UNASSIGNED: Although the proximal tibia is a common site for intraosseous (IO) line placement in pediatric patients, previously published data indicate high malposition rates in infants and children at this location. Although distal femur IO lines generally demonstrate higher flow rates than those at the proximal tibia, to date, there have been no published studies assessing distal femur IO access in pediatric patients. Thus, we aimed to compare the success rates of pediatric IO line insertion attempts between the proximal tibia and the distal femur in a prehospital setting.
UNASSIGNED: We conducted a retrospective chart review of prehospital pediatric patients who underwent at least one IO line placement attempt by Palm Beach County Fire Rescue from May 2015 to January 2024. We excluded records lacking specific documentation of IO attempt location. We compared the unadjusted success rates of distal femur to proximal tibia, and we also compared success rates after propensity score matching and multivariable logistic regression. Secondarily, we assessed the prehospital complication rate of the IO lines at each anatomical site.
UNASSIGNED: We identified 163 pediatric patients who had an IO attempt and were eligible for analysis. Median age was 1.9 years (IQR: 0.46 to 4.2 years). Among those 163 patients, there were 234 vascular access attempts, including 82 IO attempts at the distal femur and 72 at the proximal tibia. The unadjusted success rate of distal femur attempts was 89.0%, compared to 84.7% for proximal tibia attempts, a difference of 4.3% (95% CI -6.4 to 15.0%). After propensity score matching, we found an adjusted odds ratio of 2.0 (95% CI 0.66 to 6.8), favoring the distal femur for successful placement. Prehospital complication rates were similar for distal femur (5.5%) and proximal tibia (4.9%).
UNASSIGNED: This retrospective analysis of pediatric patients in a prehospital setting suggests that IO line placement at the distal femur might offer a marginally higher success rate compared to the proximal tibia. Despite not reaching statistical significance, these findings support the consideration of distal femur as a viable option for IO placement in the pediatric population.

BACKGROUND: The aim of total knee arthroplasty (TKA) is to circumvent the pain due to advanced osteoarthritis of the knee joint and correct the limb alignment and biomechanics to improve patients\' quality of life. Apart from medio-lateral balancing, balancing flexion and extension gaps is a prerogative to achieve good results. This study proposes a novel surgical technique of postero-central slice osteotomy of the proximal tibia (PCSO-PT) for correcting tight extension gaps in posterior-stabilized (PS) knees and assesses its clinical and functional outcomes.
METHODS: A prospective study was conducted on 84 consecutive knees with tricompartmental osteoarthritis and varus deformity, requiring PCSO of the proximal tibia during PS TKA between January 2016 and July 2018. Knee Society scores, flexion deformity, range of motion, antero-posterior instability, and complications were assessed at regular intervals for a minimum of two years postoperatively.
RESULTS: Residual flexion deformities less than 11° after posterior capsular release were successfully corrected by the osteotomy. The mean preoperative flexion deformity of 18.1 ± 2.5° improved to 8.6 ± 2.2° intraoperatively after posterior capsular release from the femoral end and to 0.65 ± 0.76° intraoperatively immediately after the osteotomy, with no residual flexion deformity noted in any patient six weeks postoperatively. It had no negative effect on the significant post-TKA improvement of the mean Knee Society score from 32 ± 12 preoperatively to 94 ± 3 at the terminal follow-up. A direct correlation between preoperative flexion deformity and a resistant, tight extension gap (P = 0.003) was noted. There was no increase in coronal plane or sagittal plane instabilities in midflexion or on mobilization throughout the follow-up period, nor were any major adverse effects noted in this period.
CONCLUSIONS: A postero-central slice osteotomy of the proximal tibia is an effective and safe alternative to overcoming tight extension during TKA after femoral-end capsular release, instead of capsular release from the tibial end or midcapsular region.

OBJECTIVE: This study compared outcomes of locked plating (LP) versus intramedullary nailing (IMN) techniques for treatment of extra-articular proximal-third tibia fractures.
METHODS: Data Sources: PubMed, Ovid MEDLINE STUDY SELECTION: Studies were included if they compared LP and IMN fixation for proximal one third tibial shaft fractures without articular extension or with simple articular extension into the tibial plateau. Minimum 1 year of clinical and radiographic follow up was used.
METHODS: Outcomes assessed included operative duration, postoperative knee range of motion (ROM), union outcomes (time to union, nonunion, malunion, delayed union), and incidence of postoperative complications (superficial and deep infection, secondary surgical intervention, compartment syndrome).
RESULTS: Separate random-effects meta-analyses were conducted for each outcome. For categorical data, relative risks were used whereas the standardized mean difference was used for continuous variables, with corresponding 95 % confidence intervals.
RESULTS: 7 studies were included reporting the outcomes of 319 patients treated with LP and 300 treated with IMN. IMN fixation had significantly shorter time to union (p = 0.049) and lower risk for superficial infection (p = 0.028). However, LP conferred a significantly lower risk for malunion (p = 0.017) and postoperative compartment syndrome (p = 0.018).
CONCLUSIONS: IMN demonstrated significantly shorter time to union and lower risk of superficial infection when treating extra-articular proximal tibia fractures, while LP fixation demonstrated significantly lower risk for malunion and postoperative compartment syndrome. Although successful results can be achieved with good technique in LP and IMN fixation, a significant complication profile exists with these fractures regardless of construct choice.
METHODS: Therapeutic Level III.

Giant cell tumors (GCTs) of the bone present unique challenges in management due to their locally aggressive nature and potential for recurrence. This case report describes the successful surgical management of a GCT located in the proximal tibia of a 28-year-old female. The patient presented with six months of pain and swelling following a traumatic injury to the knee. Diagnostic imaging confirmed the presence of a GCT, leading to preoperative prophylactic embolization to reduce intraoperative bleeding. Surgical excision of the tumor was performed, followed by reconstruction using autologous fibula grafts and plate fixation. Postoperative care included analgesia, antibiotics, and physiotherapy. Regular follow-up demonstrated satisfactory clinical outcomes without evidence of recurrence. This case highlights the importance of a multidisciplinary approach combining surgical expertise, preoperative planning, and postoperative rehabilitation to achieve favorable outcomes in managing GCTs.

Introduction Total knee arthroplasty is the standard of care treatment for advanced knee osteoarthritis. However, patients frequently continue to have pain and disability after surgery, with one of the most common reasons being a bone-implant mismatch. Notably, there is a significant difference reported in proximal tibia morphometry between Asian and Caucasian populations, and the currently available implants do not account for the anthropometric variations observed across ethnicities. We aimed to evaluate the proximal tibia anthropometry in a Pakistani population. Materials and methods A study was conducted at The Indus Hospital, Karachi Campus, from August 2019 to July 2020. All consecutive patients fulfilling the eligibility criteria and undergoing knee replacement surgery were included in the study. Baseline characteristics and anthropometry of proximal tibia were recorded on a pre-designed proforma. Statistical analysis was done using SPSS version 24. Results  A total of 30 patients were enrolled in this study, which included 17 females (56.7%) and 13 males (43.3%). The mean age was 61.6± 7.9 years and the BMI was 33±5.7 kg/m2. There was a significant difference found in the anteroposterior and mediolateral dimensions in both genders. A significant association was noted with body mass index (p-value 0.01) and occupation (p-value=0.02). Conclusion The results indicated that the anatomical profile of the proximal tibia in the Pakistani population is distinct, thus stressing the fact that it requires developing prostheses specifically tailored to this population\'s sizing requirements.

BACKGROUND: Patients are often instructed to avoid weight bearing on the proximal tibia for 6 - 12 weeks post-surgery to avoid fracture fixation failure. However, delayed weight bearing leads to delayed mobility, causing difficulties in daily activities; problems such as pain, limited knee ROM, reduced quadriceps muscle strength, and impaired functional outcomes are reported in long-term follow-up. This study primarily aimed to evaluate the feasibility and explore the effect size. The secondary aim was to determine the effectiveness of early weight bearing along with conventional physiotherapy on functional outcomes.
METHODS: A single-blinded pilot randomized controlled trial with 30 participants with proximal tibia type I, II, and III fractures were included; they were randomized using computer-based software. Seven patients were lost to follow-up. Group I received early weight bearing along with conventional physiotherapy whereas Group II received restricted weight bearing along with conventional physiotherapy. Assessments were made on post-operative day 3 (POD-03), at discharge, at 6 weeks, and at 12 weeks. Radiographs were recorded immediately after the operation, at discharge, and at 12 weeks.
RESULTS: A full-scale RCT is feasible with an effect size between 0.3 - 0.7. A statistically significant difference (p < 0.05) was found within both groups 12 weeks post-surgery in all outcome measures; the difference was more prominent in the intervention group. A statistically significant difference (p < 0.05) was found between both the groups post-12 weeks in all outcome measures except quadriceps isometric muscle strength.
CONCLUSIONS: A full-scale RCT for early weight bearing along with conventional physiotherapy for patients operated for Type I, II, and III proximal tibia fracture is feasible. Early weight bearing along with conventional physiotherapy could have a positive effect on reducing patient\'s pain perception and increasing knee joint mobility, quadriceps isometric muscle strength, knee function, and quality of life without any adverse effects.
BACKGROUND: ClinicalTrialsRegistry.gov (CTRI/2022/10/046797).

BACKGROUND: The advent of three-dimensional (3D)-printed custom-made implants has revolutionized orthopaedic surgery, particularly in limb- and joint-sparing surgeries. However, clinical experience in the revision for 3D-printed implant breakage is lacking, and the revision surgery remains challenging. This study reported the revision of proximal tibial prosthetic reconstruction necessitated by solid-body breakage of a 3D-printed implant, aiming to detail the surgical techniques and evaluate postoperative outcomes.
METHODS: A patient diagnosed with osteosarcoma underwent joint-sparing surgery with a 3D-printed implant, but implant breakage occurred during subsequent follow-up. The initial implant was broken into two parts: the proximal implant breakage part (IBP) integrated with the host bone and the distal IBP left in the prosthetic component. Four revision protocols were devised, each based on one of the four hypothesis results of taking out the initial implant. A new custom-made implant and a series of assistance devices (\"positioning devices,\" \"drill devices,\" \"tap devices,\" and \"separator devices\") were specifically prepared for revision surgery. The proximal IBP was taken out from the host bone, but the distal IBP was not taken out from the initial prosthetic component. The patient received the new custom-made implant for reconstruction, with the knee joint preserved. The patient recovered uneventfully after revision surgery and achieved satisfactory function. The Musculoskeletal Tumor Society was 28 at the last follow-up. No complications were detected during the follow-up period.
CONCLUSIONS: Comprehensive preoperative planning and preparation, enabling the surgeon to effectively address intraoperative challenges, are crucial for the successful revision of 3D-printed implant breakage. It is feasible to re-implant a 3D-printed custom-made implant, demonstrating satisfactory clinical and functional results.

To date, insufficient investigation has been carried out on the biocompatibility of synthetic bioactive bone substitute materials after traumatically induced bone fractures in clinical conditions. This study encompasses the safety, resorption, healing process, and complications of surgical treatment. Our current hypothesis posits that calcium phosphate-based bone substitutes could improve bone healing. In this retrospective case-control study, over 290 patients who underwent surgical treatment for acute fractures were examined. Bone defects were augmented with calcium phosphate-based bone substitute material (CP) in comparison to with empty defect treatment (ED) between 2011 and 2018. A novel scoring system for fracture healing was introduced to assess bone healing in up to six radiological follow-up examinations. Furthermore, demographic data, concomitant diseases, and complications were subjected to analysis. Data analysis disclosed significantly fewer postoperative complications in the CP group relative to the ED group (p < 0.001). The CP group revealed decreased risks of experiencing complications (p < 0.001), arthrosis (p = 0.01), and neurological diseases (p < 0.001). The fracture edge, the fracture gap, and the articular surface were definably enhanced. Osteosynthesis and general bone density demonstrated similarity (p > 0.05). Subgroup analysis focusing on patients aged 64 years and older revealed a diminished complication incidence within the CP group (p = 0.025). Notably, the application of CP bone substitute materials showed discernible benefits in geriatric patients, evident by decreased rates of pseudarthrosis (p = 0.059). Intermediate follow-up evaluations disclosed marked enhancements in fracture gap, edge, and articular surface conditions through the utilization of CP-based substitutes (p < 0.05). In conclusion, calcium phosphate-based bone substitute materials assert their clinical integrity by demonstrating safety in clinical applications. They substantiate an accelerated early osseous healing trajectory while concurrently decreasing the severity of complications within the bone substitute cohort. In vivo advantages were demonstrated for CP bone graft substitutes.

Even though, proximal tibia is a common site of giant cell tumor and bone fractures, following tumor removal, nonetheless very little attention has been paid to affecting factors on the fracture risk. Here, nonlinear voxel-based finite element models based on computed tomography images were developed to predict bone fracture load with defects with different sizes, which were located in the medial, lateral, anterior, and posterior region of the proximal tibia. Critical defect size was identified using One-sample t-test to assess if the mean difference between the bone strength for a defect size was significantly different from the intact bone strength. Then, the defects larger than critical size were reconstructed with cement and the mechanics of the bone-cement interface (BCI) was investigated to find the regions prone to separation at BCI. A significant increase in fracture risk was observed for the defects larger than 20 mm, which were located in the medial, lateral and anterior regions, and defects larger than 25 mm for those located in the posterior region of the proximal tibia. Furthermore, it was found that the highest and lowest fracture risks were associated with defects located in the medial and posterior regions, respectively, highlighting the importance of selecting the initial location of a cortical window for tumor removal by the surgeon. The results of the BCI analysis showed that the location and size of the cement had a direct impact on the extent of damage and its distribution. Identification of critical regions susceptible to separation at BCI, can provide critical comments to surgeons in selecting the optimal cement augmentation technique, which may ultimately prevent unnecessary surgical intervention, such as using screws and pins.

Over the past decades, numerous structural changes in implants, medical treatments, and surgical techniques have been made for Malignant Bone Tumors (MBT) around the knee. However, the overall care improvement is still unclear. The method is crucial when analyzing outcomes in surveys involving tumors, and a thorough assessment of the mortality is mandatory because death acts as competing event. The aims of this study were: 1) a comprehensive and longitudinal assessment of the revisions with an extensive follow-up and adequate methods; 2) a complete mortality review to consider competing risks.
The hypothesis was that some prosthesis\'s structural improvements were made while the surgical toll increased as well as an improvement of mortality was also expected.
Analyses were performed on 248 patients with MBT (mean follow-up was 8.7 years, surgeries between 1972 and 2017). Three prosthesis models were successively used over time: 120 Guepar (older model), 42 Tornier, and 86 Stanmore (more recent model). The primary outcome was the assessment of revisions sorted out according to Henderson: type-1 soft-tissue failures or instability, type-2 aseptic loosening, type-3 structural failures, type-4 periprosthetic infections, type-5 tumoral progression. Death and amputations were considered as competing events. An extensive assessment of mortality was performed by merging the dataset with the French register of Deaths (INSEE). Cumulative probabilities were computed at 2, 5, 10, and 15 years and compared with Gray\'s tests.
The overall 5-year survival was, 80% (95% CI: 73-87) for Guepar, 69% (95% CI: 56-84) for Tornier, and 71% (95% CI: 62-82) for Stanmore (p=0.4). The 5-year cumulative risks for type-1 were 5% (95% CI: 1-9), 9% (95% CI: 0-18), and 17% (95% CI: 9-25) for Guepar, Tornier, and Stanmore, respectively (p=0.01). The 15-year cumulative risks for type-2 were 22% (95% CI: 15-39), 8% (95% CI: 0-17) and 8% (95% CI: 2-14) for Guepar, Tornier, and Stanmore, respectively (p=0.10). Ten patients had an implant failure, nine Guepar, and one Tornier. The 5-year cumulative risks for type-4 were 7% (95% CI: 2-12), 19% (95% CI: 7-31), and 12% (95% CI: 5-18) for Guepar, Tornier, and Stanmore, respectively (p=0.08). There were 29 tumoral progressions; the 15-year risks were 16% (95% CI: 2-22), 2% (95% CI: 0-7%), and 12% (95% CI: 4-19%) for Guepar, Tornier, and Stanmore, respectively (p=0.08). No difference whatsoever was found between the proximal tibial and distal femur.
There were some improvements in prosthesis design (forged steel instead of cast steel) and probably also in cemented stem fixation, but not in prosthetic joint infection and local recurrence over forty years. The overall mortality did not change significantly over the last 40 years amongst this specific cohort of patients who benefited from a hinge reconstruction prosthesis.
III; comparative case series with sensibility analysis.