The management of segmental tibial shaft fractures: A systematic review.

INTRODUCTION: Segmental tibial fractures are complex injuries associated with significant soft tissue damage that are difficult to treat. This study aimed to identify the most effective method of treating segmental tibial fractures. METHOD: A PRISMA compliant systematic review was conducted. Studies investigating the management of segmental tibial fractures with intramedullary nail fixation (IMN), open reduction and internal fixation (ORIF) or circular external fixation (CEF) were included for review. The primary outcome measure was time to fracture union. Secondary outcomes were complications and functional outcome. A narrative analysis was undertaken as meta-analysis was inappropriate due to heterogeneity of the data. RESULTS: Thirteen studies were eligible and included. No randomised controlled trials were identified. Fixation with an intramedullary nail provided the fastest time to union, followed by open reduction and internal fixation and then CEF. The rate of deep infection was highest after IMN (5/162 [3%]), followed by open reduction and internal fixation (2/78 [2.5%]) and CEF (1/54 [2%]). However, some studies reported particularly high rates of infection following IMN for open segmental tibial fractures. There was limited reporting of postoperative deformities. From the studies that did include such data, there was a higher rate of deformity following ORIF (8/53 [15%]), compared to IMN (13/138 [9%]), and CEF (4/44 [9%]). Three studies, not including IMN, described patient reported outcome measures with results ranging from 'excellent' to 'fair'. DISCUSSION: The available evidence was of poor quality, dominated by retrospective case series. This prevented statistical analysis, and precludes firm conclusions being drawn from the results available. CONCLUSION: IMN has the fastest time to fracture union, however there are concerns regarding an increased deep infection rate in open segmental tibial fractures. In this subgroup, the data suggests CEF provides the most satisfactory results. However, the available literature does not provide sufficient detail to make this statement with certainty. We recommend a randomised controlled study to further investigate this challenging problem

Decision Making in the Management of Extracapsular Fractures of the Proximal Femur - is the Dynamic Hip Screw the Prevailing Gold Standard?

Currently, approximately half of all hip fractures are extracapsular, with an incidence as high as 50 in 100,000 in some countries. The common classification systems fail to explain the logistics of fracture classification and whether they all behave in the same manner. The Muller AO classification system is a useful platform to delineate stable and unstable fractures. The Dynamic hip screw (DHS) however, has remained the 'gold standard' implant of choice for application in all extracapsular fractures. The DHS relies on the integrity and strength of the lateral femoral wall as well as the postero-medial fragment. An analysis of several studies indicates significant improvements in design and techniques to ensure a better outcome with intramedullary nails. This article reviews the historical trends that helped to evolve the DHS implant as well as discussing if the surgeon should remain content with this implant. We suggest that the gold standard surgical management of extracapsular fractures can, and should, evolve

Calcaneal fractures: Where are we now?

This review article on the current management for calcaneal fractures discusses the advantages and disadvantages of different treatment options including the problems encountered. Controversies are described and the evidence reviewed. The management of some types of displaced intra-articular calcaneal fractures remains contentious; is there a preferred stabilisation method for each type of calcaneal fracture? How constant is the "constant fragment" in an intra-articular calcaneal fracture and what is the evidence for primary arthrodesis and what is its place in these fractures

Tips and Tricks in Extracapsular Hip Fracture Fixation.

Aside from the decision-making in how to fix an extracapsular hip fracture, surgeons must be conversant with systems, implants and how to maximize their potential in the shortest operative time. We present a series of steps used in our unit when performing both DHS and intramedullary nail surgery to avoid the commonest problems and maximize our patients' recovery potential

The Relationship Between Serum 25[OH]D Concentration and Orthopaedic Infection: A Case-Control Study

Background: An estimated one in two healthy adults in the United Kingdom suffer from low levels of 25[OH]D. Vitamin D is involved in modulating immune response, but there is less clarity over its role in orthopaedic infection. This study assesses the relationship between serum 25[OH]D concentration and orthopaedic infection. Methods: A total of 205 patients in a tertiary referral centre for orthopaedic infection were included in the study. They were divided into groups based on their infection status, matched by age and gender. Data were statistically analysed to determine presence and direction of relationship. Results: A total of 114 patients had an infection. There was no statistically significant difference in age or gender between the two groups. Mean serum 25[OH]D concentration was 39 nmol/L in the group with infection and 59 nmol/L in the group without an infection (p< 0.01). Overall mean serum 25[OH]D concentration was 48 nmol/L. There was a correlation between low serum 25[OH]D concentration and rate of infection (odds ratio, 5.94; 95% confidence interval [CI], 3.24 to 10.92) with a bivariate correlation of − 0.338 (p< 0.01). Conclusion: This study demonstrates an association between low levels of serum 25[OH]D and increased orthopaedic infection. Orthopaedic inpatients suffered from vitamin D insufficiency, and there was a correlation between higher levels of serum 25[OH]D and lower rates of infection. This suggests that prophylactic supplementation of 25[OH]D may improve outcomes, and provides a foundation for randomized controlled trials to assess its effectiveness in practice

Temporary Fixation Using a Long Femoral-tibial Nail to Treat a Displaced Medial Tibial Plateau Fracture in a 90-year-old Patient: A Case Report.

Introduction: Tibial plateau fractures are complex injuries in the elderly population. When traditional methods of fixation are not suitable, an alternative method needs to be chosen for a favorable outcome. We demonstrate a previously undescribed treatment for displaced tibial plateau fractures in the very elderly with poor soft-tissue integrity. Case Report: A 90-year-old woman suffered an open, Gustilo Grade IIIA, displaced fracture of the tibial plateau. An intramedullary knee arthrodesis, the femoral-tibial nail was used to temporarily stabilize her fracture. She was able to weight bear immediately postfixation. Conclusion: A long femoral-tibial nail allows favorable fracture and soft tissue healing, ease of nursing and immediate full weight-bearing. It shows good promise and should be considered as a management option when traditional methods are not applicable in select patients

An unclassified tibial plateau fracture: Reverse Schatzker type IV.

The most commonly accepted system of classification for tibia plateau fractures is that of Schatzker. Increasingly, both high energy injuries and atypical osteoporotic fragility failures have led to more complex, unusual and previously undescribed fracture patterns being recognized. We present a case of a patient with a previously unreported pattern of tibia plateau fracture and knee dislocation. We highlight the challenges confronted and present the management and the outcomes of his injury. A 28-year old male motorcyclist was involved in a head on collision with a truck and was transferred by helicopter to our level 1 major trauma centre emergency department. His injuries were a circumferential degloving injury to his left leg and a right lateral tibial plateau fracture/knee dislocation. The pattern of the lateral tibial plateau fracture was unique and did not fit any recognised classification system. The patient received a spanning external fixator initially and after latency of 12 days for soft tissue resuscitation he underwent definite fixation through an antero-lateral approach to the proximal tibia with two cannulated 6.5 mm partially threaded screws and an additional lateral proximal tibia plate in buttress mode. A hinged knee brace was applied with unrestricted range of motion post-operatively and free weight bearing were permitted post operatively. At the 6 months follow up, the patient walks without aids and with no limp. Examination revealed a stable joint and full range of motion. Plain radiographs revealed that the fracture healed with good alignment and the fixation remained stable. High energy injuries can lead to more complicated fracture patterns, which challenge the orthopaedic surgeons in their management. It is crucial to understand the individual fracture pattern and the possible challenges that may occur. This study reports a lateral tibia plateau fracture/dislocation which perhaps is best described as a reverse Schatzker IV type fracture

Heterotopic Ossification following Suprapatellar Intramedullary Nailing.

Introduction: Tibial shaft fractures are common fractures seen in trauma and orthopedic practice today. The majority of these fractures are treated with intramedullary nailing (IMN) which is rapidly becoming a gold standard. The procedure itself is performed by either a suprapatellar approach or infrapatellar approach. Suprapatellar approach is gaining popularity due to relative ease of insertion, decreased associated risk of anterior knee pain, and more accurate reduction. We report a case of heterotopic ossification noted in the knee following IMN of tibia performed using a suprapatellar approach. Case Report: A 27-year-old male, having sustained a left, Gustilo IIIB tibial shaft fracture following a motor vehicle accident, underwent a reamed intramedullary nail fixation performed through a suprapatellar approach. Two months later, he presented with intra-articular heterotopic ossification which was limiting his knee movement. He then underwent arthroscopic removal of the bony fragments which resolved his symptoms. Conclusion: An extensive search of literature did not yield any reported incidence of heterotopic ossification associated with IMN performed through a suprapatellar approach. We present this case report to raise awareness that although IMN through a suprapatellar approach is a safe approach, it does have associated risk of heterotopic ossification which needs to be included in the consent process

Harmonic oscillations and their switching in elliptical optical waveguide arrays

We have studied harmonic oscillations in an elliptical optical waveguide array in which the coupling between neighboring waveguides is varied in accord with a Kac matrix so that the propagation constant eigenvalues can take equally spaced values. As a result, long-living Bloch oscillation (BO) and dipole oscillation (DO) are obtained when a linear gradient in the propagation constant is applied. Moreover, we achieve a switching from DO to BO or vice versa by ramping up the gradient profile. The various optical oscillations as well as their switching are investigated by field evolution analysis and confirmed by Hamiltonian optics. The equally spaced eigenvalues in the propagation constant allow viable applications in transmitting images, switching and routing of optical signals.Comment: 14 pages, 5 figure

The history, evolution and basic science of osteotomy techniques.

Osteotomy techniques date back to Hippocrates circa 415 BC (Jones Hippocrates collected works I, Harvard University Press, Cambridge, 2006; Brorson in Clin Orthop Relat Res 467(7):1907-1914, 2009). There is debate about the best way to divide the bone surgically and which technique yields the best bone regenerate in lengthening; ensuring predictable new bone formation and healing of the osteotomy are the primary goals. We review the history and techniques of the osteotomy and consider the evidence for optimum bone formation. Methods discussed include variants of the 'drill and osteotome' technique, use of the Gigli saw and use of a power saw. Differences in bone formation through the different techniques are covered