Objective To determine the efficacy and safety of external fixation versus intramedulllary nailing in the treatment of adult tibial shaft fracture. Methods We searched the specialized trials register of The Cochrane Collaboration’s Bone, Joint and Muscule Trauma Group, The Cochrane Library (CENTRAL), MEDLINE (1966 to March 2006), EMBASE (1980 to March 2006) and PUBMED (1966 to March 2006). We also handsearched some Chinese orthopedic journals. Randomized controlled trials (RCTs) and quasi-randomized trials (quasi-RCTs) comparing external fixation versus intramedullary nailing for tibial shaft fractures in adults were included. The quality of these trials was critically assessed. We used the Cochrane Collaboration’s RevMan 4.2.8 for data analyses. Result Three RCTs and two quasi-RCTs involving a total of 279 patients were included. The results of meta-analyses showed that external fixation for tibial shaft fractures in adults may increase the infection rate [RR 2.45, 95%CI (1.31,4.61), P=0.005], and the malunion rate [RR 2.85, 95%CI (1.20,6.79), P=0.02] but may reduce the duration of hospitalization [RR –5.50, 95%CI (–6.99,–4.01)]. The nonunion rate, delayed healing rate, and healing time, were comparable between external fixation and intramedulllary nailing. Conclusion The trials available for this systematic review are too few and small for reliable estimates of the relative effects of external fixation and intramedulllary nailing. Further studies are needed to determine these effects , especially for patients who have GustiloШ C fractures.
Objective To describe a surgical device for closed reduction of tibial fracture and investigate its clinical effectiveness. Methods Between June 2010 and December 2012, 24 cases of tibial fractures were treated with intramedullary nailing using a surgical device for closed reduction. There were 18 males and 6 females with an average age of 40 years (range, 20-64 years). All fractures were closed. There were 3 proximal third fractures, 12 middle third fractures, and 9 distal third fractures. According to AO classification, 12 cases were classified as type A, 8 cases as type B, and 4 cases as type C. The mean time between injury and operation was 3 days (range, 1-12 days). The intraoperative fluoroscopy frequency to confirm closed reduction and guide wire passing the fracture site, and the duration between fracture reduction and nail insertion were recorded. The injured limb alignment and fracture angular deformity were measured as described by Freedman et al. The fuction of affected limb was estimated by Johner-Wruhs criteria. Results Closed reduction was successfully performed in 24 patients. The mean fluoroscopy frequency to confirm closed reduction was 3 (range, 2-5). The fluoroscopy frequency to confirm guide wire passing the fracture site was 2. The mean duration between fracture reduction and nail insertion was 30 minutes (range, 20-42 minutes). No intraoperative or postoperative complication occurred, such as infection, vessel and nerve injuries. All incisions healed by first intention. Seventeen patients were followed up 6-16 months (mean, 10 months). Radiographic evidence showed that bridging callous was observed at 2-4 months (mean, 2.5 months). The injured limb alignment was normal on anteroposterial and lateral radiographs at 5 months postoperatively, no malalignment and obvious angular deformity was observed. The internal fixator had good position. According to Johner-Wruhs criteria for evaluation of the affected limb function, the results were excellent in 12 cases and good in 5 cases with an excellent and good rate of 100%. Conclusion The surgical device for closed reduction of tibial fracture is simple and easy to use, and has good effectiveness combined with intramedullary nailing.
Objective To study the effect of the human umbilical cord blood on the content of trace elements in whole blood during fracture healing in rabbits and to explore the mechanism of promoting fracture healing. Methods The right tibial fracture model was made in 63 white New Zealand rabbits (aged, 4-5 months; weighing, 2.0-2.5 kg). The fracture site was treated with 3 mL human umbilical cord blood (group A, n=21) and 3 mL normal saline (group B, n=21) at 3 and 8 days after operation, and was not treated as a control (group C, n=21). At 1, 2, 3, 4, 5, and 6 weeks after operation, the X-ray and histological observations were done; the contents of zinc, copper, magnesium, ferrum, calcium, and phosphorus were detected. Results X-ray observation showed that the fracture healing speed of group A was significantly faster than that of groups B and C; the fracture healing X-ray score of group A was significantly higher than that of groups B and C at 2-6 weeks (P lt; 0.05). The histological observation indicated that new trabeculae and osteoid of group A were significantly more than those of groups B and C; at 2-5 weeks, the histological score of group A was significantly higher than that of groups B and C (P lt; 0.05); at 6 weeks, the score of group A was significantly higher than that of group B (P lt; 0.05), but no significant difference was found between groups A and C (P gt; 0.05). Changes trend of the trace elements in 3 groups after operation was basically consistent. The content of copper first decreased and then gradually increased; the contents of ferrum, zinc, and magnesium at different time points decreased, but were basically stable; the content of calcium first increased and then decreased; the content of phosphorus first decreased and then increased. The contents of copper, zinc, magnesium, ferrum, calcium, and phosphorus in group A were significantly higher than those in groups B and C at different time points (P lt; 0.05), but there was no significant difference between groups B and C (P gt; 0.05). Conclusion Injection of the human umbilical cord blood at the fracture end of rabbits can significantly slow down the loss of trace elements in whole blood, ensure the contents of necessary trace elements during fracture healing, which may be one of the mechanisms of the umbilical cord blood promoting fracture healing.
Objective To study the cl inical effect of expert tibial nail (ETN) in the treatment of the complex tibial fractures of type C. Methods From May to October 2008, 10 cases of complex tibial fractures of type C were treated with unreamed ETN and closed reduction. There were 7 males and 3 females aging from 23 to 50 years with an average age of 39 years. Fracture was caused by traffic accident in 6 cases, by crush in 2 cases, and by fall ing from height in 2 cases. According to Association for the Study of Internal Fixation (AO/ASIF) classification, there were 2 cases of 42-C1 fractures, 4 cases of42-C2 fractures, and 4 cases of 42-C3 fractures; including 4 cases of closed fractures and 6 cases of open fractures (2 cases of Gustilo type I and 4 cases of Gustilo type II). Results The mean duration of surgery and blood loss were 75 minutes (range, 60-110 minutes) and 55 mL (range, 20-100 mL), respectively. All the incision healed by first intension without compl ication of infection. All cases were followed up for 12-17 months (average 14 months). X-ray films showed that no breakage of nail, iatrogenic fracture, l imb shortening, and angulation deformity occurred. All fractures healed after 3-8 months (average 4.2 months). At last follow-up according to Johner-Wruhs standard for the functional recovery, the results were excellent in 8 cases and good in 2 cases. Conclusion ETN has an angular stable locking system for intramedullary nails, which can enhance axial and transverse stabil ity for the treatment of complex tibial fractures of type C. It will provide firm fixation and minimal invasion.
Objective To summarize the cl inical appl ication of minimally invasive percutaneous locking compression plate (LCP) internal fixation in the treatment of tibial fractures and to evaluate its cl inical effects. Methods From September 2005 to September 2007, 13 patients with tibial fractures were treated with indirect reduction and minimally invasive percutaneous LCP internal fixation, 8 males and 5 females, aged 18-35 years old (27 on average). Among them, the fractures were caused by traffic accidents in 3 cases, by fall ing in 5 cases, by fall ing from height in 4 cases and by bruise in 1 case. The fractures were located at 1/3 upper tibia in 2 cases, at 1/3 medium tibia in 6 cases and at 1/3 lower tibia in 5 cases. All fracture were closed ones. According to the AO classification, 4 cases were type A, 7 type B and 2 type C. The time between fractures and operation was from 3 hours to 5 days (2.5 days on average). Results All incisions obtained heal ing by first intention. All patients were followed up for 10-18 months (13 months on average). All fractures reached cl inical heal ing, and the heal ing time was 12-20 weeks (16 weeks on average). There was no delayed fracture heal ing, nonunion, infection and internal fixation failure. No compl ications such as rotation, crispatura deformity and internal fixation loosening were found. According to the HSS scoring, the function of the knee joint was graded 85-95 (90 on average), and the range of motion was 100-130° (120° on average). According to the AOFAS Ankie Hindfoot Scoring, the function of the ankle joint was graded 80-95 (92.4 on average). Nine cases were excellent, 4 good, and the choiceness rate was 100%. Conclusion Minimally invasive percutaneous LCP internal fixation is in accord with biological set principles and beneficial for tibial fracture heal ing and reconstruction of soft tissues.
Objective To research the biomechanical effect of different length bone plates on treatment of tibial shaft fracture. Methods Forty-five tibia specimens from fresh adult corpse (20-40 years old) were donated (30-38 cm in length, 34 cm on average) and were divided into 3 groups randomly (n=15). Under the following three conditions, the experiment was made separately. Compression stress-strain indexes of whole tibia were determined under the reverse, three spots curving and compression. The vertical elastic strain was 0-1 000 N, the reverse angle was 0-3º, and three bending stresswas 0-400 N. Then the center-section squint non-damage bone fracture model was made, fracture was fixed by 6, 10, 14stainless steel AO LC-DCP, respectively. The compression stress-strain indexes were determined under reverse angle, three spots curving and compression, statistical analysis was done. Results The vertical direction strain value of 6, 10 and 14 hole steel plate under vertical compressions, was 0.449 ± 0.241, 0.093 ± 0.003, 0.139 ± 0.005, respectively ; showing significant difference between 10 and 14 hole steel plates and 6 steel plate (P lt; 0.01) and no significant difference between 10 and 14 hole steel plate (P gt; 0.05). The lateral strain value of 6, 10 and 14 hole steel plate was 0.120 0 ± 0.000 4, 0.127 5 ± 0.010 0, 0.237 0 ± 0.000 6 respectively, indicating a significant difference between stell plates of 6 and 10 hole and 14 hole steel plate (P lt; 0.01) and no difference between 6 and 10 hole steel plate (P gt; 0.05). The torque of 6, 10 and 14 hole steel plate was (5.066 ± 2.715) × 10-3, (5.671 ± 2.527) × 10-3 and (4.570 ± 2.228) × 10-3 Nm, respectively and three spot curving vertical direction strain value was 0.049 ± 0.009, 0.124 ± 0.017, 0.062 ± 0.009, respectively. There were significant differences between various steel plates (P lt; 0.01). Conclusion For the fixation of tibial obl ique fracture, 14 hole steel plate’s stabil ities of anti-vertical compression, anti-reverse and anti-curving are better than those of 6 hole steel plate under the condition of the same material qual ity, thickness, width and screw quantity used.
Objective To determine the effect of non-reamed versus reamed intramedullary nailing for tibial fractures in adults on the rates of nonunion, the rates of implant failure, the rates of infection, the incidence of compartment syndrome, the rates of malunion, and the time of union. Methods We searched MEDLINE （1966 -July, 2005）, EMBASE （1974 -July, 2005 ）, The Cochrane Library （Issue 2, 2005 ）and CBMdisc （1979 -July, 2005 ）, and handsearched the relevant Chinese and English orthopedic journals. Randomized controlled trials and Clinical controlled trials of nonreamed versus reamed intramedullary nailing for tibial fractures in adults were included. The quality of trials was critically assessed. RevMan 4.2.7 software was used for data analysis. Results Four RCTs and one CCT of non-reamed versus reamed intramedullary nailing for tibial fractures in adults were included. The results of meta-analysis showed that nonreamed intramedullary nailing for tibial fractures in adult increased the rates of nonunion （RR 1.87, 95% CI 1.20 to 2. 91, P =0. 006）, implant failure （RR 2.23, 95% CI 1.49 to 3.34, P〈0. 000 1 ） and the time to union （WMD 9.00, 95% CI 3.19 to 14.81, P =0. 002）. Conclusions Compared with reamed intramedullary nailing for tibial fractures in adults, non-reamed intramedullary nailing increases the rates of nonunion and implant failure is common. There is no statistical difference in the rates of post operative infection, the rates of malunited fracture and the incidence of compartment syndrome between the two groups. However, further studies are needed to determine the effects of reamed and non-reamed intramedullary nailing on these outcomes, expecially when patient has severe open fractures （Gustilo Grade Ⅲ C）and multiple injuries.
ObjectiveTo explore the feasibility and effectiveness of bone transport technique for simultaneous repair of tibia defect and refractory soft tissue defect. MethodsThirty-five patients with tibia bone defect combined with refractory soft tissue defect were treated between January 2010 and December 2014, and the clinical data were retrospectively analyzed. There were 21 males and 14 females with an average age of 29 years (range, 18-47 years). All patients had Gustilo type Ⅲ open tibial fractures, which were caused by traffic accident. Fracture located at the upper 1/3 of the tibia in 1 case, at the middle 1/3 of the tibia in 19 cases, and at the lower 1/3 of the tibia in 15 cases. All patients underwent external fixation after 4-10 hours of trauma, and tibial skin necrosis, infection, and purulent exudation were observed after 5-10 days of operation. The time from injury to admission was 21 days to 5 months (mean, 2 months). After debridement, the average length of tibia defect was 8 cm (range, 6-11 cm); the area of soft tissue defect was 6 cm×5 cm to 10 cm×8 cm. Orthofix external fixation was applied to tract the bone and soft. ResultsAll 35 patients were followed up 12-22 months (mean, 16 months). The average time of bony healing was 15 months (range, 9-20 months), and no obvious force line offset was found. Osteotomy segment was extended from 6 to 11 cm (mean, 8 cm); after treatment, the external fixation support was retained for 2 to 10 months (mean, 5 months). No blood vessel and nerve injuries were found during treatment, and no osteomyelitis and refracture happened after operation. The skin and soft tissue defects healed, and the healing time was 1 to 3 months (mean, 1.3 months). Different degrees of infection occurred in 5 cases, and was cured after dressing change. According to Johner-Wruhs' evaluation criteria after external fixator was removed, the results were excellent in 26 cases, good in 5 cases, and moderate in 4 cases, with an excellent and good rate of 88.6%. ConclusionBone transport technique can simultaneously repair tibia bone defect and soft tissue defect by continuous bone and soft tissue traction.
ObjectiveTo discuss the efficacy of skin stretcher applied for repair of postoperative skin and soft tissue defects in tibial fractures.MethodsBetween April 2016 and March 2017, 15 cases with skin and soft tissue defects after tibial fractures fixation were treated with the skin stretcher. There were 11 males and 4 females with an age of 24-59 years (mean, 37.5 years). The causes of injury included traffic accident in 7 cases, bruise in 3 cases, falling from height in 3 cases, and falling in 2 cases; without nerve and vascular injury in all patients. These cases were followed up 1-3 months after their first surgery, consisting of 3 closed fractures treated with open reduction and plate and screw fixation, 12 open fractures treated with external fixation after debridement. The area of skin defects ranged from 14 cm×5 cm to 20 cm×7 cm, all of which were stripped or spindle shaped skin defects. First, the skin was penetrated by two Kirschner wires which were locked by skin stretchers on both sides of the skin defect longitudinally. Then, the tension of skin stretchers was timely adjusted according to the skin flap blood supply and muscle compression. Finally, Kirschner wires and skin stretchers were removed when the edge of skin contacted and been sutured.ResultsAll skin and soft tissue defects were covered after stretching for 6-13 days. The interrupted sutured wounds healed at 12 days. Clinical scores of wound healing decreased from 3.40±0.51 at immediate postoperatively to 1.27±0.46 at 12 days postoperatively, showing significant difference (t=12.911, P=0.000). All the patients were followed up 4-12 months (mean, 6.5 months). After stretching, the skin color, elasticity, and pain and touch feeling were similar with the normal skin, and the hair growth was normal. After operation, 1 case of nail tract infection and 2 cases of calf discomfort occurred, and all were relieved after treatment.ConclusionIt is an effective method for repairing postoperative skin and soft tissue defects in tibial fractures with the application of skin stretchers.