A review was carried out in 21 cases of bone transport in the tibia done between May 1995 and December 1997. These were done for the treatment of compound (Grade IIIB) fractures with extensive bone and soft tissue loss and in infective non-unions of the tibia using the Ilizarov technique and ring fixator. In 5 cases, 2 or 3 additional procedures were needed such as tendo achilles (TA) lengthening, bone grafting, revision of construct or revision of scar at the docking site. Average resection of infected bone was 5.2 cms in the infective non-union group and average bone and soft tissue loss was 8 cms in the compound Grade IIIB fracture group. The defect was bridged and regenerate bone occurred in all the cases except one. Union was achieved in all the cases although 10 needed bone grafting. Infection was eradicated in all the cases. Limb length discrepancy was corrected in all the cases except three. Mean duration of treatment was 12 months.
Aseptic non-union is a major problem following complicated fracture tibia, which carries significant morbidity and prolonged course of treatment. Plate fixation and autogenous bone grafting has been established as a method of treatment. However the risk of infection, implant failure and donor site morbidity are high. We reviewed twelve consecutive cases of established non-union tibia treated by closed reamed interlocking nail in our centre. All patients had clinical and radiological union at three months. Three patients were complicated with infection and one required removal of implant and re-reaming to eradicate infection. Reamed interlocking nailing is an alternative treatment for selected non-union of fracture tibia with promising results.
Thirty-eight tibial plateau fractures were treated with open reduction and internal fixation. The fractures were classified into six groups (Hohl's 1991 Classification) and the clinical results were evaluated using the Rasmussen (1973) criteria. The average follow-up period was 2.07 years. Overall there was one excellent, thirty-four (34) good, three fair and no poor results. In three patients with less than a good score there were other associated ipsilateral injuries and delayed mobilisation of the knee joint. There was no direct association between the type of internal fixation and the end result.
Ten patients with complex non-union of the tibia were treated by locked intramedullary nailing. These patients had scarred skin as a result of initial severe open fractures, multiple debridement or fasciotomies with external fixators and skin grafts applied. Seven of the patients also had previous osteomyelitis or pin track infections. Fully pain-free walking was achieved in all patients and radiological union in nine patients without the need for a bone graft. Four patients developed infection after nailing, of which three resolved with treatment.
Reconstruction of major bone defects using free fibular transfer provides a good biological option in unsound situations. Most authors recommend selection of the recipient blood vessels outside the zone of injury to achieve successful free fibular transfer. Occasionally, in polytraumatized patients, the surgeon has to use a previously fractured fibula as a graft, with increased risk of inclusion of the injury zone that may lead to failure.
The choice between limb salvage and primary amputation in a severely injured limb is at time difficult. A case of severe Gustilo type-IIIB open fracture of the tibia with massive soft tissue loss is presented to highlight the immediate and definitive treatment undertaken to preserve the limb.
Tibial nerve is a branch of the sciatic nerve and it is the main nerve innervating the muscles of the back of the leg. The tibial nerve divides into medial and lateral plantar nerves. The level of division may be important for surgical purpose. The main aim of the present study was to observe the exact level of division of the tibial nerve and discuss its clinical implications.
A simple technique for removal of the distal fragment of the broken intramedullary interlocking nail is described. It was successfully used in three patients with a broken nail due to nonunion. The technique requires only cerclage wire, which is available in any operating room, avoiding the difficulties obtaining the custom made hook and of excessive exposure to radiation.
The removal of broken implanted intramedullary nails secondary to re-fracture or non-union is challenging. In 12 cases a simple and safe method has been used to remove broken implants.
We present the results of our experience in treating comminuted tibial shaft fractures with reamed interlocking intramedullary nail from September 1993 to December 1995. In this retrospective study, there were fifty patients with an average follow-up of 14.3 months (range six to twenty-eight months). Ninety-eight percent of the fractures were due to motor-vehicle accident with majority of the patients being motorcyclist (96%). Thirty-eight fractures were closed and twelve were open (Gustilo grade I--8; grade II--4); 44% of them had additional fractures or other injuries. According to Winquist-Hansen classification of diaphyseal fracture comminution, there were 24% type I; 18% type II; 26% type III and 32% type IV. The union rate was 98%. There were 6 infections, 2 superficial and 4 deep. All these infections arose from closed fractures, which was possibly due to the long operative time. No patients with open fractures, which underwent delayed nailing, had infection. One of the patient had severe deep infection which required early nail removal before union. Anterior knee pain following nailing occurred in 6% of the patients. The average hospital stay after operation was 3.4 days. Ninety-four percent of the patients had excellent to good functional outcome after nailing. The mean time to regain full range of movement of knee and ankle was 8.4 weeks. Patients were allowed full weight bearing in the average time of 10.7 weeks and the mean time to return to work was 24.7 weeks.
Pilon fractures can be caused by high-energy vertical forces which may result in long-term patient immobilization. Many experts in orthopedic surgery recommend the use of a Delta external fixator for type III Pilon fracture treatment. This device can promote immediate healing of fractured bone, minimizing the rate of complications as well as allowing early mobilization. The characteristics of different types of the Delta frame have not been demonstrated yet. By using the finite element method, this study was conducted to determine the biomechanical characteristics of six different configurations (Model 1 until Model 6). CT images from the lower limb of a healthy human were used to reconstruct three-dimensional models of foot and ankle bones. All bones were assigned with isotropic material properties and the cartilages were assigned to exhibit hyperelasticity. A linear link was used to simulate 37 ligaments at the ankle joint. Axial loads of 70 and 350 N were applied at the proximal tibia to simulate the stance and swing phase. The metatarsals and calcaneus were fixed distally in order to prevent rigid body motion. A synthetic ankle bone was used to validate the finite element model. The simulated results showed that Delta3 produced the highest relative micromovement (0.09 mm, 7 μm) during the stance and swing phase, respectively. The highest equivalent von Mises stress was found at the calcaneus pin of the Delta4 (423.2 MPa) as compared to others. In conclusion, Delta1 external fixator was the most favorable option for type III Pilon fracture treatment. Graphical abstract ᅟ.
Pilon fractures are commonly caused by high energy trauma and can result in long-term immobilization of patients. The use of an external fixator i.e. the (1) Delta, (2) Mitkovic or (3) Unilateral frame for treating type III pilon fractures is generally recommended by many experts owing to the stability provided by these constructs. This allows this type of fracture to heal quickly whilst permitting early mobilization. However, the stability of one fixator over the other has not been previously demonstrated. This study was conducted to determine the biomechanical stability of these external fixators in type III pilon fractures using finite element modelling. Three-dimensional models of the tibia, fibula, talus, calcaneus, navicular, cuboid, three cuneiforms and five metatarsal bones were reconstructed from previously obtained CT datasets. Bones were assigned with isotropic material properties, while the cartilage was assigned as hyperelastic springs with Mooney-Rivlin properties. Axial loads of 350 N and 70 N were applied at the tibia to simulate the stance and the swing phase of a gait cycle. To prevent rigid body motion, the calcaneus and metatarsals were fixed distally in all degrees of freedom. The results indicate that the model with the Delta frame produced the lowest relative micromovement (0.03 mm) compared to the Mitkovic (0.05 mm) and Unilateral (0.42 mm) fixators during the stance phase. The highest stress concentrations were found at the pin of the Unilateral external fixator (509.2 MPa) compared to the Mitkovic (286.0 MPa) and the Delta (266.7 MPa) frames. In conclusion, the Delta external fixator was found to be the most stable external fixator for treating type III pilon fractures.
Internal fixation with a plate in the management of non-union for shaft of long bones has been condemned but the review of the literature does not provide such unequivocal evidence. Also there are certain situations where it is either technically not feasible or contraindicated to do closed intramedullary nailing. This study was done to see the outcome of plate-fixation for the treatment of non-union of the shaft of long bones.
We report 2 patients with congenital pseudoarthrosis of the tibia who underwent intramedullary Rush rod transfixation through the ankle joint following refracture and nonunion of vascularised fibular grafting 6 and 8 months earlier. After 9 and 5 years, both Rush rods were broken at the level of the ankle joints, while the reconstructed area was solidly united. The growth of the distal tibia increased the distance of the tips of the broken rod and hence the ankle joint motion. The broken tips may damage the articular cartilage and result in valgus deformity of the ankle and limb length discrepancy.
Although non-operative treatment is a mainstay of tibial fracture management in children, certain fractures require a surgical approach. However, choices concerning optimal methods and implants are difficult. The purpose of this study was to determine the effectiveness of percutaneous plating of tibial fractures in children.
We report the results of external fixation in 29 patients treated for tibial fractures and tibial non-union using a novel multi axial external fixator (MAXX) followed prospectively until bony union. The results of treatment were classified according to the Association for the Study and Application of the Method of Ilizarov (ASAMI). Overall, 13 patients had excellent bone results; 13 had good bone results; two had fair bone results, and 1 patient had poor bone results. Regarding functional results, 21 patients had excellent results; 6 obtained good results; none had fair results, and two had poor results. Acute patients did better functionally than chronic patients. This fixator is safe and versatile, although the indications for its use are very specific.
Primary hyperparathyroidism (PHPT) is an intriguing condition. Routine automated biochemical screening has made the diagnosis commonplace in developed countries and the disease is diagnosed early in its course when it is often asymptomatic. In developing countries or in recent immigrants from these countries, PHPT is often seen in an advanced stage with bone involvement. Associated dietary deficiencies may alter the biochemical profile and cause a diagnostic dilemma. It is important to include it in the differential diagnosis of pathological fractures. We report three cases of PHPT presenting with pathological fractures and discuss their diagnosis and management.
Surgical reconstruction of bicondylar tibial fractures with external fixation relies on indirect fracture reduction that could affect anatomical restoration. The aim of the present study is to evaluate the radiographic and clinical outcomes of tibial bicondylar fractures treated with circular external fixation. A total of 20 bicondylar fractures of the proximal tibia in 20 patients treated with circular external fixation were included in the study. Two fractures were open. Mean clinical and radiographic follow-up was 37.3 months after frame removal. Angular, translation, and length deformities were assessed on nonweight-bearing anteroposterior, lateral, and two 45 degrees oblique views. The medial proximal tibia (MPTA) and posterior proximal tibia angles (PPTA) were calculated in all cases. The condylar widening was calculated in relation to the width of the femoral condyles. Joint depressions or gaps of the articular surface were identified on the four views of the knee. The modified Hospital for Special Surgery (HSS) knee scoring system was used for clinical evaluation. The MPTA was good in 18 (90%) and fair in 2 patients (10%). The PPTA was good in 13 (65%), fair in 6 (30%), and poor in 1 patient (5%). The articular reduction was good in 12 (60%) and fair in 8 patients (40%). The condylar widening was good in 15 (75%) and fair in 5 patients (25%). Mechanical axis deviation was within the normal range in 11/12 patients (91.7%). All fractures consolidated. One deep infection was successfully treated with local debridement, the mean modified HSS knee score at the latest follow-up was 90.5 (range: 67-100). Articular reconstruction and tibia alignment based on radiographic evaluation in the present study, along with functional results compare favorably with those of external and internal fixation presented in the literature.
Post-traumatic chronic osteomyelitis and infected non-unions of the tibia following severe type-III open fracture are difficult to treat Refractoy cases often necessitate amputation despite attempts to salvage the limb. We report our experience in treating such difficult cases with an alternative surgical option using free osteocutaneous fibular graft. Eight consecutive patients with post-traumatic chronic osteomyelitis/infected non-union were treated surgically with free vascularized osteocutaneous fibular graft. Outcomes in term of graft-host union and complication were evaluated. Four patients had anastomotic venous thrombosis requiring anastomotic revision. Five patients developed surgical site infections needing extended antibiotic therapy to achieve resolution at an average of 15.2 weeks. Fibular graft fracture occurred in three patients but all grafts survived and united after a mean time to union of 42.3 weeks (range 31 to 82 weeks). At the final follow-up, union of host-graft junction and control of infection were achieved in all patients except one who required a secondary amputation. Free vascularized osteo-cutaneous fibular graft is a viable limb salvage option for refractory chronic osteomyelitis or infected non-union following treatment of grade-III open tibial fractures.
A case of traumatic posterior cruciate ligament (PCL) avulsion fracture presenting with unusual radiographic findings is described. CT scan of the right knee showed features suggestive of combined ACL and PCL avulsion fractures. Arthroscopic findings showed that the injury was in fact a PCL avulsion fracture that was displaced anteriorly so as to mimic an ACL avulsion fracture on CT scan.