The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 – 2010 were contacted and interviewed. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation in the same period. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria, of which 30 patients (61%) were followed-up. Ten of the 30 patients required revision surgery, 3 of which involved conversion to a circular frame. Twenty-two of the 30 patients (73%) recovered sufficiently to complete a basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma

The aim of this study was to establish medium term outcomes in military casualties following severe open tibia fractures. Cases from a previously published series were contacted and assessed with the SF-36 outcome tool. Their results were then compared to a similar study of military trans-tibial amputees. Of the original data set of 49 patients, 30 patients were followed up and completed an SF-36 (61%) with a median follow-up of 4 years (49 months, IQR 397–63). Ten of the 30 required revision surgery, 3 of which involved conversion from initial fixation to a circular frame. Twenty-two of the 30 patients recovered sufficiently to complete a military basic fitness test. The median physical component of SF-36 in the tibia fracture group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in the amputation or fracture group reporting pain (p= 0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). We present the patient reported outcomes following combat open tibia fracture and show that they are similar to those achieved after trans-tibial amputation

Aims

The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols.

A multicenter retrospective analysis of patients treated for tibial fracture was conducted to develop a score that correlates with fracture healing time and, ultimately, to identify the risk gradient of delayed healing.

The clinical records of 93 patients treated for tibial fracture at three orthopaedic centers were evaluated. Patients were considered healed when full weight bearing was allowed and no further controls were scheduled. For the purpose of our analysis, we separated patients healed within or after 180 days.

Patient's risk factors known to be associated to delay healing, as well as fracture morphology and orthopaedic treatment were recorded in an electronic Case Report Form (e-CRF). Information available in the literature was used to weight the relative risk (RR) associated to each risk factor; values were combined to calculate a score to be correlated to the fracture healing time: L-ARRCO (Literature-Algoritmo Rischio Ritardo Consolidazione Ossea). Among all information collected in e-CRFs, we identified other risk factors, associated to delayed healing, that were used to calculate a new score: ARRCO. Univariate logistic analysis was used to determine a correlation between the score and healing time. Analysis by receiver operating characteristic (ROC) and calculation of the area under the curve (AUC) were used for sensitivity and specificity.

Complete information was available for 53 patients. The mean value of the L-ARRCO score among patients healed within 180 days was 5.78 ± 1.59 and 7.05 ± 2.46 among those healed afterwards, p=0.044. The mean value of the ARRCO score of patients healed within 180 days was 5.92 ± 1.78 and 9.03 ± 2.79 among those healed afterwards, p<0.0001. The ROC curve shows an AUC of 0.62±0.09 for L-ARRCO and an AUC of 0.82±0.07 for ARRCO, (p<0.0001).

We have shown that the ARRCO score value is significantly correlated to fracture healing time. The score may be used to identify fractures at risk of delayed healing, thus allowing surgeon's early intervention to stimulate osteogenesis.

We report on the use of the Ilizarov method to treat 40 consecutive fractures of the tibial shaft (35 AO 42C fractures and five AO 42B3 fractures) in adults. There were 28 men and 12 women with a mean age of 43 years (19 to 81). The series included 19 open fractures (six Gustilo grade 3A and 13 grade 3B) and 21 closed injuries. The mean time from injury to application of definitive Ilizarov frame was eight days (0 to 35) with 36 fractures successfully uniting without the need for any bone-stimulating procedure. The four remaining patients with nonunion healed with a second frame. There were no amputations and no deep infections. None required intervention for malunion. The total time to healing was calculated from date of injury to removal of the frame, with a median of 166 days (mean 187, (87 to 370)). Minor complications included snapped wires in two patients and minor pin-site infections treated with oral antibiotics in nine patients (23%). Clinical scores were available for 32 of the 40 patients at a median of 55 months (mean 62, (26 to 99)) post-injury, with ‘good’ Olerud and Molander ankle scores (median 80, mean 75, (10 to 100)), ‘excellent’ Lysholm knee scores (median 97, mean 88, (29 to 100)), a median Tegner activity score of 4 (mean 4, (0 to 9)) (comparable to ‘moderately heavy labour / cycling and jogging’) and Short Form-12 scores that exceeded the mean of the population as a whole (median physical component score 55 (mean 51, (20 to 64)), median mental component score 57 (mean 53, (21 to 62)). In conclusion, the Ilizarov method is a safe and reliable way of treating complex tibial shaft fractures with a high rate of primary union.

Using human cadaver specimens, we investigated the role of supplementary fibular plating in the treatment of distal tibial fractures using an intramedullary nail. Fibular plating is thought to improve stability in these situations, but has been reported to have increased soft-tissue complications and to impair union of the fracture. We proposed that multidirectional locking screws provide adequate stability, making additional fibular plating unnecessary. A distal tibiofibular osteotomy model performed on matched fresh-frozen lower limb specimens was stabilised with reamed nails using conventional biplanar distal locking (CDL) or multidirectional distal locking (MDL) options with and without fibular plating. Rotational stiffness was assessed under a constant axial force of 150 N and a superimposed torque of ± 5 Nm. Total movement, and neutral zone and fracture gap movement were analysed.

In the CDL group, fibular plating improved stiffness at the tibial fracture site, albeit to a small degree (p = 0.013). In the MDL group additional fibular plating did not increase the stiffness. The MDL nail without fibular plating was significantly more stable than the CDL nail with an additional fibular plate (p = 0.008).

These findings suggest that additional fibular plating does not improve stability if a multidirectional distal locking intramedullary nail is used, and is therefore unnecessary if not needed to aid reduction.

Cite this article: Bone Joint J 2014;96-B:385–9.

Aims. The modified Radiological Union Scale for Tibia (mRUST) fractures score was developed in order to assess progress to union and define a numerical assessment of fracture healing of metadiaphyseal fractures. This score has been shown to be valuable in predicting radiological union; however, there is no information on the sensitivity, specificity, and accuracy of this index for various cut-off scores. The aim of this study is to evaluate sensitivity, specificity, accuracy, and cut-off points of the mRUST score for the diagnosis of metadiaphyseal fractures healing. Methods. A cohort of 146 distal femur fractures were retrospectively identified at our institution. After excluding AO/OTA type B fractures, nonunions, follow-up less than 12 weeks, and patients aged less than 16 years, 104 sets of radiographs were included for analysis. Anteroposterior and lateral femur radiographs at six weeks, 12 weeks, 24 weeks, and final follow-up were separately scored by three surgeons using the mRUST score. The sensitivity and specificity of mean mRUST score were calculated using clinical and further radiological findings as a gold standard for ultimate fracture healing. A receiver operating characteristic curve was also performed to determine the cut-off points at each time point. Results. The mean mRUST score of ten at 24 weeks revealed a 91.9% sensitivity, 100% specificity, and 92.6% accuracy of predicting ultimate fracture healing. A cut-off point of 13 points revealed 41.9% sensitivity, 100% specificity, and 46.9% accuracy at the same time point. Conclusion. The mRUST score of ten points at 24 weeks can be used as a viable screening method with the highest sensitivity, specificity, and accuracy for healing of metadiaphyseal femur fractures. However, the cut-off point of 13 increases the specificity to 100%, but decreases sensitivity. Furthermore, the mRUST score should not be used at six weeks, as results show an inability to accurately predict eventual fracture healing at this time point. Cite this article: Bone Jt Open 2021;2(10):796–805

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

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

Purpose. Tibia plateau fractures are severe knee injuries which have a great impact on the patients' lives, but in what extend is not clear yet in the literature. The purpose of this study was to investigate the gait alternations after treatment of patients who had severe tibia plateau fractures which were treated with circular ilizarov frame. Materials & Methods. We have evaluated the gait pattern of patients who were treated with circular Ilizarov frame after severe tibia plateau fractures (Schatzker IV-VI) in our department. The gait was tested by using a force plate in a walking platform. Ground Reaction Forces (GRF) data were collected during level walking at self-selected speeds. The patients performed two walking tasks for each limb and the collected data were averaged for each limb. Demographic, clinical, radiological and quality of life questionnaire (SF-12) data were also collected. Results. We have analysed the gait through the GRF of fifteen patients (aged 50.8 ±17.3 years), who had undergone treatment with circular Ilizarov frame following severe tibia plateau fractures (Schatzker IV-VI). Nine were male and six were female. The tests were performed at an average of 13.2 months after the initial treatment. SF-12 Mental scores have returned to normal (mean 54.6 ±12.3) but physical scores remained impaired (mean 40.6 ±10.8). A one-way repeated measures ANOVA was conducted to compare the GRFs and gait timing data of the affected limb with the normal one. Single limb support interval was significantly reduced to the affected limb (p=0.001) and terminal stance phase was prolonged for the normal limb (p=0.035). During this phase of the gait circle the knee is on its maximum flexion and the quadriceps contracts to bring the femur above the tibia. It seems that these patients during the gait circle reduce the flexion of their affected knee to make their single stance shorter. To the normal limb the patients manage to reduce more the GRFs during the mid-stance phase (F2 force), this difference do not reach significance, but illuminates the tendency of reduced knee flexion in that phase. The rest of the GRF and gait timing data did not had significant differences. Conclusions. One year after severe tibia plateau fracture treated with circular ilizarov frame the patients manage to return to almost normal gait pattern. Reduce single limb stance and terminal stance phase to the affected knee can be explained by the tendency of not flexing their deficient knee as much during that gait phase

Aims

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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Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets.

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Fracture-related infections (FRIs) are a devastating complication of fracture management. However, the impact of FRIs on mental health remains understudied. The aim of this study was a longitudinal evaluation of patients’ psychological state, and expectations for recovery comparing patients with recurrent FRI to those with primary FRI.

The aim of this study was to characterise severe open tibial shaft fractures sustained by UK military personnel over 10-years of combat and to determine the infection rate and factors that influence it. The UK military Joint Theatre Trauma Registry was searched and X-rays, clinical notes and microbiological records were reviewed for all patients. One hundred GA III open tibia fractures in 89 patients were identified. Three fractures were not followed up for 12-months and were therefore excluded. Twenty-two (23%) of the remaining 97 tibial fractures were complicated by infection requiring surgical treatment, with S. aureus being the causative agent in 13/22 infected fractures (59%). Neither injury severity, mechanism, the use of an external fixator, the need for vascularised tissue transfer or smoking status were significantly associated with infection. Bone loss was significantly associated with subsequent infection (p<0.0001). Most infection in combat open tibia fractures is caused by familiar organisms i.e. S. aureus. The use of external fixators to temporarily stabilise fractures is not associated with an increased risk of subsequent infection. While the overall severity of a casualty's injuries was not associated with infection, the degree of bone loss from the fracture was

Aims

The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK.

AIM. SIGN-nail system was elaborated to reduce the need in image intensifier during IM-nailing and to allow use of this method in poor countries with restricted medical facilities. The aim of this study was to evaluate efficacy of SIGN-nailing in tibia fractures treatment. MAT. 119 patients with 120 tibia fractures were treated with SIGN nails from 2006 to 2009. Mean age 41.4±12.9 years (17–72). Closed fractures - 106, open - 14 (Gustilo I-6, II-6, III-2 III). Interval from the injury to operation: 6.24±7.9 days (0–45); 71.7% of patients were operated within a week after the injury. Closed reposition achieved in all but 7 cases. Manual reaming was performed in most cases, power -9, no reaming -8 cases. Distal locking was performed with use of supplied jig. RES. Satisfactory reposition and fixation was achieved in most cases, axial deviations more than 5° were noticed post-operatively in 6 cases, or developed within 2 months in other 2, but were well tolerated clinically. All deviations were seen in joint-adjacent fractures (proximal 5, distal 3). Purulent complications were seen in 2 cases (1.6%). Follow-up results in terms exceeding 12 months were obtained in 106 patients (mean 13.6±6.6, range 6–36). No non-unions were seen. Delayed unions - 8 patients (6 of them with proximal third fractures). Radiological consolidation was achieved in terms 3–8 months after the surgery (5.7±2.3). Mean time to full weight bearing varied comprised 4.0±2.1 months: in the subgroup with middle-lower third involvement −3.43±0.8, upper third −6.1±1.3 (p<0.05). CONCL. SIGN nailing proved to be easy and reliable in most our cases of tibia shaft fractures. Higher incidence of angular deviations and slower consolidation seen in more proximal or distal fractures need further investigations

Purpose. To examine the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss. Method. A retrospective review was conducted identifying patients from our trauma database. Inclusion criteria were age (4–17 years) and open lower-limb trauma. Outcome measures included time to soft tissue coverage, surgical techniques, trauma impact scores, health-related quality of life, union and complication rates. Results. We identified 26 patients. 24 patients had open tibia fractures including 10 patients with bone loss. In 9 patients primary skin closure was achieved by acute shortening. 17 patients required soft tissue coverage including 14 free vascularised muscle flaps (89% within 48 hours). The surgical techniques applied were: circular fine wire frame (16), external fixateur (5) and open reduction internal fixation (5). Median follow up time was 8 (3–45) months. The trauma impact scores showed one in three patients were at risk of PTSD. All fractures went on to unite over a median time of 4.2 (2–9) months. No deep infections occurred. Conclusion. All our patients had limb salvage, fracture union and near normal levels of physical scores in the short term. Close psychological follow up is advisable to minimise the risk of PTSD

Objectives. External fixators are the traditional fixation method of choice for contaminated open fractures. However, patient acceptance is low due to the high profile and therefore physical burden of the constructs. An externalised locking compression plate is a low profile alternative. However, the biomechanical differences have not been assessed. The objective of this study was to evaluate the axial and torsional stiffness of the externalised titanium locking compression plate (ET-LCP), the externalised stainless steel locking compression plate (ESS-LCP) and the unilateral external fixator (UEF). Methods. A fracture gap model was created to simulate comminuted mid-shaft tibia fractures using synthetic composite bones. Fifteen constructs were stabilised with ET-LCP, ESS-LCP or UEF (five constructs each). The constructs were loaded under both axial and torsional directions to determine construct stiffness. Results. The mean axial stiffness was very similar for UEF (528 N/mm) and ESS-LCP (525 N/mm), while it was slightly lower for ET-LCP (469 N/mm). One-way analysis of variance (ANOVA) testing in all three groups demonstrated no significant difference (F(2,12) = 2.057, p = 0.171). There was a significant difference in mean torsional stiffness between the UEF (0.512 Nm/degree), the ESS-LCP (0.686 Nm/degree) and the ET-LCP (0.639 Nm/degree), as determined by one-way ANOVA (F(2,12) = 6.204, p = 0.014). A Tukey post hoc test revealed that the torsional stiffness of the ESS-LCP was statistically higher than that of the UEF by 0.174 Nm/degree (p = 0.013). No catastrophic failures were observed. Conclusion. Using the LCP as an external fixator may provide a viable and attractive alternative to the traditional UEF as its lower profile makes it more acceptable to patients, while not compromising on axial and torsional stiffness. Cite this article: B. F. H. Ang, J. Y. Chen, A. K. S. Yew, S. K. Chua, S. M. Chou, S. L. Chia, J. S. B. Koh, T. S. Howe. Externalised locking compression plate as an alternative to the unilateral external fixator: a biomechanical comparative study of axial and torsional stiffness. Bone Joint Res 2017;6:216–223. DOI: 10.1302/2046-3758.64.2000470

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This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England.

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The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs.