Cases reported "Tibial Fractures"

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1/16. Prevention of skin and soft tissue entrapment in tibial segment transportation.

    We report of a ten year old patient with soft tissue damage and bone defect of the tibia as a sequel of osteomyelitis. After excision and stabilization with an Ilizarov fixateur segment transportation was started. In order to avoid skin and soft tissue entrapment in the docking region, we used a metal cage as a space provider, which was shortened as segment transportation progressed. To our knowledge this simple method has not been described so far.
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2/16. Modified arthroscopic suture fixation of displaced tibial eminence fractures using a suture loop transporter.

    Current arthroscopic suture fixation techniques of tibial eminence fractures are time consuming and the number of anchor sutures that can be placed is limited by the cumbersome and repetitive numerous needle threading steps. This occurs at 2 stages: first, when placing anchoring sutures through the avulsed anterior cruciate ligament stump with a suture punch, and second, when there is a need to traverse the tibial bone canal with the suture ends. We describe a modification that reduces the reliance on conventional rigid instruments and instead uses a loop transporter made from readily available suture material. The suture loop transporter being malleable reduces the necessary width of the tibial bone canal to be made and has a further advantage of minimizing the bone loss during the reaming of the bone tunnel. The subsequent potential for a stress fracture at these tunnel sites is also substantially reduced. Our technique is more user friendly, more accurate, and quicker to perform.
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3/16. The "floating ankle": a pattern of violent injury. Treatment with thin-pin external fixation.

    The "floating ankle" is an underappreciated pattern of injury that results from violent trauma and/or blast injuries in military personnel. It is characterized by an intact ankle mortise with a distal tibia fracture and an ipsilateral foot fracture, creating instability around the ankle. This pattern of injury may be the result of the military boot, which both protects the foot from immediate amputation or further injury and renders the distal tibia susceptible to fracture at the boot top. Four patients with open floating ankle injuries were treated with thin-pin circular fixation with good results. Two patients required bone transport for segmental loss. All patients are ambulatory without assistance or bracing. Thin-pin external fixation is a reasonable approach to this complex injury pattern, especially in the presence of marked soft tissue compromise with or without segmental bone loss.
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4/16. The ilizarov technique in the treatment of tibial bone defects. case reports and review of the literature.

    Autogenous cancellous bone grafting has long been the hallmark of skeletal defect management. Unfortunately, the small number of donor sites in the human body constitutes an absolute limit on the quantity of fresh autogenous cancellous bone available for filling a segmental defect. In addition, the donor sites are always a source of discomfort and morbidity for the patients. Intercalary defects resulting from trauma, infection or tumour can be treated with transport of a segment of bone within the limb using the ilizarov technique. We report on three cases of local bone transportation for intercalary tibial defects by the Ilizarov method.
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5/16. Treatment of infected tibial nonunions with debridement, antibiotic beads, and the Ilizarov method.

    This study of 10 patients presents the early results of a protocol of debridement, antibiotic bead placement, and use of the Ilizarov method with a circular external fixator for treatment of infected nonunions of the tibia in a military population. The nonunions resulted from high-energy fractures in nine cases and an osteotomy in one. The Ilizarov techniques used were transport (five cases), shortening and secondary lengthening (two cases), minimal resection with compression (one case), and resection with bone grafting (two cases). Flap coverage was required for five patients. There were two recurrences of infection (20%) among patients with the most compromised soft tissue. Only 50% of patients were able to perform limited duties while wearing the external fixator. Only four patients returned to active duty; however, three patients from special operations units were able to return to jump status. Six patients underwent medical retirement because of insufficient function, resulting from decreased ankle or knee range of motion and arthrosis or muscle weakness.
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6/16. Reconstruction with distraction osteogenesis for juxta-articular nonunions with bone loss.

    BACKGROUND: Nonunions of a juxta-articular lesion with bone loss, which represent a challenging therapeutic problem, were treated using external fixation and distraction osteogenesis. methods: Seven juxta-articular nonunions (five septic and two aseptic) were treated. The location of the nonunion was the distal femur in four patients, the proximal tibia in one patient, and the distal tibia in two patients. All of them were located within 5 cm from the affected joints. Preoperative limb shortening was present in six cases, averaging 2.9 cm (range, 1-7 cm). The reconstructive procedure consisted of refreshment of the nonunion site, deformity correction, stabilization by external fixation, and lengthening to eliminate leg length discrepancy or to fill the defect. Shortening-distraction was applied to six patients and bone transport to one patient for reconstruction. Intramedullary nailing to reduce the duration of external fixation was simultaneously performed in two cases. All the patients had at least 1 year of follow-up evaluation. RESULTS: Osseous union without angular deformity or leg length discrepancy greater than 1 cm was achieved in all patients. The mean amount of lengthening was 5.8 cm (range, 2.2-10.0 cm). The mean external fixation period was 219 days (range, 98-317 days), and the mean external fixation index was 34.4 days/cm (range, 24.5-47.6 days/cm). All patients reported excellent pain reduction. There were no recurrences of infection in five patients with prior history of osteomyelitis. The functional results were categorized as excellent in two, good in three, and fair in two. CONCLUSION: Despite the length of postoperative external fixation, distraction osteogenesis can be a valuable alternative for the treatment of juxta-articular nonunions.
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7/16. [Primary Ilizarov ankle fusion for nonreconstructable tibial plafond fractures]

    OBJECTIVE: Ankle arthrodesis in a plantigrade position. In high-energy open injuries with segmental bone loss: proximal tibial metaphyseal corticotomy with distal Ilizarov bone transport for compensation of leg length discrepancy. INDICATIONS: Posttraumatic loss of the tibial plafond, usually resulting from open fracture type IIIC. CONTRAINDICATIONS: Ipsilateral foot injuries impairing ambulation after fusion. Severe injury to the posterior tibial nerve with absent plantar sensation. Soft-tissue injury not manageable surgically. Inadequate patient compliance. Advanced age. Severe osteoporosis. Acute infection. SURGICAL TECHNIQUE: Standard technique: anteromedial longitudinal incision. Removal of remaining articular cartilage. Passing of Ilizarov wires through the distal fibula, talar neck and body. Placement of 5-mm half-pins through stab incisions, perpendicular to the medial face of the tibial shaft. A lateral to medial 1.8-mm Ilizarov wire in the proximal tibial metaphysis is optional. Callus distraction/Ilizarov bone transport: exposure through an anteromedial incision or transverse traumatic wound. Removal of small residual segment of tibial plafond blocking transport. Retain small vascularized bone fragments not blocking transport. For Ilizarov external fixation, two rings in the proximal tibial region. Drill osteoclasis of the tibial metaphysis 1 cm distal to the tibial tuberosity and complete with Ilizarov osteotome. Secure the Ilizarov threaded rods or clickers. Weight bearing as tolerated. Begin distraction 14 days after corticotomy at a rate of 0.5-1 mm per day depending on patient's age. After docking: Ilizarov ankle arthrodesis. RESULTS: Between January 1993 and September 1996, four patients (two men, two women) with severe, nonreconstructable fractures of the tibial plafond were treated. Callus distraction and Ilizarov bone transport in three patients. Age range 19-68 years (average age 45.7 years). Mean follow-up 6.6 years (4 years 9 months to 7 years 4 months). Average duration of the entire treatment in external fixation 54.4 days/cm for the three bone distraction patients. Mean transport 6 cm (4.5-8.5 cm). One patient required repeat ankle arthrodesis.
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8/16. Devastating massive knee defect reconstruction using the cornucopian chimera flap from the subscapular axis: two case reports.

    Two cases of successful reconstruction of massive defects around the knee with multiple-island combined flaps based on the subscapular axis are reported. Both defects resulted from aggressive debridement for acute osteomyelitis after open fixation of high-energy fractures around the knee. In Case 1, a four-island combined flap consisting of the scapular flap, the lattissimus dorsi muscle flap, the serratus anterior muscle flap, and the scapular osseous flap, based on the same subscapular axis, was used. Partial bone transport using the Ilizarov apparatus was added as reinforcement of arthrodesis. In Case 2, a five-island combined flap, consisting of the scapular, parascapular flap, the lattissimus dorsi muscle flap, the serratus anterior fascial flap, and the scapular osseous flap, was used. Consequent ankylosis of the knee joint afforded the patient painless full weight bearing without secondary arthrodesis. Multiple-island combined flaps based on the subscapular axis can provide three-dimensional reconstruction of destructive knee defects.
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9/16. Medial fibula transport with the Ilizarov frame to treat massive tibial bone loss.

    Massive segmental tibial bone loss from trauma, tumor, or infection is a limb-threatening situation. It is a considerable surgical challenge, especially when associated with extensive skin and soft tissue damage. amputation was the only solution in the past, but current limb-salvage options include contralateral or ipsilateral microvascularized or free-fibular transfer. However, these methods are not without risks and disadvantages. We report seven patients with massive tibial bone loss treated by gradual medial transport of the ipsilateral fibula using an Ilizarov traction apparatus with olive wires after proximal and distal fibular osteotomies. This method has the advantages of avoiding surgery on the contralateral limb while allowing early weightbearing because of the stability of the Ilizarov frame. hypertrophy of the transported fibula accompanied by full weightbearing and satisfactory joint motion occurred in all patients. All patients were satisfied with the results, and none thought amputation would have been a better treatment. The minimum followup was 5 years. We think the Ilizarov frame for ipsilateral fibular gradual transport is a reasonable alternative for limb salvage in patients with massive tibial bone loss. LEVEL OF EVIDENCE: Therapeutic Study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.
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10/16. Tibial defects. Reconstruction using the method of Ilizarov as an alternative.

    Although used in the ussr since the 1950s, the method of Ilizarov has only recently been employed in north america to manage bone defects. Seven cases of patients with tibial bone defects are presented (five with deep infection) that were treated by gradual compression at the defect with one or two transported tibial segments that not only filled the tibial defect but preserved or regained the original bone length. Six of the seven patients had their defect obliterated while leg length was maintained. The method is minimally invasive, allows immediate weight-bearing and permits modifications in strategy while treating the bone defects but requires close attention to detail and has a steep learning curve.
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