To provide a best estimate of the average treatment effect when microfracture was chosen as the intervention of choice in patients with full-thickness cartilage defects of the knee. We focussed on controlled studies which either referred to microfracture alone or in comparison with any other surgical treatment of articular cartilage of the knee. Papers including patients who had been treated by microfracture and concomitant adjuvant procedures like ACL reconstruction or meniscus repair were accepted too, whereas papers reporting on the microfracture technique combined with the implantation of a scaffold were excluded. To achieve a best estimate of the average, to be expected treatment effect we pooled pooled before–after data of study arms using microfracture. Because cartilage studies employ various scales to measure functional improvements, we standardized treatment effects using Hedges' g. To provide clinically meaningful estimates we converted the pooled summary effect back into the respective scales by multiplying the pooled effect with pooled standard deviations of each included clinical scale.Objective
Design
According to the International Classification of Psychic Disturbances (ICD 10) accidents are among the traumatic incidents in a person’s experience and can lead to acute or persisting post traumatic strain reactions. During the primary medical treatment and care the patient first of all has to come to terms with the consequences of the accident. If an acute osteomyelitis occurs later on, this will be a further strain on the patient’s convalescence. At this point in time the extent of this infection is not foreseeable, neither for the team treating the patient nor for the patient him/herself. While the accident itself is to be seen as an acute trauma, the development of a chronic infection is a creeping and uncertain process. On the one hand the patient is confronted with the psychic effect of the accident and its consequences and on the other hand with the psychic effects of drawn-out treatment. Apart from functional restrictions and cosmetically straining outcomes the patients suffer under the social effects, such as loss of work and threats to finances, changes, or loosing a partner and the social surroundings and restrictions in leisure activities. The psychological effects of chronic strain are a depressive attitude, loosing control when acute pain occurs, a decrease in sexual needs, alcohol or medication abuse and not rarely a permanent change in personality. Added to this are worries about the future, fear that the infection can “flare-up” again or the necessity of an amputation. According to the literature the existence of chronic pain is the most serious influential factor on a patient’s quality of life. The question which personality factors contribute to the development of chronic osteomyelitis has not been answered to date. Investigations only show a connection between patients with psychiatric illnesses and a higher liability to be ill. Klemm et al. (1988) specified that for a small group of patients psychosomatic factors are involved in the “definition” (but not the cause) of chronic osteomyelitis. The psychological treatment deals with the results of the accident and the effect of the drawn-out treatment. Starting point is a detailed psychological and social requirement and problem orientation with an active analysis of problems and to look for resolutions. A subjective appraisal of the illness, the psychic resilience, intellectual abilities, cognitive handling strategies, personal and social resources all have a decisive effect on the progress of the therapy.
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.
Classification systems for open fractures help the surgeon to follow guidelines for treatment, to predict the prognosis, and to allow comparison of results. The systems of Gustilo and Anderson and of Oestern and Tscherne are most widely used. Although both systems have undergone several revisions, the crucial factors have not changed. They deal with the size of the wound, level of contamination, extent of soft tissue injury, and comminution of bone. In recent years additional classification systems have been created to classify severe open fractures (type III), mainly of the lower extremity. The Mangled Extremity Severity Score (MESS) became the most practicable score for establishing a dividing line between possible functional limb salvage and the need for primary amputation. Management: The principle of surgical debridement of all necrotic tissues has to be followed. Nowadays, soft tissue coverage and restoration of lost bone can be achieved secondarily by different means. However, the method of primary skeletal stabilization has a high impact on the final outcome after open diaphyseal fractures. Upper extremity: Most open fractures of the humerus and forearm can be stabilized sufficiently with plates. Because of the good soft tissue coverage of the humerus and proximal forearm and the good blood supply of this region, coverage of implants can usually be achieved in cases with vast soft tissue destruction and severe bone comminution. External fixation with the option of primary shortening and secondary bone transport is a good alternative in cases of humeral fracture. Indications for intramedullary nailing are limited to minor open fractures that do not require radial nerve exploration. At the distal forearm, the thin soft tissue layer and the necessity of two approaches often make coverage of plates impossible. External fixation is the method of choice in these cases. Lower extremity: Femoral fractures are a domain for intramedullary nailing. The indications for nailing are restricted more by systemic factors rather than by the extent of soft tissue injury. The advantages of intramedullary nailing are based on the closed surgical procedure that leaves the actual fracture site untouched. Static interlocking ensures axial and rotational stability and warrants early functional treatment and weight-bearing mobilisation. External fixation is indicated as emergency treatment, and plating should be restricted to condylar and supracondylar fractures. Tibial fractures leaving 7 cm intact bone proximally and 5 cm distally can be sufficiently stabilized by intramedullary locking nails. In cases of open fractures, small diameter nails can be inserted in the unreamed technique without deterioration of the endosteal vascular supply. This method has better reported results concerning time to union, axial alignment, joint function, and infection rates in comparison with the use of external fixation devices. However, external fixation is an adequate method, especially in cases with extreme proximal and distal fractures. If insufficient stabilization or delayed union with the use of unreamed nails or external fixators occurs, reamed nailing can be performed in a second step with good results. Plating should be restricted to tibial head and pylon fractures.
A multicentre trial of four Level One trauma centres retrospectively analysed complications and odds for complications in complex open and closed tibial fractures stabilised by unreamed, small diameter nails. 467 tibial fractures were included in the study. There were 52 proximal fractures (11.1%), 219 mid-shaft fractures (46.9%), and 196 distal fractures (42%). Breakdown into different AO/OTA groups revealed 135 type A fractures (28.9%), 216 type B fractures (46.3%), and 116 type C fractures (24.8%). 265 were closed fractures (56.7%) and 202 were open fractures (48 Gustilo grade I (10.3%), 80 grade II (17.1%), and 74 grade III (15.9%). Analysis revealed five (1.1%) deep infections (with a 5.4% rate of deep infections in Gustilo grade III open fractures), 43 delayed unions (9.2%), and twelve (2.6%) non-unions. Compartment syndromes occurred in 62 cases (13.3%), screw fatigue in 47 cases (10%), and fatigue failure of the tibial nail in three cases (0.6%). Fracture distraction of more than 3 mm should not be tolerated when stabilizing tibial fractures with unreamed, small diameter nails as this increases the odds to acquire delayed union by twelve times (p <
0.001), and the odds to acquire non union by four times (p = 0.057). There was a significant increase of complications in the group of grade III open fractures (p <
0.001), AO/OTA type C fractures (p = 0.002), and to a lesser extent in distal fractures. However, the rate of severe complications resulting in major morbidity was low compared to other methods of stabilisation in these severe fractures.
