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 biomechanical model of distal metaphyseal tibial fractures was created using a fourth-generation composite bone model. Three fracture patterns were tested: spiral, oblique, and multifragmented. Each fracture extended to within 4 cm to 5 cm of the plafond. The models were nearly-anatomically reduced and stabilized with an intramedullary nail and three distal locking screws. Cyclic loading was performed to simulate normal gait. Loading was completed in compression at 3,000 N at 1 Hz for a total of 70,000 cycles. Displacement (shortening, coronal and sagittal angulation) was measured at regular intervals.Aims
Methods
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:
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. This was a population-based cohort study using data from the Danish Fracture Database with a follow-up period of 24 months. Data were linked to the Danish National Patient Registry to ensure complete information regarding reoperations due to complications, which were divided into major and minor. The relative risk of reoperations for the tourniquet group compared with the non-tourniquet group was estimated using Cox proportional hazards modelling.Aims
Methods
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. Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded.Aims
Method
This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England. Longitudinal data collected by the Trauma Audit and Research Network were used to identify 38,347 patients with open fractures, and a subgroup of 12,170 with severe open fractures of the tibia, between 2008 and 2019 in England. Incidence rates per 100,000 person-years and 95% confidence intervals were calculated. Clinical care was compared with the British Orthopaedic Association Standards for Trauma and National Major Trauma Centre audit standards.Aims
Methods
The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs. Resource use was measured during the six months that followed open fractures of the lower limb in 748 adults recruited as part of two large clinical trials within the UK Major Trauma Research Network. Resource inputs were valued using unit costs drawn from primary and secondary sources. Economic costs (GBP sterling, 2017 to 2018 prices), estimated from both a NHS and Personal Social Services (PSS) perspective, were related to the degree of complexity of the open fracture based on the OTS classification.Aims
Methods
The aim of this study was to assess whether it is possible to predict the mortality, and the extent and time of neurological recovery from the time of the onset of symptoms and MRI grade, in patients with the cerebral fat embolism syndrome (CFES). This has not previously been investigated. The study included 34 patients who were diagnosed with CFES following trauma between 2012 and 2018. The clinical diagnosis was confirmed and the severity graded by MRI. We investigated the rate of mortality, the time and extent of neurological recovery, the time between the injury and the onset of symptoms, the clinical severity of the condition, and the MRI grade. All patients were male with a mean age of 29.7 years (18 to 70). The mean follow-up was 4.15 years (2 to 8), with neurological recovery being assessed by the Glasgow Outcome Scale and the Mini-Mental State Examination.Aims
Methods
Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP. This is a retrospective and observational study containing data from nine patients with a mean age of 14.1 years (9 to 25; three female, six male) with OP who were treated in our hospital between April 2008 and October 2018 with 20 surgical procedures due to 17 different fractures. Patient data included age, sex, operating time, length of stay, genetic type of the disease, previous surgery, fractures, complications, and comorbidity.Aims
Methods
Open fractures of the tibia are a heterogeneous group of injuries that can present a number of challenges to the treating surgeon. Consequently, few surgeons can reliably advise patients and relatives about the expected outcomes. The aim of this study was to determine whether these outcomes are predictable by using the Ganga Hospital Score (GHS). This has been shown to be a useful method of scoring open injuries to inform wound management and decide between limb salvage and amputation. We collected data on 182 consecutive patients with a type II, IIIA, or IIIB open fracture of the tibia who presented to our hospital between July and December 2016. For the purposes of the study, the patients were jointly treated by experienced consultant orthopaedic and plastic surgeons who determined the type of treatment. Separately, the study team (SP, HS, AD, JD) independently calculated the GHS and prospectively collected data on six outcomes for each patient. These included time to bony union, number of admissions, length of hospital stay, total length of treatment, final functional score, and number of operations. Spearman’s correlation was used to compare GHS with each outcome. Forward stepwise linear regression was used to generate predictive models based on components of the GHS. Five-fold cross-validation was used to prevent models from over-fitting.Aims
Methods
The aim of this study was to evaluate near-infrared spectroscopy
(NIRS) as a continuous, non-invasive monitor for acute compartment
syndrome (ACS). NIRS sensors were placed on 86 patients with, and 23 without
(controls), severe leg injury. NIRS values were recorded for up
to 48 hours. Longitudinal data were analyzed using summary and graphical
methods, bivariate comparisons, and multivariable multilevel modelling.Aims
Patients and Methods
The aim of this study was to explore the patients’ experience
of recovery from open fracture of the lower limb in acute care. A purposeful sample of 20 participants with a mean age of 40
years (20 to 82) (16 males, four females) were interviewed a mean
of 12 days (five to 35) after their first surgical intervention took
place between July 2012 and July 2013 in two National Health Service
(NHS) trusts in England, United Kingdom. The qualitative interviews
drew on phenomenology and analysis identified codes, which were
drawn together into categories and themes.Aims
Patients and Methods
The aim of this study was to compare the cost-effectiveness of
intramedullary nail fixation and ‘locking’ plate fixation in the
treatment of extra-articular fractures of the distal tibia. An economic evaluation was conducted from the perspective of
the United Kingdom National Health Service (NHS) and personal social
services (PSS), based on evidence from the Fixation of Distal Tibia
Fractures (UK FixDT) multicentre parallel trial. Data from 321 patients
were available for analysis. Costs were collected prospectively
over the 12-month follow-up period using trial case report forms
and participant-completed questionnaires. Cost-effectiveness was
reported in terms of incremental cost per quality adjusted life
year (QALY) gained, and net monetary benefit. Sensitivity analyses
were conducted to test the robustness of cost-effectiveness estimates.Aim
Patients and Methods
This study explores the relationship between
delay to surgical debridement and deep infection in a series of
364 consecutive patients with 459 open fractures treated at an academic
level one trauma hospital in North America. The mean delay to debridement for all fractures was 10.6 hours
(0.6 to 111.5). There were 46 deep infections (10%). There were
no infections among the 55 Gustilo-Anderson grade I open fractures.
Among the grade II and III injuries, a statistically significant
increase in the rate of deep infection was found for each hour of
delay (OR = 1.033: 95% CI 1.01 to 1.057). This relationship shows
a linear increase of 3% per hour of delay. No distinct time cut-off
points were identified. Deep infection was also associated with
tibial fractures (OR = 2.44: 95% CI 1.26 to 4.73), a higher Gustilo-Anderson
grade (OR = 1.99: 95% CI 1.004 to 3.954), and contamination of the
fracture (OR = 3.12: 95% CI 1.36 to 7.36). These individual effects
are additive, which suggests that delayed debridement will have
a clinically significant detrimental effect on more severe open
fractures. Delayed treatment appeared safe for grade 1 open fractures. However,
when the negative prognostic factors of tibial site, high grade
of fracture and/or contamination are present we recommend more urgent
operative debridement. Cite this article:
Nonunion of the tibia associated with bone loss, previous infection, obliteration of the intramedullary canal or located in the distal metaphysis poses a challenge to the surgeon and significant morbidity to patients. We retrospectively reviewed the records of 24 patients who were treated by central bone grafting and compared them to those of 20 who were treated with a traditional posterolateral graft. Central bone grafting entails a lateral approach, anterior to the fibula and interosseous membrane which is used to create a central space filled with cancellous iliac crest autograft. Upon consolidation, a tibiofibular synostosis is formed that is strong enough for weight-bearing. This procedure has advantages over other methods of treatment for selected nonunions. Of the 24 patients with central bone grafting, 23 went on to radiographic and clinical union without further intervention. All healed within a mean of 20 weeks (10 to 48). No further bone grafts were required, and few complications were encountered. These results were comparable to those of the 20 patients who underwent posterolateral bone grafting who united at a mean of 31.3 weeks (16 to 60) but one of whom required below-knee amputation for intractable sepsis. Central bone grafting is a safe and effective treatment for difficult nonunions of the tibia.
