Aims. To compare results of institutional preferences with regard to treatment of soft tissues in the setting of open tibial shaft fractures. Methods. We present a retrospective review of open tibial shaft fractures at two high-volume level 1 trauma centres with differing practices with regard to the acute management of soft tissues. Site 1 attempts acute primary closure, while site 2 prefers delayed closure/coverage. Comparisons include percentage of primary closure, number of surgical procedures until definitive closure, percentage requiring soft tissue coverage, and percentage of 90-day wound complication. Results. Overall, there were 219 patients at site 1 and 282 patients at site 2. Differences in rates of acute wound closure were seen (168 (78%) at site 1 vs 101 (36%) at site 2). A mean of 1.5 procedures for definitive closure was seen at site 1 compared to 3.4 at site 2. No differences were seen in complication, nonunion, or amputation rates. Similar results were seen in a sub-analysis of type III injuries. Conclusion. Comparing outcomes of open tibial shaft fractures at two institutions with different rates initial wound management, no differences were seen in 90-day wound complications, nonunion rates, or need for amputation. Attempted acute closure resulted in a lower number of planned secondary procedures when compared with planned delayed closure. Providers should consider either acute closure or delayed coverage based on the injury characteristics, surgeon preference and institutional resources without concern that the decision at the time of index surgery will lead to an increased risk of complication. Cite this article: Bone Joint Open 2020;1-8:481–487

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

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

Aims. The study objective was to prospectively assess clinical outcomes for a pilot cohort of tibial shaft fractures treated with a new tibial nailing system that produces controlled axial interfragmentary micromotion. The hypothesis was that axial micromotion enhances fracture healing compared to static interlocking. Methods. Patients were treated in a single level I trauma centre over a 2.5-year period. Group allocation was not randomized; both the micromotion nail and standard-of-care static locking nails (control group) were commercially available and selected at the discretion of the treating surgeons. Injury risk levels were quantified using the Nonunion Risk Determination (NURD) score. Radiological healing was assessed until 24 weeks or clinical union. Low-dose CT scans were acquired at 12 weeks and virtual mechanical testing was performed to objectively assess structural bone healing. Results. A total of 37 micromotion patients and 46 control patients were evaluated. There were no significant differences between groups in terms of age, sex, the proportion of open fractures, or NURD score. There were no nonunions (0%) in the micromotion group versus five (11%) in the control group. The proportion of fractures united was significantly higher in the micromotion group compared to control at 12 weeks (54% vs 30% united; p = 0.043), 18 weeks (81% vs 59%; p = 0.034), and 24 weeks (97% vs 74%; p = 0.005). Structural bone healing scores as assessed by CT scans tended to be higher with micromotion compared to control and this difference reached significance in patients who had biological comorbidities such as smoking. Conclusion. In this pilot study, micromotion fixation was associated with improved healing compared to standard tibial nailing. Further prospective clinical studies will be needed to assess the strength and generalizability of any potential benefits of micromotion fixation. Cite this article: Bone Jt Open 2021;2(10):825–833

Aims. Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures. Patient and Methods. This was a consecutive cohort study of 113 patients, who had sustained type IIIB fractures of the tibia following blunt trauma, over a four-year period in a level 1 trauma centre. The median age was 44.3 years (interquartile range (IQR) 28.1 to 65.9) with a median follow-up of 1.7 years (IQR 1.2 to 2.1). There were 73 male patients and 40 female patients. The primary outcome measures were deep infection rate and number of operations. The secondary outcomes were nonunion and flap failure. Results. In all, 44 patients had ORDB as part of their reconstruction, with the remaining 69 not requiring it. Eight out of 113 patients (7.1%) developed a deep infection (ORDB 1/44, non-ORDB 7/69). The median number of operations was two. A total of 16/242 complication-related reoperations were undertaken (6.6%), with 2/16 (12.5%) occurring in the ORDB group. Conclusion. In the setting of an effective orthoplastic approach to type IIIB open diaphyseal tibial fractures, using mechanically relevant debrided devitalized bone fragments in the definitive reconstruction appears to be safe. Cite this article: Bone Joint J 2019;101-B:1002–1008

There is no absolute method of evaluating healing of a fracture of the tibial shaft. In this study we sought to validate a new clinical method based on the systematic observation of gait, first by assessing the degree of agreement between three independent observers regarding the gait score for a given patient, and secondly by determining how such a score might predict healing of a fracture. We used a method of evaluating gait to assess 33 patients (29 men and four women, with a mean age of 29 years (15 to 62)) who had sustained an isolated fracture of the tibial shaft and had been treated with a locked intramedullary nail. There were 15 closed and 18 open fractures (three Gustilo and Anderson grade I, seven grade II, seven grade IIIA and one grade IIIB). Assessment was carried out three and six months post-operatively using videos taken with a digital camera. Gait was graded on a scale ranging from 1 (extreme difficulty) to 4 (normal gait). Bivariate analysis included analysis of variance to determine whether the gait score statistically correlated with previously validated and standardised scores of clinical status and radiological evidence of union. An association was found between the pattern of gait and all the other variables. Improvement in gait was associated with the absence of pain on weight-bearing, reduced tenderness over the fracture, a higher Radiographic Union Scale in Tibial Fractures score, and improved functional status, measured using the Brazilian version of the Short Musculoskeletal Function Assessment questionnaire (all p < 0.001). Although further study is needed, the analysis of gait in this way may prove to be a useful clinical tool

Fractures of the tibial shaft are common injuries, but there are no long-term outcome data in the era of increased surgical management. The aim of this prospective study was to assess the clinical and functional outcome of this injury at 12 to 22 years. Secondary aims were to determine the short- and long-term mortality, and if there were any predictors of clinical or functional outcome or mortality. From a prospective trauma database of 1502 tibial shaft fractures in 1474 consecutive adult patients, we identified a cohort of 1431 tibial diaphyseal fractures in 1403 patients, who fitted our inclusion criteria. There were 1024 men, and mean age at injury was 40.6 years. Fractures were classified according to the AO system, and open fractures graded after Gustilo and Anderson. Requirement of fasciotomy, time to fracture union, complications, incidence of knee and ankle pain at long-term follow-up, changes in employment and the patients’ social deprivation status were recorded. Function was assessed at 12 to 22 years post-injury using the Short Musculoskeletal Function Assessment and short form-12 questionnaires. Long-term functional outcome data was available for 568 of the surviving patients, 389 were deceased and 346 were lost to follow-up. Most fractures (90.7%, n = 1363) united without further intervention. Fasciotomies were performed in 11.5% of patients; this did not correlate with poorer functional outcome in the long term. Social deprivation was associated with a higher incidence of injury but had no impact on long-term function. The one-year mortality in those over 75 years of age was 29 (42%). At long-term follow-up, pain and function scores were good. However, 147 (26%) reported ongoing knee pain, 62 (10%) reported ankle pain and 97 (17%) reported both. Such joint pain correlated with poorer functional outcome. Cite this article: Bone Joint J 2014;96-B:1370–7

Objectives. The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison. Methods. A total of 15 radiographs of tibial shaft fractures treated by intramedullary nailing (IM) were scored by three observers using the RUST system. Following discussion on how the criteria of the RUST system should be implemented, 45 sets (i.e. AP and lateral) of radiographs of IM nailed tibial fractures were scored by five observers. Finally, these 45 sets of radiographs were rescored with the baseline post-operative radiograph available for comparison. Results. The initial intraclass correlation (ICC) on the first 15 sets of radiographs was 0.67 (95% CI 0.63 to 0.71). However, the original description was being interpreted in different ways. After agreeing on the interpretation, the ICC on the second cohort improved to 0.75. The ICC improved even further to 0.79, when the baseline post-operative radiographs were available for comparison. Conclusion. This study demonstrates that the RUST scoring system is a reliable and repeatable outcome measure for assessing tibial fracture healing. Further improvement in the reliability of the scoring system can be obtained if the radiographs are compared with the baseline post-operative radiographs. Cite this article: Mr J.M. Leow. The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre. Bone Joint Res 2016;5:116–121. DOI: 10.1302/2046-3758.54.2000628

Aims. This 501-patient, multi-centre, randomised controlled trial sought to establish the effect of low-intensity, pulsed, ultrasound (LIPUS) on tibial shaft fractures managed with intramedullary nailing. We conducted an economic evaluation as part of this trial. Patients and Methods. Data for patients’ use of post-operative healthcare resources and time taken to return to work were collected and costed using publicly available sources. Health-related quality of life, assessed using the Health Utilities Index Mark-3 (HUI-3), was used to derive quality-adjusted life years (QALYs). Costs and QALYs were compared between LIPUS and control (a placebo device) from a payer and societal perspective using non-parametric bootstrapping. All costs are reported in 2015 Canadian dollars unless otherwise stated. Results. With a cost per device of $3,995, the mean cost was significantly higher for patients treated with LIPUS versus placebo from a payer (mean increase = $3647, 95% confidence interval (CI) $3244 to $4070; p < 0.001) or a societal perspective (mean increase = $3425, 95% CI $1568 to $5283; p < 0.001). LIPUS did not provide a significant benefit in terms of QALYs gained (mean difference = 0.023 QALYs, 95% CI -0.035 to 0.069; p = 0.474). Incremental cost-effectiveness ratios of LIPUS compared with placebo were $155 433/QALY from a payer perspective and $146 006/QALY from a societal perspective. Conclusion. At the current price, LIPUS is not cost-effective for fresh tibial fractures managed with intramedullary nailing. Cite this article: Bone Joint J 2017;99-B:1526–32

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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 study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI).

Although it is widely accepted that grade IIIB open tibial fractures require combined specialised orthopaedic and plastic surgery, the majority of patients in the UK initially present to local hospitals without access to specialised trauma facilities. The aim of this study was to compare the outcome of patients presenting directly to a specialist centre (primary group) with that of patients initially managed at local centres (tertiary group). We reviewed 73 consecutive grade IIIB open tibial shaft fractures with a mean follow-up of 14 months (8 to 48). There were 26 fractures in the primary and 47 in the tertiary group. The initial skeletal fixation required revision in 22 (47%) of the tertiary patients. Although there was no statistically-significant relationship between flap timing and flap failure, all the failures (6 of 63; 9.5%) occurred in the tertiary group. The overall mean time to union of 28 weeks was not influenced by the type of skeletal fixation. Deep infection occurred in 8.5% of patients, but there were no persistently infected fractures. The infection rate was not increased in those patients debrided more than six hours after injury. The limb salvage rate was 93%. The mean limb functional score was 74% of that of the normal limb. At review, 67% of patients had returned to employment, with a further 10% considering a return after rehabilitation. The times to union, infection rates and Enneking limb reconstruction scores were not statistically different between the primary and tertiary groups. The increased complications and revision surgery encountered in the tertiary group suggest that severe open tibial fractures should be referred directly to specialist centres for simultaneous combined management by orthopaedic and plastic surgeons

Aims

The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture.

We report four patients who sustained secondary fractures of the posterior wall of the tibial shaft during the removal of one pattern of intramedullary nail after fracture healing. The cause of this complication is discussed

We have analysed associated factors in 164 patients with acute compartment syndrome whom we treated over an eight-year period. In 69% there was an associated fracture, about half of which were of the tibial shaft. Most patients were men, usually under 35 years of age. Acute compartment syndrome of the forearm, with associated fracture of the distal end of the radius, was again seen most commonly in young men. Injury to soft tissues, without fracture, was the second most common cause of the syndrome and one-tenth of the patients had a bleeding disorder or were taking anticoagulant drugs. We found that young patients, especially men, were at risk of acute compartment syndrome after injury. When treating such injured patients, the diagnosis should be made early, utilising measurements of tissue pressure

Aims

The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion.

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.

The reliability of the radiological assessment of the healing of tibial fractures remains undetermined. We examined the inter- and intraobserver agreement of the healing of such fractures among four orthopaedic trauma surgeons who, on two separate occasions eight weeks apart, independently assessed the radiographs of 30 patients with fractures of the tibial shaft which had been treated by intramedullary fixation. The radiographs were selected from a database to represent fractures at various stages of healing. For each radiograph, the surgeon scored the degree of union, quantified the number of cortices bridged by callus or with a visible fracture line, described the extent and quality of the callus, and provided an overall rating of healing. The interobserver chance-corrected agreement using a quadratically weighted kappa (κ) statistic in which values of 0.61 to 0.80 represented substantial agreement were as follows: radiological union scale (κ = 0.60); number of cortices bridged by callus (κ = 0.75); number of cortices with a visible fracture line (κ = 0.70); the extent of the callus (κ = 0.57); and general impression of fracture healing (κ = 0.67). The intraobserver agreement of the overall impression of healing (κ = 0.89) and the number of cortices bridged by callus (κ = 0.82) or with a visible fracture line (κ = 0.83) was almost perfect. There are no validated scales which allow surgeons to grade fracture healing radiologically. Among those examined, the number of cortices bridged by bone appears to be a reliable, and easily measured radiological variable to assess the healing of fractures after intramedullary fixation

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To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes.

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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.