating there are devastating outcomes like limb ablation. Pulse examination in these patients is not sensitive to exclude vascular injuries. That often lead to clinicians opting for Computed Tomography Angiogram (CTA) to exclude vascular. this usually leads to a burden in Radiology Department. This study aimed to evaluate the prevalence of vascular injury in patient with orthopaedic injury in the knee. The computed tomography (CT) done in patients with distal femur fracture, knee dislocation and proximal tibia fractures were retrieved from the picture archiving and comunication system (PACS). The CTs were done between June 2017 and June 2022. The computed tomography angiogram (CTA) reports were reviewed to determine cases that vascular injury. A sample size of 511 cases was collected. 386 cases were done CTA and 125 cases were not done CTA. There were 218 tibial plateau fractures, 79 knee dislocations, 72 distal metaphyseal femur fractures, 61 floating knees, 55 distal femure intraarticular and 26 proximal metaphyseal tibia fractures. The mechanisms of injury in these were gunshot, fall from standing height, fall from height, MVA, MBA, PVA and sports. Prevalance was 9.17% (47) of the total injuries in the knee. Prevalance in patients who were sent for CTA was 12.08%. Routine CTA in patients with injuries in the knee is not recomended. The use of ankle brachial index may decrease the number of CTA done

The October 2023 Trauma Roundup. 360. looks at: Intramedullary nailing versus sliding hip screw in trochanteric fracture management: the INSITE randomized clinical trial; Five-year outcomes for patients with a displaced fracture of the distal tibia; Direct anterior versus anterolateral approach in hip joint hemiarthroplasty; Proximal humerus fractures: treat them all nonoperatively?; Tranexamic acid administration by prehospital personnel; Locked plating versus nailing for proximal tibia fractures: a multicentre randomized controlled trial; A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution

The August 2023 Trauma Roundup. 360. looks at: A comparison of functional cast and volar-flexion ulnar deviation for dorsally displaced distal radius fractures; Give your stable ankle fractures some AIR!; Early stabilization of rib fractures – an effective thing to do?; Locked plating versus nailing for proximal tibia fractures: A multicentre randomized controlled trial; Time to flap coverage in open tibia fractures; Does tranexamic acid affect the incidence of heterotropic ossification around the elbow?; High BMI – good or bad in surgical fixation of hip fractures?

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Patient decision aids have previously demonstrated an improvement in the quality of the informed consent process. This study assessed the effectiveness of detailed written patient information, compared to standard verbal consent, in improving postoperative recall in adult orthopaedic trauma patients.

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The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

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The aim of this retrospective cohort study was to assess and investigate the safety and efficacy of using a distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children.

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

Osteosynthesis of high-energy metaphyseal proximal tibia fractures is still challenging, especially in patients with severe soft tissue injuries and/or short stature. Although the use of external fixators is the traditional treatment of choice for open comminuted fractures, patients' acceptance is low due to the high profile and therefore the physical burden of the devices. Recently, clinical case reports have shown that supercutaneous locked plating used as definite external fixation could be an efficient alternative. Therefore, the aim of this study was to evaluate the effect of implant configuration on stability and interfragmentary motions of unstable proximal tibia fractures fixed by means of externalized locked plating. Based on a right tibia CT scan of a 48 years-old male donor, a finite element model of an unstable proximal tibia fracture was developed to compare the stability of one internal and two different externalized plate fixations. A 2-cm osteotomy gap, located 5 cm distally to the articular surface and replicating an AO/OTA 41-C2.2 fracture, was virtually fixed with a medial stainless steel LISS-DF plate. Three implant configurations (IC) with different plate elevations were modelled and virtually tested biomechanically: IC-1 with 2-mm elevation (internal locked plate fixation), IC-2 with 22-mm elevation (externalized locked plate fixation with thin soft tissue simulation) and IC-3 with 32-mm elevation (externalized locked plate fixation with thick soft tissue simulation). Axial loads of 25 kg (partial weightbearing) and 80 kg (full weightbearing) were applied to the proximal tibia end and distributed at a ratio of 80%/20% on the medial/lateral condyles. A hinge joint was simulated at the distal end of the tibia. Parameters of interest were construct stiffness, as well as interfragmentary motion and longitudinal strain at the most lateral aspect of the fracture. Construct stiffness was 655 N/mm (IC-1), 197 N/mm (IC-2) and 128 N/mm (IC-3). Interfragmentary motions under partial weightbearing were 0.31 mm (IC-1), 1.09 mm (IC-2) and 1.74 mm (IC-3), whereas under full weightbearing they were 0.97 mm (IC-1), 3.50 mm (IC-2) and 5.56 mm (IC-3). The corresponding longitudinal strains at the fracture site under partial weightbearing were 1.55% (IC-1), 5.45% (IC-2) and 8.70% (IC-3). From virtual biomechanics point of view, externalized locked plating of unstable proximal tibia fractures with simulated thin and thick soft tissue environment seems to ensure favorable conditions for callus formation with longitudinal strains at the fracture site not exceeding 10%, thus providing appropriate relative stability for secondary bone healing under partial weightbearing during the early postoperative phase

Aims

This observational study examines the effect of the COVID-19 pandemic upon the paediatric trauma burden of a district general hospital. We aim to compare the nature and volume of the paediatric trauma during the first 2020 UK lockdown period with the same period in 2019.

Background. There exists no consensus opinion as to the most suitable post-operative rehabilitation and weight bearing status for proximal tibia articular fractures treated with internal fixation using plates and screws. Objectives. The aim of this study is to investigate whether the post-operative weight bearing status is associated with loss of reduction and articular collapse. Study Design and Methods. Data was retrospectively analysed from our prospective database in a major trauma centre. Group I were non-weight bearing for the first six weeks post-operation and Group II were instructed to weight bear fully immediately post-operation. Radiographs were taken day one post-operation, at six weeks and at three months and analysed for fracture displacement and joint depression or loss of fixation. Results. 90 patients were included in the study. The follow up radiographs demonstrated no failure of fixation in either study group. One patient from the weight bearing group had >1mm joint depression (4mm) identified at the first follow up, which did not worsen by the second. Conclusions. This study shows immediate post-operative full weight bearing does not affect the fixation or cause articular collapse up to three months after surgery. We propose that patients should be encouraged to weight bear immediately post-operation

The traditional techniques involving an oblique tunnel or triangular wedge resection to approach a central or mixed-type physeal bar are hindered by poor visualisation of the bar. This may be overcome by a complete transverse osteotomy at the metaphysis near the growth plate or a direct vertical approach to the bar. Ilizarov external fixation using small wires allows firm fixation of the short physis-bearing fragment, and can also correct an associated angular deformity and permit limb lengthening.

We accurately approached and successfully excised ten central- or mixed-type bars; six in the distal femur, two in the proximal tibia and two in the distal tibia, without damaging the uninvolved physis, and corrected the associated angular deformity and leg-length discrepancy. Callus formation was slightly delayed because of periosteal elevation and stretching during resection of the bar. The resultant resection of the bar was satisfactory in seven patients and fair in three as assessed using a by a modified Williamson–Staheli classification.

Cite this article: Bone Joint J 2015;97-B:1726–31.

Non- or semi-constraint TKA implants do have their limitations in the absence of collateral ligaments, severe deformity, large osseous defects and gross flexion - extension instability or mismatch, even in primary TKA. Additionally instability is increasingly recognised as a major failure factor in primary and revision TKA. Historically most of the first pure hinged TKA implants have shown disappointing results, due to early loosening based on excessive force transmission from the hinge mechanism to the bone-cement interface, used the use of all metal articulation, suboptimal instrumentation or design. Consequently a hinged design was abandoned by most US surgeons. However, some European centres continued with the use of some early European designed pure- and rotating hinged implants. Although most indication in primary TKA can be solved with modular non- or semi-constrained implants, an adequate balancing might require a relevant soft tissue release or reconstruction with allografts. This consequently increases the complexity and operative time with less predictable results in the elderly patient with principal less healing potential, desirable early post-operative full weightbearing and full range of motion. Thus potential indications in the elderly for a rotating- or pure hinged implant in primary TKA include: . –. Complete MCL instability. –. Severe varus or valgus deformity (>25°) with necessary relevant soft tissue release. –. Relevant bone loss with insertions of collaterals. –. Gross flexion-extension in balance. –. Post-traumatic with distal femur or proximal tibia fracture. –. Stiff knee. –. Severe osteoporosis in the old patient. –. Post infectious for a one staged implantation with specific antibiotics in cement. While some authors showed excellent survival rates in of 96% after 15 years in primary TKA, some recent studies revealed high complication rates of up to 25%, including a high infection rate of 2.9%. This remains inconsistent with our clinical results in primary TKA, which revealed an overall survival rate in patients over 60 years of 94% after 13 years, while patients < 60 years revealed a survival rate of only 77%. Correlation between survival rate and deformity revealed in varus alignment a survival rate of 97%, whereas in valgus only a rate of 79%. Consequently we strictly reserve a rotational hinge for patients > 60 years with a combined varus alignment, whereas in severe valgus deformities a pure hinged should be used for our implant design. Limitations of most hinged implants are relatively rare. In our hands the main limitation is hyperextension and weak extensor mechanism, because this leads to early loosenings

Alpine ski sports changed rapidly in the last decade. Complex fractures of the proximal tibia, typically seen in high energy trauma, has been seen more frequently and more often related to alpine skiing. The aim of our study was to identify reasons for proximal tibia fracture in alpine skiing and observe the outcome. All patients with proximal tibia fractures related to alpine skiing, which were treated in our two trauma centers were included. The patients received a questionnaire at the emergency department, dealing with accident details and the skiing habits. The fractures were classified according to the AO fracture classification scheme. The follow up was performed at least one year after trauma with the Lysholm, the Tegner activity, as well as the WOMAC VAS Score. Between 2007 and 2010 a total of 188 patients with proximal tibia fractures caused by alpine skiing were treated. 43 patients had a type A, 96 patients a type B and 49 a type C injury. The incidence was increasing over the period continuously. The main trauma mechanism was an accident without a third party involvement with an increased rotational and axial compression impact. All outcome scores were related to fracture severity with significant worse results for the type C fractures. In conclusion, proximal tibia fractures are an increasing and serious injury during alpine skiing. Further technical progress in skiing material should focus on these knee injuries in future

Introduction. 47 yrs male patient had a prior history. 2005 Fx. proximal tibia (open Fx.). 2007 Metal removal. 2008 Arthroscopic debridement (2 times). He visited out hospital with severe pain and tenderness X-ray (Fig 1) and MRI (Fig 2) findings as follows. Conclusively, He had a chorinic osteomylitis of proximal tibia with soft tissue absess. 1st Surgery. I did arthroscopic debridement Arthroscopic finding shows synovitis, meniscus tear and chondromalacia. I did meticulous debridement (irrigation & curettage). 2nd Surgery. He did primary total knee arthro-plasty instead of two-stage exchange arthroplasty in may, 2010 at the another hospital. 3rd Surgery. After 7 months since he had did total knee arthroplasty, he visited to my hospital again with sudden onset of painful swelling & heating sensation. 4th Surgery. I did second stage reimplantation for infected total Knee arthroplasty after 7 weeks. Now he got a pain relief & ROM restroration. Results. Follow up 12 months X-ray showing all implants to be well-positioned and stable. Clinically, there was no implant considered to be loose. In this study, the knee society and functional scores at final follow up were 82 and 68. Conclusion. The infection after sequales of open proximal tibia fracture is treated by two-stage exchange total knee arthroplasty instead of primary total knee arthroplasty. Two-stage reimplantation of an infected total knee arthroplasty using a static antibiotic-cement spacer achieved an infection control and improvement in the clinical result 3). We use an antibiotic-loaded cement spacer(ALACS) preserved knee function between stages, resulting in effective treatment of infection, facilitation of reimplantation, and improved patient satisfaction 1). The principle surgical technique used for two-stage revision of infected total knee including: (1) exposure, (2) implant removal and debridement, and (3) construction of both static and mobile antibiotic spacers 2

Introduction and objectives. Intramedullary nailing is indicated to stabilization of tibia shaft fractures. Intramedullary nailing through an infra-patellar incision is commonly the technique of choice. While intramedullary nailing of simple diaphyseal fracture patterns is relatively easy, proximal tibia fractures, extremely comminuted/segmental tibia fractures, politrauma with multiple fractures in both extremities and reconstruction of bone loss segment with stiffness of the knee joint can be very challenging to treat. A novel technique for intramedullary tibia nailing through the patella-femoral joint is described. This technique allow extension tibia during intervention time and it supplies easier reduction of the pattern of fracture above. The purpose of our investigation was to evaluate the use of this new technique in described above pattern fracture and patient situation; because we have thought that new technique can perform better outcomes in this situations. Materials and Methods. An observational study of tibia fractures or bone defect was performed for consecutive patients who presented: proximal tibia fractures, extremely comminuted/segmental tibia fractures, politrauma with multiple fractures in both extremities and reconstruction of bone loss segment in the Trauma unit of our institution from September 2009 to August 2010. A total of 32 were included in our study, which performed surgery intervention with Trigen tibia nail (Smith & Nephew, Memphis) with suprapatelar device. Demographic data, mechanism of injury, fracture classification, ROM (2 and 6 weeks, and 3 months), consolidation rate, reduction fracture quality and knee pain at 3 months were recorded. Results. Male was the gender most frequent (64%), the average age was 39,5 years and the main mechanism of injury was motor vehicle injury (30,6%). There were 7 proximal fractures, 1 bifocal fracture, 6 politrauma and 2 reconstruction bone loss segment, the others were comminuted and segmental tibia fracture. In all the patients, the fracture was consolidated between 8 to 14 weeks with average of 10,6 weeks. The quality of reduction was correct in all patients in different axis. The average of ROM at 2 weeks was (−2°/95°) at 3 months was (−0,4°/133°). The knee pain (VAS) average was 0,6 only in 2 patients were (4). Poller screw was used in 7 patients. Conclusion. The suprapatelar nailing is optimal technique to resolve complex fracture of the tibia (proximal, segmental conminution, politrauma) that perform correct consolidation rate without misalignment in the patients. Concerns about knee pain (VAS) from the technique not appear in our data. Prospective and clinical trials are needed to validate this approach

This review considers the surgical treatment of displaced fractures involving the knee in elderly, osteoporotic patients. The goals of treatment include pain control, early mobilisation, avoidance of complications and minimising the need for further surgery. Open reduction and internal fixation (ORIF) frequently results in loss of reduction, which can result in post-traumatic arthritis and the occasional conversion to total knee replacement (TKR). TKR after failed internal fixation is challenging, with modest functional outcomes and high complication rates. TKR undertaken as treatment of the initial fracture has better results to late TKR, but does not match the outcome of primary TKR without complications. Given the relatively infrequent need for late TKR following failed fixation, ORIF is the preferred management for most cases. Early TKR can be considered for those patients with pre-existing arthritis, bicondylar femoral fractures, those who would be unable to comply with weight-bearing restrictions, or where a single definitive procedure is required.

Anatomically contoured periarticular plates for treatment of proximal tibia fractures is fast becoming the standard for care. The aim of our study was to assess the accuracy of the anatomic contour of proximal lateral tibial plates of AO Stryker and Zimmer in Indian patients. We assessed the accuracy of the anatomic contour of proximal lateral tibial plates of AO Stryker and Zimmer in 50 Indian dry tibiae. All the plates were placed on the 50 tibia by two independent surgeons according to what they felt was the best fit. The tibiae and the plate fits were mapped, quantified, and analysed using digital image capturing and adobe photoshop software. By corresponding the clinical appearance of good fit with our digital findings, we created numerical criteria for plate fit in three planes: coronal (volume of free space between the plate and bone), sagittal (alignment with the tibial plateau and shaft), and axial (match in curvature between the proximal horizontal part of the plate and the tibial plateau). An anatomic fit should mirror the shape of the tibia in all three planes and only ten plates of different companies qualified this. Recognising and understanding the substantial variations in fit that exist between anatomically contoured plates, it might be worthwhile developing proximal tibia plates specific for the Indian population or validating this study by having a larger multicentric study group. This paper would suggest caution when these plates are used as a tool for indirect reduction of the fractures

Arteriovenous fistula formation after a closed extremity fracture is rare. We present the case of an 11-year-old boy who developed an arteriovenous fistula between the anterior tibial artery and popliteal vein after closed fractures of the proximal tibia and fibula. The fractures were treated by closed reduction and casting. A fistula was diagnosed 12 weeks after the injury. It was treated by embolisation with coils. Subsequent angiography and ultrasonography confirmed patency of the popliteal vein and anterior and posterior tibial and peroneal arteries, with no residual shunting through the fistula. The fractures healed uneventfully and he returned to full unrestricted activities 21 weeks after his injury.