Application of unilateral external fixation by the “joystick technique” in the treatment of pediatric tibia shaft fractures: technical note

Background The aims of current study were to present the clinical outcomes in patients with pediatric tibia shaft fractures who were treated with unilateral external fixation combined with joystick for fracture reduction and describe the details of our technique. Methods We retrospectively analyzed the patients with pediatric tibia shaft fractures who were treated with unilateral external fixation combined with joystick for fracture reduction between July 2018 and March 2020. The clinical outcomes were evaluated. Results A total of 23 patients were included in the current study with the average age of 8.0 years (ranged 4–14 years). The average duration of hospital and follow-up were 5.9 days (ranged 4–8 days) and 17.4 months (ranged 8–27 months), respectively. At postoperative 3 days, the visual analog scale (VAS) score was 3.1 ± 1.43, which was significantly lower than the preoperative score of 7.3 ± 1.5. Of these, 2 cases showed redness and swelling of pin-tract and exudation at postoperative 1 month, who improved after oral antibiotics without causing fixation failure. The average time to full weight-bearing without crutches was 5.1 weeks (ranged 3–8 weeks). All patients achieved fracture healing and good functional recovery. No complications including fixation failure, reoperation, epiphyseal injury occurred, infection around implants, vessel damage, nerve damage, and limitation of joint movement were observed. The Johner-Wruh scores showed that 21 cases (91.3%) were “excellent” and 2 cases (8.7%) were “good.” Conclusions This procedure had advantages of simple operation, minimum trauma, early recovery of lower limb function, and no risk of complications. It may provide a new choice for children with tibia shaft fractures who require surgical treatment.

Rethinking the Coronal Anatomic Axis of the Distal Tibia for Intramedullary Nail Placement: A Cadaveric Study

Background: Recent studies have reported that targeting a center-center position at the distal tibia during intramedullary nailing (IMN) may result in malalignment. Although not fully understood, this observation suggests that the coronal anatomic center of the tibia may not correspond to the center of the distal tibia articular surface. Questions/Purposes: To identify the coronal anatomic axis of the distal tibia that corresponds to an ideal start site for IMN placement utilizing intact cadaveric tibiae. Methods: IMN placement was performed in 9 fresh frozen cadaveric tibiae. A guidewire was used to identify the ideal start site in the proximal tibia and an opening reamer allowed access to the canal. Each nail was then advanced without the use of a reaming rod until exiting the distal tibia plafond. Cadaveric and radiographic measurements were performed to determine the center of the nail exit site in the coronal plane. Results: Cadaveric and radiographic measurements identified the IMN exit site to correspond with the lateral 59.5% and 60.4% of the plafond, respectively. Conclusions: Tibial nails inserted using an ideal start site have an endpoint that corresponds roughly to the junction of the lateral and middle third of the plafond. Further studies are warranted to better understand the impact of IMN endpoint placement on the functional and radiographic outcomes of tibia shaft fractures.

Formulae derived from Anthropometric Measurements to Estimate Ideal Tibial Nail Length

ABSTRACT Introduction: Ideal Nail Length (INL) provides better outcomes after Intramedullary Nailing (IMN) of Tibia Shaft Fractures (TSF). Intraoperative methods do not allow for preoperative planning. Changing the nail may cause complications. X-rays are commonly used, but displacement or magnification errors may occur. Forearm measurements may be benefical in bilateral TSF. We aim to examine correlations of anthropometric measurements (AMs) and INL and use them to obtain formulae. Materials and methods: Tuberositas Tibia-Medial Malleolus (TM), Tuberositas Tibia-Ankle joint (TA), knee-ankle joint (JJ), and olecranon tip-5th Metacarpal head (OM) distances were evaluated in 76 IMN patients. Correlation analyses were performed and the results used to create formulae. Results: The correlations between INL and TM-left, TM-right, TA-left, TA-right, OM-left, OM-right, JJ-left, JJ-right were 0.81, 0.83, 0.77, 0.77, 0.82, 0.80, 0.90, 0.91 respectively for males; and 0.93, 0.89, 0.88, 0.86, 0.80, 0.82, 0.90, 0.89 respectively for females. AMs show excellent correlation in both sexes (p<0.0001). Regression analysis was statistically significant in all formulae. The most compatible correlations in males were JJ-right and JJ-left; and in females, TM-left, TM-right, and JJ-right. Conclusion: The most compatible correlations wth INL were JJ in males, and TM and JJ in females. OM can be used in the presence of bilateral TSF, edema, wounds and obesity. AMs are useful preoperatively. The formulae can be used to ensure INL and reduce errors, time and radiation. Level of Evidence: Level I, Testing of previously developed diagnostic criteria on consecutive patients (with the universally applied reference gold standard).

Fracture-related outcome study for operatively treated tibia shaft fractures (F.R.O.S.T.): registry rationale and design

Background Tibial shaft fractures (TSFs) are among the most common long bone injuries often resulting from high-energy trauma. To date, musculoskeletal complications such as fracture-related infection (FRI) and compromised fracture healing following fracture fixation of these injuries are still prevalent. The relatively high complication rates prove that, despite advances in modern fracture care, the management of TSFs remains a challenge even in the hands of experienced surgeons. Therefore, the Fracture-Related Outcome Study for operatively treated Tibia shaft fractures (F.R.O.S.T.) aims at creating a registry that enables data mining to gather detailed information to support future clinical decision-making regarding the management of TSF’s. Methods This prospective, international, multicenter, observational registry for TSFs was recently developed. Recruitment started in 2019 and is planned to take 36 months, seeking to enroll a minimum of 1000 patients. The study protocol does not influence the clinical decision-making procedure, implant choice, or surgical/imaging techniques; these are being performed as per local hospital standard of care. Data collected in this registry include injury specifics, treatment details, clinical outcomes (e.g., FRI), patient-reported outcomes, and procedure- or implant-related adverse events. The minimum follow up is 12 months. Discussion Although over the past decades, multiple high-quality studies have addressed individual research questions related to the outcome of TSFs, knowledge gaps remain. The scarcity of data calls for an international high-quality, population-based registry. Creating such a database could optimize strategies intended to prevent severe musculoskeletal complications. The main purpose of the F.R.O.S.T registry is to evaluate the association between different treatment strategies and patient outcomes. It will address not only operative techniques and implant materials but also perioperative preventive measures. For the first time, data concerning systemic perioperative antibiotic prophylaxis, the influence of local antimicrobials, and timing of soft-tissue coverage will be collected at an international level and correlated with standardized outcome measures in a large prospective, multicenter, observational registry for global accessibility. Trial registration ClinicalTrials.gov: NCT03598530.

Clinical and Radiographic Comparisons of Distal Tibia Shaft Fractures Stabilized with an Intramedullary Nail: Blocking Pin Versus Blocking Screw

Background: Distal tibia shaft fractures have a high risk of mal-alignment when treated with intramedullary nailing (IMN). Permanent blocking screws (BSs) and temporary blocking pins (BPs) are often used as supplements to help IMN get good alignment. The purpose of this study was to compare the clinical and radiographic outcomes of temporary BPs and permanent BSs for distal tibia shaft fractures.Methods: From March 2014 to May 2019, a total of 89 patients with distal tibia shaft fractures were included in this retrospective study and divided into two groups. All fractures were located below the isthmus but 4 cm above the tibial plafond. The differences in operating time, intraoperative bleeding, fibula plate fixation, number of BP/BS, initial and final alignment, loss of reduction, fracture healing time, and postoperative complications were analyzed. Functional outcomes of the ankle were assessed with the American Orthopedic Foot and Ankle Society (AOFAS) score.Results: All patients underwent a minimum follow-up of 13 months. The operating time was (73.9±6.1) min and (80.2±8.6) min in the BP group and BS group, respectively (P < 0.05); intraoperative bleeding was (88.2±18.0) mL and (92.9±26.6) mL, respectively (P > 0.05); initial reduction deformity in coronal plane was (0.5±2.3) degrees and (0.9±2.3) degrees, respectively (P > 0.05); final alignment deformity in coronal plane was (1.2±2.7) degrees and (1.3±2.4) degrees, respectively (P > 0.05); initial reduction deformity in sagittal plane was (0.6±2.2) degrees and (0.6±2.4) degrees, respectively (P > 0.05); final alignment deformity in sagittal plane was (0.9±2.3) degrees and (1.0±2.2) degrees, respectively (P > 0.05); As for the loss of reduction, there was no significant difference in sagittal plane between the two groups(P > 0.05). Although the loss of reduction in the coronal plane of the BP group (0.8±0.7 degrees) is statistically higher than that of the BS group (0.5±0.5 degrees), the small difference was not clinically important (P < 0.05). No significant differences were found between the two groups in fracture healing time, AOFAS score and complications (P > 0.05).Conclusion: Both temporary BP and permanent BS can help achieve equivalent overall alignment. However, BP technique is simpler and takes less time.