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PubMed1994

Collagen turnover after tibial fractures.

Collagen turnover after tibial fractures was examined in 16 patients with fracture of the tibial diaphysis and in 8 patients with fracture in the tibial condyle area by measuring sequential changes in serological markers of turnover of types I and III collagen for up to 26 weeks after fracture. The markers were the carboxy-terminal extension peptide of type I procollagen (PICP), the amino-terminal extension peptide of type III procollagen (PIIINP), and the pyridinoline cross-linked carboxy-terminal telopeptide of type I collagen (ICTP). The latter is a new serum marker of degradation of type I collagen. A group comparison showed characteristic sequential changes in the turnover of types I and III collagen in fractures of the tibial diaphysis and tibial condyles. The turnover of type III collagen reached a maximum after 2 weeks in both groups. The synthesis of type I collagen reached a maximum after 2 weeks in the diaphyseal fractures and after 6 weeks in the condylar fractures. The degradation of type I collagen increased after 4 days and reached a maximum at 2 weeks in both groups. The interindividual variation was wide. On a group basis, the turnover of types I and III collagen had levelled of within 26 weeks, although some patients had clearly elevated parameters at the end of the observational period. We suggest that delayed healing of tibial diaphyseal fractures is accompanied by an early increase in the turnover of types I and III collagen.

Adult↗
PubMed1996

Effect of loading and fracture motions on diaphyseal tibial fractures.

A computerized motion sensor was used to record the three-dimensional components of interfragmentary motion during healing in three patients with closed, low-energy fractures of the tibial diaphysis treated with functional braces. At the first measurement session 2 weeks after fracture, the patients applied approximately 15 kg to the injured limb. Although this produced 1-4 mm of translation of the fragments, this was recovered when the load was removed. The maximum rotational and angulatory displacements often occurred as the patients rose from the chair with no weight applied to the limb and frequently were reduced as the 15 kg of load was applied. Under load, the maximum axial rotation was 3 degrees and the maximum angular displacement was 1 degree. As with the translations, the initial rotational and angulatory positions of the fragments were recovered when the load was removed and the patient returned to the seated position. At 8 weeks, the patient applied full body weight, producing a maximum interfragmentary translation of 0.5 mm and maximum axial rotation or angulation of 0.5 degrees. Abundant peripheral callus formed in all three fractures, and they healed by 15 weeks through typical gradual consolidation and mineralization of the callus, accompanied by a corresponding reduction in interfragmentary motions.

Adult↗
PubMed1998

Local or free muscle flaps and unreamed interlocked nails for open tibial fractures.

The treatment of open tibial fractures associated with severe soft tissue injuries remains a difficult dilemma, even to the experienced fracture surgeon. To ascertain the efficacy of nailing tibial fractures with severe soft tissue injuries, a review of all open tibial fractures treated at the authors' institution was done. Those fractures initially stabilized with nonreamed nails which required muscle flaps for coverage were selected for study. Thirty-three patients (26 men, seven women) were treated with intramedullary nailing and muscle flap coverage for the soft tissue defects. The average length of followup was 12.1 months (range, 7-42 months). The average time to union was 27 weeks (range, 14-45 weeks). There were five (15%) infections: two (6%) superficial wound infections, one (3%) flap infection, and two (6%) cases of osteomyelitis. In no patient did the infection result in limb ablation. Thirteen of 33 (42%) patients required secondary procedures to enhance union. In this study, it was found that although delayed procedures frequently were required to promote fracture union, the time to union, and infection rates were not significantly different from those reported for external fixation of fractures that require local or free muscle transfers.

Adolescent↗
PubMed2003

Operative treatment of extra-articular proximal tibial fractures.

BACKGROUND: Extra-articular proximal tibial fractures are often the result of high-energy trauma with displacement and comminution. Most authors agree that operative management of these fractures is warranted to optimize patient outcomes. It is unclear, however, which surgical option (plate, nail, external fixator, or combination) is preferable. (1-17) OBJECTIVE: To evaluate the effect of alternative operative techniques in the management of extra-articular proximal third tibial fractures on rates of nonunion, malunion, infection, compartment syndrome, and implant failure. HIGHEST AVAILABLE EVIDENCE: 1. Intramedullary nail (level 3 prospective case series). 2. Plates (level 3 prospective case series). 3. External fixator (level 4 case series). STUDY IDENTIFICATION: 1. Cochrane Database: 0 articles. 2. PubMed Search: Proximal tibial fractures: 568 hits; And external fixation: 69 hits; And plate: 103 hits; And intramedullary nail: 77 hits. Clinical queries search: proximal tibial fracture (specificity/therapy): 1 hit; proximal tibial fracture (sensitivity): 24 hits. Systematic reviews: 3 hits (none relevant). 3. OTA website abstract database: 8 abstracts. Total number potentially relevant articles: 29 (following review of all study titles and abstracts). Total number included after review: 17 (1-17) .

Evidence-Based Medicine↗
PubMed1996

[Classifications of 202 tibial fractures in dogs and cats].

202 Tibial fractures, in 138 dogs and 64 cats, were classified according to the system of Unger. The animals were presented between 1989 and 1994 to four Dutch veterinary orthopaedic referral clinics. In addition to the type of fracture, demographic information was taken into account including the species, the age of the patient, the size of the breed, the treatment, whether it was a open or closed fracture and the orthopaedic clinic. Possible correlation between the type of fracture and the variables, as well as correlations among the latter, were examined statistically. In this study 73% of the tibial fractures in dogs and cats were in the diaphysis, oblique fracture being the most frequent (24%). Proximal tibial fractures in dogs were usually extra-articular and 87% of these involved avulsion of the tibial tubercle. Malleolar fractures accounted for 57% of the distal fractures. A significant correlation was found between the localization of the fracture (proximal, diaphyseal or distal) and the species (cat or dog), between an avulsion fracture of the tibial tubercle and the age in dogs, between an incomplete tibial fracture and the age, between a malleolar fracture and a complicated (i.e., open) fracture, between a butterfly fracture and a complicated fracture, and between the applied therapy and the orthopaedic clinic. The classification system of Unger is very useful for inventory and documentation, but because of the lack of data about physeal fractures, the degree of injury to the surrounding soft tissues, and the influence of differences between surgeons, it cannot be used to determine therapy.

Animals↗
PubMed1995

[What are the advantages of UTN (unreamed tibial nail) in open tibial fractures?].

The AO-unreamed tibial nail (UTN) is an alternative to external fixation in the treatment of open tibial fractures. In order to compare the two implants we did a retrospective study. 70 unselected cases of open tibial fractures were treated by either method. 35 patients with primary UTN were compared to another 35 patients with primary external fixator. Demographic data, localisation and classification of fractures and soft tissue trauma showed no differences between the two groups. The main complications in UTN-group were hardware problems, in external fixator-group infections. Following UTN-treatment duration of first hospital stay and whole fracture treatment were shortened with earlier full weight bearing and fracture healing. Our study shows advantages in the treatment of open tibial fractures using the UTN compared to the external fixation.

Adolescent↗
PubMed2003

Percutaneous plating for unstable tibial fractures.

Twenty-four unstable tibial fractures were stabilized with a narrow limited contact-dynamic compression plate inserted using a percutaneous plating technique under fluoroscopic guidance. The major indication for this technique was a tibial fracture for which intramedullary nailing would be difficult. There were 16 proximal or distal metaphyseal fractures and 5 segmental fractures in adults and 3 mid-shaft fractures in adolescents who still had an open physis. Of the 24 fractures, 22 healed without a second procedure; the two failures included one that required an early bone graft for severe comminution and another with a superficial infection that healed after early removal of the plate. There were no other infections. There were three cases of screw breakage, but they did not require a further procedure. At the final follow-up, one patient had healed with 5 degrees varus alignment and another with 10 degrees external rotation. All the patients had good knee or ankle function. We are confident that the percutaneous plating technique to treat unstable tibial fractures for which intramedullary nailing would be difficult will prove to be an alternative stabilization method, as it avoids the risk of infection or soft tissue compromise.

Adolescent↗
PubMed2004

Delayed presentation is no barrier to satisfactory outcome in the management of open tibial fractures.

The management of open tibial fractures is a challenge to all orthopaedic trauma surgeons. The major goals are fracture union, uncomplicated soft tissue healing and return to pre-injury level of function. The geographical isolation and vastness of the Northern Territory of Australia complicates the management of these injuries by adding a significant delay to treatment. Forty-five patients sustained 48 open tibial fractures over the 30-month period of the study. Twelve received primary surgical treatment within 6h of injury but 33 were treated more than 6h after injury. The mean time to treatment in this latter group was 12h 15min (median 9h 45min, range 6-37h). The majority of injuries were high energy, with 23 patients having multiple injuries and 29 fractures (60%) being classified as AO C3 with 35 (73%) having Gustilo III soft tissue injuries. There was a mean time to union of 7.5 months and an overall complication rate of 42.2%. Thirteen patients (29%) required additional (late) surgical procedures subsequent to definitive fracture and soft tissue management. The zone of injury infection rate was 12.5%. The high incidence of open tibial fractures places a large financial burden on the state. However, despite the absence of a plastic surgical service and delays in presentation, satisfactory outcomes can be obtained by the application of the established surgical principles of thorough debridement, soft tissue management and fracture stabilisation.

Adolescent↗
PubMed1987

Tibial fractures with infrapopliteal arterial injuries.

Tibial fractures with associated infrapopliteal arterial injuries have been inadequately documented in the literature. Eighteen patients with these injuries were admitted to Boston City Hospital during a 10-year period. Three patients required below-knee amputation, and two of these had ischemic intervals of greater than 8 h before vascular treatment. Six patients had delayed diagnoses of arterial injuries, but none required amputation. There were 15 open and three closed tibial fractures. Nine fractures were badly comminuted. Eight of the 14 viable limbs had delayed unions, but only one was associated with local vascular insufficiency. Five patients had complaints attributed to vascular insufficiency without clinical findings. Our conclusion is that the limb with an infrapopliteal arterial insult combined with a tibial fracture can survive with patency of only the anterior tibial or posterior tibial artery. Poor clinical results correlate with the severity of bony injury and not with the particular arterial injury. The incidence of below-knee amputation can best be related to delay in vascular treatment.

Adolescent↗
PubMed2005

Percutaneous plate stabilization of proximal tibial fractures.

BACKGROUND: Despite various treatment methods, proximal tibial fractures are common injuries associated with poor outcomes and high rates of complications. To improve this, a percutaneous plating technique was performed to treat proximal tibial fractures. METHODS: Twenty-four proximal tibial fractures (17 proximal fractures [AO 41] and 7 proximal shaft fractures [AO 42]) were treated using percutaneous plating with either or both sides without bone graft. One was an open fracture. RESULTS: All fractures healed. The average time for fracture healing was 16.5 weeks (range, 8-24 weeks). Complications included one case of shortening (1 cm) and two cases of malalignments; one valgus of 6 degrees and one varus of 5 degrees. There was one case of superficial infection that was healed after removal, but no patient showed deep infection. Results were evaluated by the modified Rasmussen scoring system. Most patients had excellent or good results; only one patient had fair results. CONCLUSION: Minimally invasive percutaneous plating can provide favorable results in the treatment of proximal tibial fractures.

Adult↗
PubMed1987

Changing patterns in tibial fractures resulting from skiing.

Of the 734 adult tibial fractures treated in Aspen, Colorado, from 1968-1978, follow-up results were obtained on 527 (72%). The fractures were analyzed with regard to rate of healing, age of patient, and location of fractures. There was a statistically significant increase in healing time with increasing age between ages 16-40. The location of tibial fracture (proximal, middle, distal) had no significant influence on rate of healing. The occurrence of open tibial fracture was low (3% of total) and in most instances wounds were benign (Class I). Compartment syndrome is rarely encountered in skiing fracture because of the relatively low energy involved. All tibial fractures occurring between 1982-1984 were reviewed and compared to the earlier series. This comparison confirmed the continual overall decline in rate of tibial fracture from skiing (from 12.9/100,000 skier days in 1968 to 2.9/100,000 skier days in 1983). This decline was primarily in spiral fractures (from 70% of total in 1968 to 50% in 1983). The percent of transverse fractures was unchanged (+/- 15%) while the percent of short oblique fractures increased from 11% to 33%. Properly adjusted and maintained safety equipment afforded reasonable protection from spiral fractures of the tibia, but a conceptual departure from the current release binding design would be required to protect against the benign moments that produced transverse and short oblique fracture. The current treatment philosophy is based on fracture type and the availability or experience with newer treatment modes.

Adolescent↗
PubMed2005

Intramedullary nailing of distal metaphyseal tibial fractures.

BACKGROUND: The treatment of distal metaphyseal tibial fractures remains controversial. This study was performed to evaluate the results of intramedullary nailing of distal tibial fractures located within 5 cm of the ankle joint. METHODS: Over a sixteen-month period at two institutions, thirty-six tibial fractures that involved the distal 5 cm of the tibia were treated with reamed intramedullary nailing with use of either two or three distal interlocking screws. Ten fractures with articular extension were treated with supplementary screw fixation prior to the intramedullary nailing. Radiographs were reviewed to determine the immediate and final alignments and fracture-healing. The Short Form-36 (SF-36) and Musculoskeletal Function Assessment (MFA) questionnaires were used to evaluate functional outcome. RESULTS: Acceptable radiographic alignment, defined as <5 degrees of angulation in any plane, was obtained in thirty-three patients (92%). No patient had any change in alignment between the immediate postoperative and the final radiographic evaluation. Complications included one deep infection and one iatrogenic fracture at the time of the intramedullary nailing. Six patients could not be followed. The remaining thirty fractures united at an average of 23.5 weeks. Three patients with associated traumatic bone loss underwent a staged autograft procedure, and they had fracture-healing at an average of 44.3 weeks. The functional outcome was determined at a minimum of one year for nineteen patients and at a minimum of two years (average, 4.5 years) for fifteen patients. At one year, there were significant limitations in several domains despite fracture union and maintenance of alignment, but there was improvement in the MFA scores with time. CONCLUSIONS: Intramedullary nailing is an effective alternative for the treatment of distal metaphyseal tibial fractures. Simple articular extension of the fracture is not a contraindication to intramedullary fixation. Functional outcomes improve with time.

Adolescent↗
PubMed2000

Treatment of infection and non-union after bilateral complicated proximal tibial fracture.

BACKGROUND AND AIMS: Complicated tibial fractures form a great challenge for orthopaedic surgeons. Non-unions and infections are more common in complicated than in closed fractures. In the present study, we describe a patient case treated for non-union combined to chronic osteomyelitis after bilateral open proximal tibial fractures. MATERIAL AND METHODS: A female patient born in 1946 was multi-traumatised, when a car hit her as a pedestrian. She went through multiple operations of both tibias due to bilateral complicated proximal fractures. Fractures were stabilised at first with internal fixation, which had to be changed to external fixation due to infection of both sides. During the last operative step a commercial bone graft based on hydroxyapatite and bovine type I fibrillar collagen/tricalcium phosphate ceramic (Collagraft) mixed with autogenous bone marrow was applied. RESULTS: Fractures united after 28 (right tibia) and 22 (left tibia) months of follow-up. At the final follow-up visit 55 months after the initial accident patient walked without any aid and showed no signs of an infection. CONCLUSIONS: The use of commercial mixed xeno-/autogenous-bone graft may provide a feasible alternative in complicated chronic non-unions of the tibia even when an infection is present, especially when autogenous bone is not easily available after previous attempts of bone grafting.

Calcium Phosphates↗
PubMed1990

Primary or delayed closure for open tibial fractures.

Of 110 consecutive open tibial fractures 90 were reviewed and analysed retrospectively with particular reference to wound closure, method of stabilisation, infection rate and the incidence of non-union. There were 41% Gustilo type I, 39% type II and 20% type III injuries. The incidence of deep infection was 20% after primary wound closure compared with 3% after delayed closure, and eight of the nine non-unions followed primary closure. We conclude that primary wound closure should be avoided in the treatment of open tibial fractures.

Adult↗
PubMed1989

Reconstruction of large diaphyseal defects, without free fibular transfer, in Grade-IIIB tibial fractures.

Eight Grade-IIIB tibial fractures that were associated with large soft-tissue and segmental diaphyseal defects, averaging ten centimeters in length, were successfully reconstructed without the use of a free fibular transfer. A free tissue flap was the preferred form of soft-tissue coverage. The osseous reconstruction was accomplished by using a massive amount of autogenous cancellous bone graft. Beads that were made from polymethylmethacrylate and impregnated with two antibiotics at the time of operation were used as soft-tissue spacers to preserve the volume of the diaphyseal defect for later receipt of the cancellous bone graft. The beads prevented the soft-tissue flap from collapsing into and adhering to the site of the tibial defect. The beads also served as vehicles for local delivery of the antibiotics that they contained. When the soft-tissue flap had healed, the beads were replaced with cancellous graft. All of the tibiae healed. The time to healing averaged nine months. The average duration of external fixation was 5.5 months. One deep infection developed, but resolved after debridement and antibiotic therapy. This conservative technique is safe and reliable for patients who have sustained a high-energy tibial fracture and a large segmental diaphyseal defect.

Adolescent↗
PubMed1986

Treatment of failures after plating of tibial fractures.

Eighteen patients with tibial fractures treated by plating that had failed were treated by intramedullary nailing. Nine patients had a broken plate or screw that had pulled out. In seven, the plate and screws were intact but no healing was evident, and in two patients the plate was intact but one or more screws were broken. The plate and screws were removed from all patients and immediate limited open intramedullary nailing was done with a Küntscher nail after the bone was reamed. In one patient the method failed, while in fifteen patients the fracture united and in the two remaining patients who could not be contacted union was thought to be in process when they were last seen, five and ten months postoperatively. Two bone grafts were used in one patient. Six fibular osteotomies were performed in conjunction with the intramedullary nailing.

Adult↗
PubMed1994

Muscle contraction increases the strength of healing tibial fracture in the rat.

Tibial fractures in 7-week-old rats were fixed with intramedullary nails. After 25 days of healing the nails were removed and the tibiae loaded in vivo with intact soft tissues until refracture. The animals were tested in three-point anterior cantilever bending either during muscle contraction (n 8) or with relaxed muscles (n 8). Muscle contraction increased the ultimate bending moment by 84 percent, energy absorption by 108 percent, bending stiffness by 21 percent, and ultimate deflection by 49 percent.

Animals↗