Analysis of clinical and radiological outcomes of long tibial stemmed total knee arthroplasty in knee osteoarthritis complicated by tibial stress fracture

( Neelam V. Ramana Reddy ),( Mukesh Kumar Saini ),( Pera Jayavardhan Reddy ),( Ajay Singh Thakur ),( Challa Dinesh Reddy ) 대한슬관절학회 2022 대한슬관절학회지 Vol.34 No.-

Objective: Knee arthritis associated with tibial stress fractures represents an uncommon and difficult clinical scenario to treat. The use of long, fluted tibial extension rods has been vital in the management of such cases owing to immediate fracture stability and single-stage surgery without the need to open the fracture site. This study investigates clinical and radiological outcomes following total knee arthroplasty using a tibial extension stem in cases of knee osteoarthritis with tibial stress fracture. Methods: From February 2015 to December 2020, 17 patients who had total knee arthroplasty implanted with a long stemmed tibial component were included in the study. Patient data were analyzed for knee range of motion, deformities, Knee Society score, knee function score, and time to fracture union in the pre- and postoperative periods. Results: The mean follow-up duration was 22.7 ± 11.68 months (range 12-60 months), and mean time to fracture healing was 10.23 ± 2.81 weeks (range 8-20 weeks). The preoperative mean fixed flexion deformity improved from 8.53 ± 3.43° to a mean of 0.29°, and knee flexion improved from 79.4 ± 13.90° to 125.29 ± 8.74° on postoperative assessment. The Knee Society score improved from a mean preoperative score of 18.94 ± 5.55 (range 8-28) to 89.41 ± 7.5 (range 74-102, p value < 0.001). Similarly, the knee function score improved significantly from a mean preoperative score of 15.5 ± 4.48 (range 8-26) to a mean of 85 ± 6.09 (range 72-94, p value < 0.001). Conclusion: Total knee arthroplasty using long tibial extenders has been an effective and safe surgical option for patients with advanced osteoarthritis with tibial stress fractures.

대퇴골 및 경골간부 골절 치료에서 확공성 금속정과 비확공성 금속정의 비교

김성수 ( Sung Soo Kim ),김철홍 ( Chul Hong Kim ),이명진 ( Myung Jin Lee ),강진헌 ( Jin Hun Kang ) 대한골절학회 2006 대한골절학회지 Vol.19 No.2

목적: 대퇴골 및 경골 간부 골절의 치료에 있어서 확공성 금속정을 사용한 경우와 비확공성 금속정을 사용한 경우, 임상적 차이점과 결과를 평가하여 보고하고자 한다. 대상 및 방법: 16개월 이상 추시가 가능했던 대퇴골 및 경골 간부 골절의 치료에서 확공성 및 비확공성 금속정을 사용한 예를 비교 분석하였다. 분쇄 정도는 대퇴골과 경골에서 각각 Winquist-Hansen 및 Johner-Wruhs의 분류를 사용하였다. 본 연구는 후향적 연구로 이루어졌으며 수술시간, 수술시 출혈량, 최초 가골 형성 시기, 골절 유합 시기, 수술 후 체중 부하시기, 정과 협부의 직경, 폐 색전증과 금속실패를 포함한 임상적인 합병증을 분석하였다. 결과: 수술시간은 확공성 금속정과 비확공성 금속정에서 각각 대퇴골의 경우 평균 104분과 평균 95분, 경골의 경우 평균 96분과 평균 87분으로 통계학적인 유의성을 보였으며 (p<0.05), 수술시 출혈량의 경우 확공성 금속정과 비확공성 금속정에서 각각 대퇴골의 경우 평균 360 ml과 223 ml, 비확공성 금속정의 경우 평균 280 ml와 205 ml로 통계학적 유의성을 보였다 (p<0.001). 정과 협부의 직경의 비는 확공성 금속정과 비확공성 금속정에서 대퇴골의 경우 각각 105.5% 및 87.0%, 경골의 경우 각각 106.3% 및 85.3%로 나타났다. 지연유합으로 역동화한 경우는 비확공성 금속정에서 대퇴골의 경우 2예, 경골의 경우 1예, 금속 파단이 경골에서 비확공성의 경우에서 1예 관찰되었다. 결론: 비확공성 금속정은 대퇴골과 경골에서 확공성에 비해 수술시간과 출혈량을 통계학적으로 의미 있게 감소시키지만, 최초 가골 형성 시기, 골절 유합 시기, 수술 후 체중 부하시기에서는 모두 통계학적인 유의성이 없었다. 비확공성 금속정에서의 지연유합이나 금속의 파단 등의 합병증이 나타나는 것에는 골절의 정도가 심하고, 낮은 isthmic ratio, 다발성 손상이 동반된 점 등이 기인한 것으로 생각된다. Purpose: To comparative analysis of clincal difference between reamed and unreamed interlocking intramedullary nailing in the treatment of femoral and tibial shaft fractures. Materials and Methods: We reviewed femoral and tibial shaft fracture who were treated with reamed or unreamed nail. They were followed for a minimum of 16 months. Winquist-Hansen and Johner-Wruhs criteria were applied for the classification of the fractures. Retrospectively we evaluated the duration of operation, the amount of bleeding, the first time of callus formation, union time, the time of partial weight bearing, isthmic ratio, complications. Results: The average duration of operation for femoral fractures with reamed and unreamed nail were 104 minutes, 95 minutes, respectively. And those for tibial fractures were 96 minutes, 87 minutes, and the difference was statistically significant (p<0.05). The amount of bleeding in femoral fractures with reamed and unreamed nail were 360 ml, 223 ml, respectively. And those in tibial fractures were 280 ml, 205 ml, respectively, and the difference was statistically significant (p<0.001). The isthmic ratio in femoral fracture with reamed and unreamed nail were 105.5%, 87.0%, respectively and those in tibial fracture were 106.3%, 85.3%, respectively. There were 2 delayed unions in femoral fractures and 1 delayed union in tibial fracture with undreamed nail, and 1 metal failure in tibial fracture with unreamed nail. Conclusion: Unreamed femoral intramedullary nailing involves fewer steps and less intraoperative blood loss than reamed nailing. There was no statistical difference the first time of callus formation, union time, the time of partial weight bearing. It must be consider that delayed union and metal failure in the unreamed intramedullary nailing due to high grade fracture, lower isthmic ratio, combined with multiple trauma.

Tibial bone fractures occurring after medioproximal tibial bone grafts for oral and maxillofacial reconstruction

Il-Kyu Kim,Hyun-Young Cho,Sang-Pill Pae,Bum-Sang Jung,Hyun-Woo Cho,Ji-Hoon Seo 대한구강악안면외과학회 2013 대한구강악안면외과학회지 Vol.39 No.6

Objectives: Oral and maxillofacial defects often require bone grafts to restore missing tissues. Well-recognized donor sites include the anterior and posterior iliac crest, rib, and intercalvarial diploic bone. The proximal tibia has also been explored as an alternative donor site. The use of the tibia for bone graft has many benefits, such as procedural ease, adequate volume of cancellous and cortical bone, and minimal complications. Although patients rarely complain of pain, swelling, discomfort, or dysfunction, such as gait disturbance, both patients and surgeons should pay close attention to such after effects due to the possibility of tibial fracture. The purpose of this study is to analyze tibial fractures that occurring after osteotomy for a medioproximal tibial graft. Materials and Methods: An analysis was intended for patients who underwent medioproximal tibial graft between March 2004 and December 2011 in Inha University Hospital. A total of 105 subjects, 30 females and 75 males, ranged in age from 17 to 78 years. We investigated the age, weight, circumstance, and graft timing in relation to tibial fracture. Results: Tibial fractures occurred in four of 105 patients. There were no significant differences in graft region, shape, or scale between the fractured and non-fractured patients. Conclusion: Patients who undergo tibial grafts must be careful of excessive external force after the operation.

Treatment of Schatzker Type V and VI Tibial Plateau Fractures Using a Midline Longitudinal Incision and Dual Plating

( Kye Youl Cho ),( Hyun Sup Oh ),( Jae Ho Yoo ),( Duk Hyun Kim ),( Young Joo Cho ),( Kang Il Kim ) 대한슬관절학회 2013 대한슬관절학회지 Vol.25 No.2

Purpose: The purpose of this study was to evaluate the results of the treatment of Schatzker type V and VI tibial plateau fractures using a midline longitudinal incision and dual-plate fixation. Materials and Methods: Ten patients with Schatzker type V and VI tibial plateau fractures treated with a midline longitudinal incision and dual plating were analyzed. The patients were followed for a minimum of one year. Clinical outcomes were evaluated using range of motion, visual analogue scale (VAS) and Knee Society Score. Radiological outcomes were evaluated using the bony union time, medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA). Results: The mean VAS score was 2.2 points, and the mean Knee Society function score was 85 points at the final follow-up. The mean flexion contracture was 2.5o and the mean further flexion was 125o. It took an average of 4 months until bony union occurred. The mean MPTA and PPTA were 90.5o and 4.4o, respectively. There was one case of delayed wound healing, but no other complications were observed. Conclusions: The treatment of Schatzker type V and VI tibial plateau fractures with a midline longitudinal incision and dua -plate fixation resulted in satisfactory clinical and radiological outcomes. This can be an option when treating Schatzker type V and VI tibial plateau fractures.

Ogden Type IV Tibial Tuberosity Fractures in Healthy Adolescents: Preoperative Magnetic Resonance Imaging and 2-Year Clinical Follow-up Study

Jinhee Park,Kunhyung Bae,Soo-Sung Park,Michael Seungcheol Kang 대한정형외과학회 2023 Clinics in Orthopedic Surgery Vol.15 No.3

Background: Ogden type IV tibial tuberosity fractures, defined as a type of fracture with posterior–inferior metaphyseal extension (Salter-Harris type II variant), are uncommon but challenging pediatric fractures. The purpose of this study was to investigate the clinical and radiological presentation and associated surgical outcomes. Methods: Ten previously healthy patients who had been surgically treated at the authors’ institution between 2015 and 2018 with at least 2 years of postoperative follow-up were included. Demographic, clinical, and radiological characteristics and treatment/ follow-up data were investigated. Results: All included patients were male. All injuries resulted from jump-landings. Unacceptable remaining angular deformity after closed reduction, particularly increased posterior tibial slope angle, was the leading cause of surgery. All preoperative magnetic resonance images (MRIs) showed entrapped periosteum on the anteromedial side of the proximal tibial physis. Surgical removal of the entrapped periosteum achieved successful reduction. Metaphyseal fracture angles between the fracture plane of the metaphyseal beak and the posterior tibial condyle on the axial image of MRI were relatively constant, with an average of 24.3° ± 6.0°. Mean bone age at the time of trauma was older than mean chronological age (16.4 ± 1.0 years vs. 14.6 ± 1.1 years, respectively; p = 0.005). All patients reached skeletal maturity within 2 postoperative years, with little posttraumatic residual height growth (mean, 1.6 ± 0.7 cm from injury to skeletal maturity). At final follow-up, no patients showed significant angular deformity, tibial length discrepancy, or functional deficit. Conclusions: In healthy adolescents, Ogden type IV tibial tuberosity fractures typically occur by jump-landing injuries, when they have little residual growth remaining. Therefore, accurate fracture reduction was required because of limited remodeling potential. Patients with unacceptable reduction should be investigated for entrapped periosteum on the anteromedial side of the physis because it was the primary obstacle in achieving adequate reduction.

Intra-operative fractures in primary total knee arthroplasty - a systematic review

Purudappa Prabhudev Prasad,Ramanan Sruthi Priyavadhana,Tripathy Sujit Kumar,Varatharaj Sushrruti,Mounasamy Varatharaj,Sambandam Senthil Nathan 대한슬관절학회 2020 대한슬관절학회지 Vol.32 No.-

Background: One of the rare complications of primary total knee arthroplasty is intra-operative fracture. Intraoperative fracture during revision knee arthroplasty has been well-documented but there is limited literature on fractures occurring during primary knee arthroplasty. We conducted a systematic review of the literature to compare and contrast the various studies to clearly define the predisposing factors, incidence, and characteristics of the fracture itself and to arrive at a consensus on the management and prevention of intra-operative fractures during primary knee arthroplasty. Methods: The PubMed/Medline, Cochrane, Scopus and Embase databases were searched using keywords “intraoperative fracture”, “distal femoral fracture”, “tibial fracture”, “patella fracture” and “primary total knee arthroplasty”. A total of 158 articles were retrieved and after further filtration and exclusion processing, 10 articles that evaluated intra-operative fractures in primary total knee arthroplasty were included for the review. Results: The reported incidence of intra-operative fractures varied from 0.2% to 4.4%. A higher incidence in female patients with a male to female ratio of 0.4 was reported. Posterior stabilized (PS) total knee arthroplasty was associated with higher risk of intra-operative femoral fractures by many authors in this review. Timing of occurrence and location of the intra-operative fractures can vary widely, with femoral fractures occurring more commonly during bone preparation, trialing and impaction of the final implant and tibial fractures occurring during preparation for the tibial keel and impaction of the tibial component. Conclusions: Intra-operative fractures during primary total knee arthroplasty are rare with higher risk associated with osteoporosis, rheumatoid arthritis, advanced age, female gender, chronic steroid use, metabolic bone disorders, PS type of femoral implant and difficult surgical exposure of the knee joint due to severe deformities. A plethora of management options have been utilized according to surgeon preference. Standard principles of fracture fixation and arthroplasty principles should be followed to achieve stable internal fixation and any unstable fracture site should be bypassed with the utilization of stemmed components. Satisfactory radiographic and functional outcome can be expected with appropriate treatment.

개방성 경골 간부 골절의 임상적 고찰

조광희,강수일,이강현,오종건 최신의학사 1987 最新醫學 Vol.30 No.9

경골 원위부 골절에서 석회화된 전경골 동맥의 포착 -증례 보고-

양규현 ( Kyu Hyun Yang ),원유건 ( Yougun Won ),김상범 ( Sang Bum Kim ),박원근 ( Won Kuen Park ),정유선 ( You Sun Jung ) 대한골절학회 2016 대한골절학회지 Vol.29 No.1

경골 원위부에서 전경골 동맥은 전경골 표면에서 가까이 전외측 방향으로 주행한다. 임상적 상황에서 혈관 자체에 대한 평가없이는 전경골 동맥의 손상이나 포착은 쉽게 판단하기 어려운 경우가 많으며 이는 후경골 동맥으로 측부 분지되어 혈류를 공급받는 족배동맥의 촉지가 잘 유지되기 때문이다. 포착된 전경골 동맥은 응급실에서 비관혈적 정복술을 시행하거나 수술실에서 관혈적 정복술 및 내고정술을 시행하는 과정에서 의인성 손상으로 이어질 수 있다. 이를 방지하기 위해서는 포착 가능성에 대한 주의를 필요로 한다. 본 증례에서 우리는 조영제 없이도 석회화로 인해 단순 방사선 영상 및 컴퓨터 단층촬영에서 포착된 전경골의 드문 예를 경험하여 보고하고자 한다. In the distal third of the tibia, the anterior tibial artery runs close to the anterolateral surface of the tibial cortex. In a clinical situation, without vascular evaluation, injury or entrapment of the anterior tibial artery is difficult to detect. Because, an intact dorsalis pedis pulse is supplied with the collateral vessels of the posterior tibial artery. An entrapped anterior tibial artery can be injured during closed reduction in an emergency room or open reduction and internal fixation in the operating room. Care must be taken to prevent iatrogenic anterior tibial artery. In this case, an entrapped anterior tibial artery was observed in a simple radiograph and computed tomograph without contrast media for the vessel. We report on a rare case of calcified anterior tibial artery entrapment in a distal tibial fracture.

경골 고평부 골절에서 자기 공명 영상을 이용한 골절 행태 및 연부조직 손상의 평가

전지용 ( Ji Yong Chun ),박희곤 ( Hee Gon Park ),황성수 ( Sung Su Hwang ) 대한골절학회 2007 대한골절학회지 Vol.20 No.4

목적: 경골 고평부 골절에서 단순 방사선 사진과 MRI에서의 골절 형태에 대한 정보를 비교하여 골절 형태와 동반된 연부조직 손상을 평가하여, MRI의 유용성을 알아보고자 하였다. 대상 및 방법: 경골 고평부 골절로 MRI를 시행하였던 68예를 대상으로 단순 방사선 사진과 MRI에서 Schatzker 골절형, 관절면의 함몰, 골절편의 전위를 비교하였고, MRI에서 슬관절부의 연부조직 손상을 조사하였다. 결과: 단순 방사선 사진의 Schatzker 골절형이 MRI에서 변경된 경우가 7예 있었으며 관절면의 함몰은 단순 방사선 사진에서 평균 2.93 ㎜, MRI에서 평균 4.28 ㎜로 1.35 ㎜ 증가되어 통계학적으로 의미가 있었다 (p<0.05). 골절편의 전위는 유의한 차이가 없었다 (p=0.168). MRI에서 인대 및 반월상 연골 손상은 58예 (85.3%)에서 발견되었다. 결론: 경골 고평부 골절에서 MRI는 추가의 골절선이나 함몰을 발견할 수 있어 골절 분류가 바뀔 수 있고, 관절면의 함몰과 연부조직 손상에 대한 정보를 제시하여 수술적 치료 계획을 세우는 데 많은 도움이 된다. 경골 고평부 골절 시 수술 전에 MRI를 시행하는 것이 보다 나은 골절 치료와 연부 조직의 치료를 위하여 반드시 필요하다고 생각한다. Purpose: To compare information about fracture type in MRI with simple radiograph in tibial plateau fractures and evaluate tibial plateau fractures type and accompanying soft tissue injury, and evaluate usefulness of MRI in tibial plateau fractures. Materials and Methods: Compared MRI with simple radiograph about Schatzker classification, depression of articular surface and displacement of bone fragment from the 68 examples who checked MRI and we evaluated soft tissue injury around knee joint. Results: There were 7 examples of Schatzker type change after MRI check. Average depression of articular surface in simple radiograph was 2.93 ㎜ and 4.28 ㎜ in MRI. It in creased by 1.35 ㎜ and it was meaningful statistically (p<0.05). There was no significant difference between MRI and simple radiograph of displaced bone fragment (p=0.168). There were 58 (85.3%) cases of soft tissue injury in MRI. Conclusion: MRI can find additional fracture line or articular depression that can`t be found in simple radiograph and gives more information about articular depression and soft tissue that is useful in surgical plans. I think preoperative MRI is necessary to better treatment of fracture & treatment of periarticular soft tissue injury in tibial plateau fracture.

Fibular Fixation in Same-Level Distal Third Tibiofibular Fractures: Is Fibular Fracture Regarded as a Secondary Importance?

Jin Woo Lee,Seong-Eun Byun,Young-Woo Kim,Young-Soo Byun,Yong-Cheol Yoon,Hoon-Sang Sohn 대한정형외과학회 2023 Clinics in Orthopedic Surgery Vol.15 No.5

Background: Although most studies focused on the alignment or union of the tibia in same-level distal third tibiofibular fractures, the outcome of a concomitant fibular fracture is generally regarded as being of secondary importance in the literature. This study aimed to assess the outcomes of fibular fractures in same-level distal third tibiofibular fractures. Methods: In this retrospective study, we enrolled 111 patients with same-level distal third tibiofibular fractures treated at our institute between January 2016 and August 2020. Tibial fractures were stabilized with intramedullary nailing, and the cases were divided into two groups based on whether they additionally underwent fibular fixation (group 1, 57 cases) or not (group 2, 54 cases). Clinical and radiographic outcomes were used for the evaluation of tibial and fibular alignments, union of the tibia and fibula, number of interlocking screws in the distal tibial fragment, range of motion of the ankle joint, and complications. Results: No statistically significant differences in the tibial union rate or mean tibial alignment were observed between the two groups on either the immediate postoperative or final radiographs. The fibular union rate in group 1 was significantly higher than that in group 2 (fibular nonunion, 0 vs. 15; p < 0.001). Statistically significant differences in fibular displacement were observed on immediate postoperative radiographs between patients with fibular union and those without it. At the final follow-up, the mean range of ankle motion and lower extremity functional scale scores did not differ between the two groups. Conclusions: Regardless of whether fibular fixation was performed, the overall tibial alignment with intramedullary nailing was well restored and the union rate of the tibia was comparable in the two groups. Fibular nonunion is not uncommon in unfixed fibula fractures. Displacement of the fibula as seen on immediate postoperative radiographs was related to fibular nonunion.