Results of tibia nailing with Angular Stable Locking Screws (ASLS); A retrospective study of 107 patients with distal tibia fracture.
|
|
- Kelly Poole
- 6 years ago
- Views:
Transcription
1 Results of tibia nailing with Angular Stable Locking Screws (ASLS); A retrospective study of 107 patients with distal tibia fracture. stud. med. David Andreas Lunde Hatfield stud. med. Mohammed Sherif Supervisor M.D. Michael Brix, Department of Orthopaedic Surgery, Odense University Hospital, Denmark Words: 3452
2 Abstract Aim of project The aim of the study was to present early and mid-term experiences and results of tibial nailing combined with angular stable locking screws (ASLS) in distal tibial fractures. Fracture types AO42 and AO43 were included except AO43 B2,B3 and C3. To explore whether this treatment provides stable conditions, which has been shown in biomechanical studies. Furthermore, to show whether ASLS provides a favourable postoperative course with fewer complications, optimal healing, high union rate and lower rate of secondary loss of reduction. Background Therapy with ASLS is widely used. At present there are no published clinical data to be found in the relevant literature. Several biomechanical studies have been carried out showing positive results and capacities of the ASLS. Due to the lack of clinical data presented in the literature the study is considered to be highly relevant to promote quality assurance as well as evidence of effectiveness and safety of the method. Current standard treatment of tibia fractures involves a high rate of unwanted complications and non-unions. The most distally located fractures, as well as intraarticular fractures are commonly treated with tibial plate. Alternatively, a treatment with intramedullary nailing together with fibula plate is chosen. Both these methods are followed by a high rate of non-union and complications. Methods During the period from September 2009 until June 2014 a consecutive series of 107 patients with AO42 and AO43 fractures were treated with Synthes Expert Tibial Nail combined with ASLS screws. One patient was lost to follow up. Two patients were excluded due to earlier operation on the affected bone. All fractures except 14 were preoperatively CT scanned analysing the presence of intraarticular fracture involvement as well as the pattern of the fracture. The patients followed a post-operative control programme including X-ray and clinical control until healing. The average follow-up time was 38,3 months. All patients except eight were followed for at least a year. However, these eight patients have confirmed healing at present. Results All 104 patients experienced healing. No patients had non-union. 37 patients were reoperated; 34 patients because of minor complications and three patients because of major complications. Two patients had perioperative complications. Two patients had malunion. One patient missed the follow-up X-ray. Conclusion We found 100% union with an average of 5,1 months to healing and a low rate of complications. In particular, a low rate of infection (one patient) was found. However, 37 of 104 patients were re-operated, mostly due to local irritation around the osteosynthesis material. This suggests that the treatment could possibly become a standard procedure in the future for distal tibia fractures. Such fractures are traditionally treated with plating and external fixation methods, which has shown relative high rates of reoperation and complications. 2
3 Index Abstract...2 Introduction...4 Objectives...4 Tibia fracture...4 Current research...5 ASLS; technique and method...5 Materials and method...6 Results...7 Discussion...7 Missing data...7 Study limitations...8 Conclusion...8 Figure and charts...9 References
4 Introduction Treatment with Angular Stable Locking Screws (ASLS) has in recent years been introduced as an alternative to current standard treatment of distal tibia fractures. At present (November 20, 2014) there are no published clinical data to be found in the relevant literature (PubMed, Cochrane Library). Several biomechanical studies have been carried out showing positive results and capacities of the ASLS Due to the lack of clinical data presented in the literature this study is considered to be highly relevant to promote quality assurance as well as evidence of effectiveness and safety of the method. Current standard treatment of tibia fractures involves a high rate of unwanted complications and non-unions 3. The most distally located fractures, as well as intra-articular fractures are commonly treated with tibial plate. Alternatively, a treatment with intramedullary nailing together with fibula plate is chosen. Both these methods are followed by a high rate of non-union and complications Objectives The aim of the study was to present early and mid-term experiences and results of tibial nailing combined with angular stable locking screws (ASLS) in distal tibia fractures. Fracture types AO42 and AO43 were included except AO43 B2, B3 and C3. The study aims to explore whether this treatment provides stable conditions, which has been shown in biomechanical studies Furthermore, to show whether ASLS provides a favourable post-operative course with fewer complications, optimal healing, high union rate and lower rate of secondary loss of reduction. Tibia fracture Tibia fractures are among the commonest of long bone fractures accounting for an estimated 40% of all lower limb fractures 1. With approximately cases per year and an average incidence of 26 tibia fractures per per year in the USA it represents a major burden on the health care system 2. The following epidemiological data show particular age and sex differences 2. The overall average age of patients with tibia fracture is 37 years, with an average age of 31 years among men and 54 years among women. Interestingly, there are two peaks in the incidence distribution. The first peak represents dominance among young males aged with an incidence of 109 cases per A second peak is seen among the female population older than 80 years. This second peak is commonly acknowledged to be related with osteoporosis. Tibia fractures are regarded as one of the most challenging to be treated by the orthopedic surgeon. As a common injury it does present with a great variability, and the final individual outcome is often unpredictable. Therefor, it is a subject of continuous discussion, however, still without reaching consensus. This emphasizes a need for further innovation. Treatment with ASLS represents another such innovative initiative, which adds useful arguments and experience to the debate. Lastly, tibia fractures cause substantial impact on morbidity, health care use and costs. Non-unions after tibia fractures are, in particular, a relevant factor to this, often requiring secondary surgery to achieve satisfactory union. One study found a reoperation rate of 35,8% 3.Of these 13,2% tibiae required minor revision surgery and 22.6% tibiae required major revision surgery 3. As such, non-union represents a core challenge with treatment of tibia fractures and accounts for a significant cost and use of health care resources as well as high use of strong opioids. Furthermore, patients with non-union are at greater risk of having additional subsequent injuries in the affected limb, trunk, spine or skull 4. A median total care cost for a patient with non-union is estimated to be 65% higher than those without non-union 4. 4
5 Current research Therapy with intramedullary nailing has become widely used in the management of distal tibia fractures. With such method follows an increased risk of weakened biomechanical stability. During the past several years the indication for intramedullary nailing has expanded and the use of ASLS screws has been introduced as an alternative to conventional screws with the aim of providing increased stability. However, as of November 20, 2014 there are no clinical data to be found in the relevant literature (PubMed, Cochrane Library) that can confirm this. Several biomechanical studies have been carried out showing positive results and capacities of the ASLS One biomechanical study showed no significant difference in terms of construct stability capacities when comparing a four-screw ASLS configuration and a standard solution with five locking screws 8. The same study found in the ASLS solution a higher stiffness of the construct and less motion in the fracture gap during early loading. Thus one might conclude that the ASLS solution offers sufficient fixation stability of distal tibia fractures with fewer locking screws, consequently reducing the risk of intraoperative nerve and vessel injury as well as reducing operating time and cost. Another biomechanical study evaluated the long-term stability comparing conventional locking screws and the ASLS screws 9. This study evaluated biomechanical testing over a period of 12 weeks, finding a significantly higher long-term stability with the ASLS system compared with conventional locking screws. It concludes the finding of increased stability and resistance to torsional loading to have clinical relevance. Furthermore, it suggests the overall mechanical capacities of the ASLS system to have the potential to reduce common complications such as secondary loss of reduction and mal-/non-union. All these studies show promising results. Due to the lack of clinical data presented in the literature this study is considered to be highly relevant to promote quality assurance as well as evidence of effectiveness and safety of the method. We found one multi-centre on-going randomized control trial with ClinicalTrials.gov identifier: NCT This study aims to evaluate the effectiveness of ASLS. According to ClinicalTrials.gov the study has been completed and thus published results should be expected to present in the very near future. ASLS technique Synthes intramedullary nails are designed to anatomically fit the medullary canal, allowing indirect reduction. ASLS reduces the risk of secondary loss of reduction by providing axial and angular stability between nail and screws, by using resorbable sleeves as dowels in the nail locking holes. Intramedullary nailing has become an alternative treatment choice for the most displaced diaphyseal tibia fractures. It provides increased mechanical stability However, fractures of the most distal one third of the tibia treated with intramedullary nailing and conventional screws often results in delayed union and non-unions 10. To improve the mechanical stability of intramedullary nailed tibia fractures, ASLS have been developed. The use of ASLS in tibial nailing results in fixation stiffness comparable with that of external fixation Indications and Contraindications ASLS is compatible with all Synthes Expert Tibial cannulated titanium nails. It is used as an alternative to standard locking screws. ASLS is used for the operative treatment and stabilization of long bones in the upper and lower extremities, according to specific indications. ASLS is particularly indicated in cases where stability is needed, for example, in fractures close to the metaphyseal area. The contraindications of the nail system are applicable, e.g in patients with acute or chronic infections, poor bone quality, reduced blood circulation, allergy, or in situations where internal fixation is contraindicated for other reasons. 5
6 Product information - Screws: The ASLS-screws are made up of about 90% titanium. They have blunt tips, 4 or 5 mm in diameter. The Screw shaft has three diameters [D]; D1 provides fixation in near cortex D2 expands sleeve, thus providing angular stability D3 - provides fixation in the far cortex - Sleeves: Made up of biodegradable polylacatide material. Its purpose is to decrease fracture site motion during first 12 weeks of healing, by expanding in the nail locking hole. They are resorbable within two years. - Nail: Expert Tibial Nail (9 or 11 mm in diameter). Traditional screws (B) have one single and continuous diameter and attach only to the near and distant cortex. ASLS, on the other hand, (B) has three different diameters and attach to the near and distant cortex as well as the intramedullary nail, creating angular stability. See figure 1 for in vivo installation. (A) (B) Materials and Method The study is designed as a retrospective study of a consecutive series of 107 patients, 57 male patients and 50 female patients. During the period from September 2009 until June 2014 a consecutive series of 107 patients with Müller AO42 and AO43 fractures were treated at Odense University Hospital with Synthes Expert Tibial Nail combined with ASLS screws. See figure 2 for a flow chart of the study process. The distribution of the Müller AO classification among the patients is showed in figure 3. Figure 4 shows the most commonly occurring fractures in the study. The following material is summarized in figure 5. All fractures except 14 were preoperatively CT-scanned analysing the presence of intra-articular fracture involvement as well as the pattern of the fracture. 41 of 93 patients with such pre-operative CT-scan had their Müller AO fracture code modified after the CT-scan. 13 patients were treated as trauma patients. All patients were operated after an average of 3,1 days after the injury. 19 patients were operated on the same day as the injury. The longest interval between injury and operation was 14 days. 46 patients were found to have intra-articular fracture. 30 of these intra-articular fractures were identified only after the pre-operative CT-scan. 63 patients had an additional fracture of the most distal one third of fibula. 35 of these fibula fractures were treated with osteosynthesis. 40 patients were treated with additional screws in the proximity of a joint. 7 patients were treated with additional Poller screws. Each patient was treated with an average of 2,6 ASLS screws. The average postoperative hospitalization was 5,1 days. Evaluation of fracture union and time to healing was performed by assessment of radiographs. Healing is most commonly defined as cortical bridging of at least 3 out of 4 cortices 11 The patients followed a post-operative control programme including X-ray and 6
7 clinical control every 6 weeks until healing. The average follow-up time was 38,3 months. All patients except eight (operated in 2014) were followed for at least a year. However, these eight patients have confirmed healing at present. One patient was lost to follow up. Two patients were excluded due to earlier operation on the affected bone. Results All 104 patients included in the study experienced healing. No patients had non-union 1 year post-operatively. Two patients had mal-union. Average time to healing was 5,1 months. 37 patients were re-operated; o 34 patients because of minor complications, These 34 patients represent a relatively homogenous group requiring removal of the osteosynthesis material. We found that these patients experienced local irritation around the osteosynthesis material and therefore qualified for the indication for its removal; 16 patients underwent removal of only screws. 18 patients removed both the intramedullary nail and screws. Among the 34 patients, 28 patients (82%) had an additional fibula fracture. 10 (35%) of these 28 patients had an additional fibula ostesynthesis whereas the remaining 18 patients (65%) o had not. Three patients because of major complications. One patient with confirmed deep infection, one patient with suspected deep infection (not found) and one patient had autograft bone transplantation. One patient had minor perioperative complications. o Tibial splinting. Discussion We found 100% union with an average of 5,1 months to healing and a low rate of complications. No patients had secondary loss of reduction. In particular, a low rate of infection (one patient) was found. However, 37 of 104 patients were re-operated, mostly (34 patients) due to local irritation around the osteosynthesis material. 28 (82%) of the 34 patients re-operated due to local irritation around the osteosynthesis material had an additional fibula fracture, as shown in figure 7. This may suggest fibula fracture as a complicating factor in the healing process. Figure 7 also shows that local irritation followed by removal of the osteosynthesis material among patients with fibula fracture was more common if the an additional osteosynthesis of the fibula was not applied. These results suggest that treatment with ASLS could possibly become a standard procedure for distal tibia fractures in the future. ASLS offers all the advantage of an intramedullary approach. Stable fixation, provided by ASLS, permits controlled, early and active rehabilitation, which is pivotal to optimal recovery. Finally, the results of our study correlates with the promising results of biomechanical studies performed on ASLS. Tibial intramedullary nailing combined with ASLS screws seems to be a secure and effective treatment method for distal fractures in the tibia. Our study suggests that the treatment could possibly become a standard procedure for distal tibia fractures in the future. Missing data One patient was lost to the study due to missed follow up X-ray. 14 patients were operated without a pre-operative CT-scan, but had only a pre-operative X-ray. We found that 41 (44%) of the 93 patients with a pre-operative CT-scan changed the Müller AO classification of their fracture. Therefor, the group of patients without a pre-operative CT- 7
8 scan may not have been classified as precisely as possible according to the Müller AO classification. Smokers/previous smokers, chronic alcoholism, diabetes, cardiovascular disease and other chronic comorbidities are all parameters that were not registered and assessed in this study. They are all confounding factors that possibly could affect other parameters such as time to healing and mal-union. Study limitations 40 patients were treated with additional screws and 7 patients with Poller screws. These may influence as external factors adding stability to the main construction of intramedullary nail and ASLS. Quite a substantial number of the patients (63) also had a fracture in the most distal one third of fibula. This might also influence the result in terms of additional pain, edema and decreased stability of the crus. For coming studies of the ASLS we suggest to add these to the exclusion criteria in order to obtain a more precise evaluation of the ASLS. Alternatively, the importance of an additional osteosynthesis in the fibula may be evaluated by performing a randomized controlled trial. Some of the patients missed some of the X-ray and clinical control programme every 6 weeks. However, all patients included in the study had X-ray which confirmed healing within 12 months post-operatively. Finding a precise time to healing was challenged by this component. An X-ray, which confirms healing, cannot reveal for how long time healing has been present. Therefor, patients who only underwent the 12 months X-ray might have had healing already for up to 8-9 months. It is likely to suggest that the real time to healing is less than the average 5,1 months we found in this study. Conclusion 1. We found 100% union with an average of 5,1 months to healing and a low rate of complications. In particular, a low rate of infection (one patient) was found. However, 37 of 104 patients were re-operated, mostly due to local irritation around the osteosynthesis material. This suggests that the treatment could possibly become a standard procedure in the future for distal tibia fractures, replacing traditional methods, which carry relative high rates of reoperation and complications A coincidental finding in the study emphasizes the importance of a pre-operative CT scan in order to obtain the most precise diagnosis. The pre-operative CT scan of the 93 patients resulted in a change of Müller AO classification code for a total of 41 patients (44%), as shown in figure 8. Furthermore, 30 (65%) of the 46 patients found with intra-articular fracture had their intra-articular fracture involvement confirmed only after the CT-scan. Hence, one may conclude that the CT-scan instrumental in precise diagnosis, and particularly effective in identifying an intra-articular involvement of the fracture. 8
9 Tables and graphs Figure 1. In vivo installation of the ASLS system. 9
10 Figure 2. Flow chart of study process. 10
11 Figure 3. Overview of all fracture types. Figure 4. Most common fracture types found in the study. 11
12 Figure 5. Materials, summarized. Figure 6. Selected variables. 12
13 Figure 7. Implant removal among patients with additional fibula fracture. Figure 8. Change of diagnosis after pre-operative CT-scan. 13
14 References 1 C.M. Court-Brown, S. Rimmer, U.Prakash, M.M. McQueen. Injury: International Journal of the Care of the Injured Vol. 29, No. 7, Murali Poduval, MBBS, MS, DNB, article on Diaphyseal Tibial Fracture from updated on May 13, Link available at: 3 Harris I, Lyons M. Reoperation rate in diaphyseal tibia fractures. ANZ Journal of Surgery, 2005 Dec;75(12): Antonova et al. Tibia shaft fractures: costly burden of nonunions BMC Musculoskeletal Disorders 2013, 14:42 5 Hoegel et al - J Trauma Acute Care Surg Oct;73(4): Horn J, Linke B, Höntzsch D, Georguiev B, Schwieger K. Angle stable interlocking screws improve construct stability of intramedullary nailing of distal tibia fractures: A biomechanical study. Injury, Int. J. Care Injured 40 (2009) Gueorguiev B, Ockert B, Schwieger K, Wähnert D, Lawson-Smith M, Windolf M, Stoffel K. Angular Stability Potentially Permits Fewer Locking Screws Compared With Conventional Locking in Intramedullary Nailed Distal Tibia Fractures: A Biomechanical Study. J Orthop Trauma,Volume 25, Number 6, June Gueorguiev B, Ockert B, Schwieger K, Wähnert D, Lawson-Smith M, Windolf M, Stoffel K. Angular Stability Potentially Permits Fewer Locking Screws Compared With Conventional Locking in Intramedullary Nailed Distal Tibia Fractures: A Biomechanical Study. J Orthop Trauma,Volume 25, Number 6, June Dirk Wähnert, Yves Stolarczyk, Konrad L Hoffmeier et al. Long-term stability of angle-stable versus conventional locked intramedullary nails in distal tibia fractures. BMC Musculoskeletal Disorders 2013, 14:66 10 Attal R. Hansen M. Kirjavainen M. et al. A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) Arch Orthop Trauma Surg (2012) 132: Shisha T. Parameters for defining efficacy in fracture healing. Clin Cases Miner Bone Metab Jan-Apr; 7(1):
Locked plating constructs are creating a challenge for surgeons.
Locked plating constructs are creating a challenge for surgeons. Three recent studies examining supracondylar femur fractures show concern for the high degree of stiffness of locked plating constructs
More informationAO / Synthes Proximal Posterior Medial Tibia Plate. Tibial Plateau Fx. Osteosynthesis
Tibial Plateau Fx. Osteosynthesis Articular Fractures Osteosynthesis Characteristics of the LCP system LCP 3.5 system LCP 4.5 system Many different traditional plates (small, large) Lag screws Rafting
More informationPROXIMAL TIBIAL PLATE
SURGICAL NÁSTROJE TECHNIQUE PRO ARTROSKOPII PROXIMAL INSTRUMENTS TIBIAL FOR PLATE ARTHROSCOPY Proximal Tibial Plate Description of medical device The Proximal Tibial Plate is used in epyphyseal and metaphyseal
More informationTechique. Results. Discussion. Materials & Methods. Vol. 2 - Year 1 - December 2005
to each other. The most distal interlocking hole is 3 mm proximal to distal end of nail, is in anteroposterior direction & proximal distal interlocking hole is in medial to lateral direction i.e. at right
More informationA comparative study of locking plate by MIPO versus closed interlocking intramedullary nail in extraarticular distal tibia fractures
2018; 4(3): 145-149 ISSN: 2395-1958 IJOS 2018; 4(3): 145-149 2018 IJOS www.orthopaper.com Received: 26-05-2018 Accepted: 27-06-2018 Kanachur Institute of Medical Sciences Mangalore University Road, Natekal,
More informationPrinciples of intramedullary nailing. Management for ORP
Principles of intramedullary nailing Eakachit Sikarinklul,MD Basic Principles of Fracture Management for ORP Bangkok Medical Center Bangkok, 22-24 July 2016 Learning outcomes At the end of this lecture
More informationIntramedullary fibular fixation in the operative management of fractures of the distal tibia and fibula
Royal Liverpool & Broadgreen University Hospitals NHS Foundation Trust Intramedullary fibular fixation in the operative management of fractures of the distal tibia and fibula Michael Smith MBChB, Zuned
More informationThe Role of Biplanar Distal Locking in Intramedullary Nailing of Tibial Shaft Fractures
)33( COPYRIGHT 2019 BY THE ARCHIVES OF BONE AND JOINT SURGERY RESEARCH ARTICLE The Role of Biplanar Distal Locking in Intramedullary Nailing of Tibial Shaft Fractures Kadir Bahadır Alemdaroğlu, MD; Serkan
More informationOrthopedics in Motion Tristan Hartzell, MD January 27, 2016
Orthopedics in Motion 2016 Tristan Hartzell, MD January 27, 2016 Humerus fractures Proximal Shaft Distal Objectives 1) Understand the anatomy 2) Epidemiology and mechanisms of injury 3) Types of fractures
More informationScrew Placement and Types Matter
Screw Placement and Types Matter The Blasted Distal Femur Facture: How to Improve Outcomes Abstract ID#: 1506 Friday October 13, 2017 Kyle Jeray University of South Carolina, Greenville Pinpoint open 59
More informationFractures of the tibia shaft treated with locked intramedullary nail Retrospective clinical and radiographic assesment
ARS Medica Tomitana - 2013; 4(75): 197-201 DOI: 10.2478/arsm-2013-0035 Șerban Al., Botnaru V., Turcu R., Obadă B., Anderlik St. Fractures of the tibia shaft treated with locked intramedullary nail Retrospective
More informationAdvantage and limitations of a minimally-invasive approach and early weight bearing in the treatment of tibial shaft fractures with locking plates
Orthopaedics & Traumatology: Surgery & Research (2012) 98, 564 569 Available online at www.sciencedirect.com ORIGINAL ARTICLE Advantage and limitations of a minimally-invasive approach and early weight
More informationInternational Journal of Health Sciences and Research ISSN:
International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571 Original Research Article A Study on Surgical Management of Distal Tibial Fractures by Using Minimally Invasive Technique
More informationA Clinical Study For Evaluation Of Results Of Closed Interlocking Nailing Of Fractures Of The Shaft Of The Tibia
ISPUB.COM The Internet Journal of Orthopedic Surgery Volume 17 Number 2 A Clinical Study For Evaluation Of Results Of Closed Interlocking Nailing Of Fractures Of The Shaft Of R Gupta, T Motten, N Kalsotra,
More informationOsteosynthesis involving a joint Thomas P Rüedi
Osteosynthesis involving a joint Thomas P Rüedi How to use this handout? The left column contains the information given during the lecture. The column at the right gives you space to make personal notes.
More informationIntramedullary Nailing: History & Rationale
Intramedullary Nailing: History & Rationale Overview 1. What is IM Nailing? 2. History 3. Design Rationale & Evolution 4. Modern IM Nails 5. The Future What is IM Nailing? Method of internal fixation in
More informationIncreasing surgical freedom Restoring patient function
Increasing surgical freedom Restoring patient function Fracture specific plating solutions for the most common tibia and fibula fractures Frequency of fracture occurrences* 66% 61% 36% 36% 28% 14% 20%
More informationCASE REPORT. Bone transport utilizing the PRECICE Intramedullary Nail for an infected nonunion in the distal femur
PRODUCTS CASE REPORT Bone transport utilizing the PRECICE Intramedullary Nail for an infected nonunion in the distal femur Robert D. Fitch, M.D. Duke University Health System 1 1 CONDITION Infected nonunion
More informationZimmer Small Fragment Universal Locking System. Surgical Technique
Zimmer Small Fragment Universal Locking System Surgical Technique Zimmer Small Fragment Universal Locking System 1 Zimmer Small Fragment Universal Locking System Surgical Technique Table of Contents Introduction
More informationIntramedullary Rodding of Distal Tibial Shaft Fractures with Intra Articular Extension
Intramedullary Rodding of Distal Tibial Shaft Fractures with Intra Articular Extension My Name is Claude Sagi CSOT Tampa, FL 2018 Disclosures: None, I am just a simple man. This talk is about treating
More informationLCP Medial Distal Tibia Plate, without Tab. The Low Profile Anatomic Fixation System with Angular Stability and Optimal Screw Orientation.
LCP Medial Distal Tibia Plate, without Tab. The Low Profile Anatomic Fixation System with Angular Stability and Optimal Screw Orientation. Technique Guide LCP Small Fragment System Table of Contents Introduction
More informationThe study of distal ¼ diaphyseal extra articular fractures of humerus treated with antegrade intramedullary interlocking nailing
2018; 4(4): 46-50 ISSN: 2395-1958 IJOS 2018; 4(4): 46-50 2018 IJOS www.orthopaper.com Received: 01-08-2018 Accepted: 03-09-2018 Dr. Ankur Parikh Orthopaedics, Jehangir Hospital, Sassoon road, Pune, Dr.
More informationClinical. Solutions. Synthes Solutions. Foot and Ankle.
Clinical Solutions Foot and Ankle. Foot and Ankle. Fractures of the tibial shaft Fractures of the distal fibula Fractures of the distal tibia Fractures and osteotomies of the calcaneus Arthrodesis Fractures,
More informationSurgical Technique. Fibula Rod System
Surgical Technique Fibula Rod System Acumed is a global leader of innovative orthopaedic and medical solutions. We are dedicated to developing products, service methods, and approaches that improve patient
More informationImproving Fixation of a Previously Designed Pediatric Tibial Stent
Improving Fixation of a Previously Designed Pediatric Tibial Stent Evan Lange, Karl Kabarowski, Tyler Max, Sarah Dicker, Lida Acuña-Huete Client: Dr. Matthew Halanski, MD Advisor: Dr. Wan-Ju Li, PhD Biomedical
More informationEVOS MINI with IM Nailing
Case Series Dr. John A. Scolaro EVOS MINI with IM Nailing A series of studies Introduction Intramedullary nailing has become the standard for many long bone fractures. Fracture reduction prior to nail
More informationFibula Rod System. Lateral Malleolus Fracture Indications:
Fibula Rod System Fibula Rod System Since 1988, Acumed has been designing solutions for the demanding situations facing orthopaedic surgeons, hospitals and their patients. Our strategy has been to know
More informationLCP Extra-articular Distal Humerus Plate.
Technique Guide LCP Extra-articular Distal Humerus Plate. The anatomically shaped and angular stable fixation system for extraarticular fractures of the distal humerus. Table of Contents Introduction
More informationThe Flower Straight Fibula Plate
The Flower Straight Fibula Plate PROCEDURE GUIDE www.flowerortho.com The Flower Foot & Ankle Application STRAIGHT LOCKING FIBULA PLATE ANTERIOR LATERAL DISTAL TIBIAL PLATE MEDIAL DISTAL TIBIAL PLATE ANATOMIC
More informationIMPORTANT MEDICAL INFORMATION Advanced Orthopaedic Solutions INTRAMEDULLARY NAILS Warnings and Precautions (SINGLE USE ONLY)
IMPORTANT MEDICAL INFORMATION Advanced Orthopaedic Solutions INTRAMEDULLARY NAILS Warnings and Precautions (SINGLE USE ONLY) IMPORTANT NOTE Intramedullary nails provide an alternative to open reduction
More informationComparitive Study between Proximal Femoral Nailing and Dynamic Hip Screw in Intertrochanteric Fracture of Femur *
Open Journal of Orthopedics, 2013, 3, 291-295 Published Online November 2013 (http://www.scirp.org/journal/ojo) http://dx.doi.org/10.4236/ojo.2013.37053 291 Comparitive Study between Proximal Femoral Nailing
More informationLCP Medial Proximal Tibial Plate 4.5/5.0. Part of the Synthes LCP periarticular plating system.
LCP Medial Proximal Tibial Plate 4.5/5.0. Part of the Synthes LCP periarticular plating system. Technique Guide This publication is not intended for distribution in the USA. Instruments and implants approved
More informationConventus CAGE PH Surgical Techniques
Conventus CAGE PH Surgical Techniques Conventus Orthopaedics The Conventus CAGE PH (PH Cage) is a permanent implant comprised of an expandable scaffold, made from nitinol and titanium, which is deployed
More informationOlecranon fracture. Lonnie Froberg, MD, Ph.D Rigshospitalet, Copenhagen University Hospital
Olecranon fracture Lonnie Froberg, MD, Ph.D Rigshospitalet, Copenhagen University Hospital 20% of forearm fracture 12 per 100.000 persons per year Low-energy fall Increased risk >50 years 90% AO 21.B1.1
More informationTechnique Guide. LCP Proximal Femoral Hook Plate 4.5/5.0. Part of the LCP Periarticular Plating System.
Technique Guide LCP Proximal Femoral Hook Plate 4.5/5.0. Part of the LCP Periarticular Plating System. Table of Contents Introduction Features and Benefits 2 AO ASIF Principles 4 Indications 5 Surgical
More informationTo study outcome of surgical management of distal 3rd and proximal 3rd fractures of tibia in adults using expert tibial nails
International Journal of Research in Orthopaedics Kachhap ND et al. Int J Res Orthop. 2017 Jul;3(4):862-866 http://www.ijoro.org Original Research Article DOI: http://dx.doi.org/10.18203/issn.2455-4510.intjresorthop20172887
More informationHumerus Block. Discontinued December 2016 DSEM/TRM/0115/0296(1) Surgical Technique. This publication is not intended for distribution in the USA.
Humerus Block Surgical Technique Discontinued December 2016 DSEM/TRM/0115/0296(1) This publication is not intended for distribution in the USA. Instruments and implants approved by the AO Foundation. Contents
More informationTechnique Guide. 3.5 mm LCP Proximal Tibia Plate. Part of the Synthes Small Fragment LCP System.
Technique Guide 3.5 mm LCP Proximal Tibia Plate. Part of the Synthes Small Fragment LCP System. Table of Contents AO ASIF Principles of Internal Fixation 4 Indications/Contraindications 5 Surgical Technique
More informationSurgical Technique. Cannulated Angled Blade Plate 3.5 and 4.5, 90
Surgical Technique Cannulated Angled Blade Plate 3.5 and 4.5, 90 Cannulated Angled Blade Plate 3.5 and 4.5, 90 Table of contents Indications/Contraindications 2 Implants 3 Surgical technique 5 Implant
More informationTriLock 1.5 Scaphoid Plate
PRODUCT INFORMATION TriLock 1.5 Scaphoid Plate APTUS Hand 2 TriLock 1.5 Scaphoid Plate TriLock 1.5 Scaphoid Plate Angular stable treatment for scaphoid nonunion Clinical Benefits and Plate Features Optimized
More informationPosteromedial approach to the distal humerus for fracture fixation
Acta Orthop. Belg., 2006, 72, 395-399 ORIGINAL STUDY Posteromedial approach to the distal humerus for fracture fixation Cédric LAPORTE, Maurice THIONGO, Dominique JEGOU From the General Hospital of Meaux,
More informationLCP Medial Proximal Tibial Plate 3.5. Part of the Synthes small fragment Locking Compression Plate (LCP) system.
LCP Medial Proximal Tibial Plate 3.5. Part of the Synthes small fragment Locking Compression Plate (LCP) system. Technique Guide This publication is not intended for distribution in the USA. Instruments
More informationLOCKING TEP LOCKING TITANIUM ELASTIC PIN INTRAMEDULLARY NAIL
LOCKING TEP LOCKING TITANIUM ELASTIC PIN INTRAMEDULLARY NAIL ... Index -3 3-8 8 9 9 0 7 Introduction Features Indicatiıons Surgical Technique Femoral Surgical Technique Tibial Surgical Technique Ulna Radius
More informationInion FreedomScrew Syndesmosis Repair. Biodegradable Fixation System
Inion FreedomScrew Syndesmosis Repair Biodegradable Fixation System Inion FreedomScrew for Syndesmosis Repair Inion FreedomScrew is a strong and versatile resorbable screw for orthopaedic fixations. Because
More informationLCP Metaphyseal Plates. For extra-articular fractures.
LCP Metaphyseal Plates. For extra-articular fractures. Surgical Technique This publication is not intended for distribution in the USA. Instruments and implants approved by the AO Foundation. Image intensifier
More informationTreatment of Diaphysio-Metaphyseal Fracture of Tibia by Intramedullary Nail in Combination with Poller Screw
Research Article imedpub Journals http://www.imedpub.com DOI: 10.4172/2469-6684.10001 Treatment of Diaphysio-Metaphyseal Fracture of Tibia by Intramedullary Nail in Combination with Poller Screw Ram Kewal
More informationHigh Association of Posterior Malleolus Fractures with Spiral Distal Tibial Fractures
Clin Orthop Relat Res (2008) 466:1692 1698 DOI 10.1007/s11999-008-0224-5 ORIGINAL ARTICLE High Association of Posterior Malleolus Fractures with Spiral Distal Tibial Fractures Sreevathsa Boraiah MD, Michael
More informationCASE REPORT. Antegrade tibia lengthening with the PRECICE Limb Lengthening technology
CASE REPORT Antegrade tibia lengthening with the PRECICE Limb Lengthening technology Austin T. Fragomen, M.D. Hospital for Special Surgery New York, NY 1 1 PR O D U CTS CONDITION Nonunion of an attempted
More information7/23/2018 DESCRIBING THE FRACTURE. Pattern Open vs closed Location BASIC PRINCIPLES OF FRACTURE MANAGEMENT. Anjan R. Shah MD July 21, 2018.
BASIC PRINCIPLES OF FRACTURE MANAGEMENT Anjan R. Shah MD July 21, 2018 DESCRIBING THE FRACTURE Pattern Open vs closed Location POLL OPEN HOW WOULD YOU DESCRIBE THIS FRACTURE PATTERN? 1 Spiral 2 Transverse
More information.org. Tibia (Shinbone) Shaft Fractures. Anatomy. Types of Tibial Shaft Fractures
Tibia (Shinbone) Shaft Fractures Page ( 1 ) The tibia, or shinbone, is the most common fractured long bone in your body. The long bones include the femur, humerus, tibia, and fibula. A tibial shaft fracture
More informationPlate vs Nail for Distal Tibia Fxs
Plate vs Nail for Distal Tibia Fxs Frank A. Liporace, MD Associate Professor Dept. of Orthopaedics NYU / HJD Chief Dept. Of Orthopaedics JCMC / RWJBH ??? Controversy??? Nails Minimal invasive Low blood
More informationTHE RING BUTTERFLY FRAGMENT
THE RING BUTTERFLY FRAGMENT Pages with reference to book, From 80 To 82 Philip D`Sousa, Masood Umer, Riaz Hussain Lakdawala ( Department of Surgery (Orthopaedics), The Aga Khan University, Karachi. ) In
More informationIntramedullary Nailing of Proximal Quarter Tibial Fractures
ORIGINAL ARTICLE Intramedullary Nailing of Proximal Quarter Tibial Fractures Downloaded from https://journals.lww.com/jorthotrauma by 8WXeIBH/bhCDXSJhqO4He3zMjDdiDlokyQtApC91PNKG9a/tPy2o9wvYA84dGjHINiBelbocxVu63ADM4AGx5PeXfLYAE9Wwxl/hAO/UvnoQeL/3rrYADLWqdS4+DwtVQeM+OnUtY1I=
More informationTechnique Guide. TomoFix Osteotomy System. A comprehensive plating system for stable fixation of osteotomies around the knee.
Technique Guide TomoFix Osteotomy System. A comprehensive plating system for stable fixation of osteotomies around the knee. Table of Contents Introduction TomoFix Osteotomy System 2 AO Principles 4 Indications
More informationThoracolumbar Spine Locking Plate (TSLP) System. A low-profile plating system for anterior stabilization of the thoracic and lumbar spine.
Thoracolumbar Spine Locking Plate (TSLP) System. A low-profile plating system for anterior stabilization of the thoracic and lumbar spine. Technique Guide Instruments and implants approved by the AO Foundation
More informationPFNA-II. Proximal Femoral Nail Antirotation.
PFNA-II. Proximal Femoral Nail Antirotation. Surgical Technique This publication is not intended for distribution in the USA. Instruments and implants approved by the AO Foundation. PFNA-II. Proximal Femoral
More informationLCP Low Bend Medial Distal Tibia Plates 3.5 mm. Anatomic plates with low profile head for intra- and extraarticular fractures.
LCP Low Bend Medial Distal Tibia Plates 3.5 mm. Anatomic plates with low profile head for intra- and extraarticular fractures. Surgical Technique This publication is not intended for distribution in the
More information2016 SIGN Conference: Treatment of Difficult Fractures Around The World
2016 SIGN Conference: Treatment of Difficult Fractures Around The World September 21-24, 2016 Long Bone Osteosynthesis Failure DUONG BUNN Trauma-Orthopedique ward Preah Kossamak Preah Sihaknouk Ville Beach
More informationSurgical Management of aseptic Femoral Shaft Non-union after Intramedullary Fixation
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (7), Page 4946-4950 Surgical Management of aseptic Femoral Shaft Non-union after Intramedullary Fixation Eissa Ragheb Refaie 1, Ahmed Abd El
More informationOBSOLETED. LCP Medial Distal Tibia Plate, without Tab. The Low Profile Anatomic Fixation System with Angular Stability and Optimal Screw Orientation.
LCP Medial Distal Tibia Plate, without Tab. The Low Profile Anatomic Fixation System with Angular Stability and Optimal Screw Orientation. Surgical Technique LCP Small Fragment System This publication
More informationA locking plate system that expands a surgeon s options in trauma surgery. Zimmer NCB Plating System
A locking plate system that expands a surgeon s options in trauma surgery Zimmer NCB Plating System The Power of Choice The power of having true intraoperative options is at your fingertips. Using standard
More informationLISS DF and LISS PLT. Less Invasive Stabilization Systems for Distal Femur and Proximal Lateral Tibia.
LISS DF and LISS PLT. Less Invasive Stabilization Systems for Distal Femur and Proximal Lateral Tibia. LISS DF and LISS PLT. Less Invasive Stabilization Systems for Distal Femur and Proximal Lateral Tibia.
More informationIntramedullary nailing without interlocking screws for femoral and tibial shaft fractures
DOI 10.1007/s00402-013-1775-9 Trauma Surgery Intramedullary nailing without interlocking screws for femoral and tibial shaft fractures Dieuwertje L. Kreb Taco J. Blokhuis Karlijn J. P. van Wessem Mike
More informationANATOMIC LOCKED PLATING SYSTEM
ANATOMIC LOCKED PLATING SYSTEM There is only one...dvr Anatomic. There is only one... ANATOMIC LOCKED PLATING SYSTEM Distal Tibia TiMAX for strength, biocompatibility and enhanced imaging capabilities
More informationCase Report. Antegrade Femur Lengthening with the PRECICE Limb Lengthening Technology
Case Report Antegrade Femur Lengthening with the PRECICE Limb Lengthening Technology S. Robert Rozbruch, MD Hospital for Special Surgery New York, NY, USA ABSTRACT This is a case illustrating a 4.5 cm
More informationTechnique Guide. LCP Distal Fibula Plates. Part of the Synthes locking compression plate (LCP) system.
Technique Guide LCP Distal Fibula Plates. Part of the Synthes locking compression plate (LCP) system. Table of Contents Introduction LCP Distal Fibula Plates 2 AO Principles 4 Indications 5 Surgical Technique
More informationPreface. Hvidovre, d. 12. September, Anders Troelsen, Michael Brix, Kirill Gromov
Preface The annual report from the Danish Fracture Database (DFDB) 215 is the third of its kind. It contains data based on over 4. fracture related surgeries, of which over 3. are primary surgeries registered
More informationHinged Laminoplasty System surgical technique
BlackbirdTM Hls Hinged Laminoplasty System surgical technique Blackbird TM Hls The ChoiceSpine Blackbird Hinged Laminoplasty System (HLS) design eliminates fitting plates through trial and error bending.
More informationEXPERT TIBIAL NAIL PROTECT
EXPERT TIBIAL NAIL PROTECT Enhance your first line of defense This publication is not intended for distribution in the USA. CLINICAL EVIDENCE CONTENT AUTHOR TITLE OF CHAPTER PAGE ETN PROtect clinical evidence
More informationEVIDENCE BASED MEDICINE VOICE
EVIDENCE BASED MEDICINE VOICE Orthofix approach to Evidence Based Medicine: For years, clinical decision-making was based primarily on physician knowledge and expert opinion. Now, the medical community
More informationPlate Fixation Options
Distal tibia extra-articular fractures can be difficult to treat Tenuous soft tissue Complex fracture patterns Plate Fixation Options Medial plating: Minimally invasive approach Technical ease Anterolateral
More informationTECHNIQUE FOR CLOSED REDUCTION OF FEMORAL SHAFT DISPLACED FRACTURE USING INTRAMEDULLARY NAIL WITH STEINMANN PIN SUPPORT: CASE STUDY
TECHNIQUE FOR CLOSED REDUCTION OF FEMORAL SHAFT DISPLACED FRACTURE USING INTRAMEDULLARY NAIL WITH STEINMANN PIN SUPPORT: CASE STUDY Nitesh Raj Pandey 1, Sumendra raj pandey, Jue-HuaJing 1, XuXin Zhong
More informationCannulated Angled Blade Plate 3.5 and 4.5, 90.
Cannulated Angled Blade Plate 3.5 and 4.5, 90. Technique Guide This publication is not intended for distribution in the USA. Instruments and implants approved by the AO Foundation. Table of Contents Introduction
More informationROTATIONAL PILON FRACTURES
CHAPTER 31 ROTATIONAL PILON FRACTURES George S. Gumann, DPM The opinions and commentary of the author should not be construed as refl ecting offi cial U.S. Army Medical Department policy. Pilon injuries
More informationOrthopedic Bone Nail System - Distal Femoral Nail Surgical Technique Manual
Orthopedic Bone Nail System - Distal Femoral Nail Surgical Technique Manual Note: The surgical procedures should be performed under the guidance of qualified skilled orthopedic surgeons, and this surgical
More informationMinimally Invasive Plate Osteosynthesis (MIPO) for Proximal and Distal Fractures of The Tibia: A Biological Approach
http://dx.doi.org/10.5704/moj.1603.006 Minimally Invasive Plate Osteosynthesis (MIPO) for Proximal and Distal Fractures of The Tibia: A Biological Approach Gupta P, MS Orth, Tiwari A, MS Orth, Thora A,
More informationForearm Fracture Solutions. Product Overview
Forearm Fracture Solutions Product Overview Acumed Forearm Fracture Solutions Acumed Forearm Fracture Solutions includes plating and rodding systems with a range of diaphyseal radius and ulna fracture
More informationLCP Distal Tibia Plate
Surgical Technique LCP Locking Compression Plate Original Instruments and Implants of the Association for the Study of Internal Fixation AO/ASIF Table of contents Indications 3 Implants/Instruments 5 Surgical
More informationTechnique Guide. 2.4 mm Variable Angle LCP Distal Radius System. For fragment-specific fracture fixation with variable angle locking technology.
Technique Guide 2.4 mm Variable Angle LCP Distal Radius System. For fragment-specific fracture fixation with variable angle locking technology. Table of Contents Introduction 2.4 mm Variable Angle LCP
More informationKEYWORDS: Tibial fracture, Diaphyseal fracture, closed interlocking intramedullary nailing,
International Journal of scientific research and management (IJSRM) Volume 3 Issue 4 Pages 2529-2534 2015 \ Website: www.ijsrm.in ISSN (e): 2321-3418 Closed Intra-Medullary Interlocking Nail Improves Surgical
More informationFactors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures
Trauma Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures G. I. Drosos, M. Bishay, I. A. Karnezis, A. K. Alegakis From Royal United
More informationTechnique Guide. 3.5 mm LCP Low Bend Medial Distal Tibia Plates. Part of the Synthes locking compression plate (LCP) system.
Technique Guide 3.5 mm LCP Low Bend Medial Distal Tibia Plates. Part of the Synthes locking compression plate (LCP) system. Table of Contents Introduction 3.5 mm LCP Low Bend Medial Distal Tibia Plates
More informationJMSCR Vol 3 Issue 9 Page September 2015
www.jmscr.igmpublication.org Impact Factor 3.79 ISSN (e)-2347-176x DOI: http://dx.doi.org/10.535/jmscr/v3i9.08 Treatment for Lower One Third Fractures of Tibia by Interlocking Nailing Authors Suresh Reddy.S
More informationTreatment of ipsilateral femoral neck and shaft fractures. Mohamed E. Habib, Yasser S. Hannout, and Ahmed F. Shams
Treatment of ipsilateral femoral neck and shaft fractures Mohamed E. Habib, Yasser S. Hannout, and Ahmed F. Shams Department of Orthopedic Surgery, Faculty of Medicine, University of El Minoufiya, Egypt
More informationLCP Anterolateral Distal Tibia Plate 3.5. The low profile anatomic fixation system with optimal plate placement and angular stability.
LCP Anterolateral Distal Tibia Plate 3.5. The low profile anatomic fixation system with optimal plate placement and angular stability. Technique Guide LCP Small Fragment System Table of Contents Introduction
More informationTSLP Thoracolumbar Spine Locking Plate
Anterior thoracolumbar spine locking plate TSLP Thoracolumbar Spine Locking Plate Surgical Technique Image intensifier control This description alone does not provide sufficient background for direct use
More informationLCP Metaphyseal Plate for distal medial tibia. Anatomically precontoured metaphyseal plate.
Indications The LCP Metaphyseal Plate for distal medial tibia is a preshaped plate that allows optimal treatment of juxta-articular fractures of the distal tibia extending into the shaft area. This plate
More informationLCP Periprosthetic System. Part of the Synthes locking compression plate (LCP) system.
LCP Periprosthetic System. Part of the Synthes locking compression plate (LCP) system. 4.5 mm LCP curved broad plates 5.0 mm periprosthetic locking screws Orthopaedic cable components LCP Periprosthetic
More informationLarge Distractor Femur
Fracture Reduction and Provisional Stabilization Large Distractor Femur Surgical Technique Table of Contents Introduction Standard Femoral Distraction 2 Large Distractor System 4 Surgical Technique Prepare
More informationTechnique Guide. 2.7 mm/3.5 mm LCP Distal Fibula Plates. Part of the Synthes locking compression plate (LCP) system.
Technique Guide 2.7 mm/3.5 mm LCP Distal Fibula Plates. Part of the Synthes locking compression plate (LCP) system. Table of Contents Introduction 2.7 mm/3.5 mm LCP Distal Fibula Plates 2 AO Principles
More information2.4 mm Variable Angle LCP Volar Extra-Articular Distal Radius System. For fragment-specific fracture fixation with variable angle locking technology.
Technique Guide 2.4 mm Variable Angle LCP Volar Extra-Articular Distal Radius System. For fragment-specific fracture fixation with variable angle locking technology. Table of Contents Introduction 2.4
More informationTitanium Distal Femoral Nail System
For Retrograde Insertion Titanium Distal Femoral Nail System Surgical Technique Table of Contents Introduction Titanium Distal Femoral Nail System 2 AO Principles 4 Indications 5 Clinical Cases 6 Surgical
More informationCalcaneus Fractures: My Small Incision Tricks
Calcaneus Fractures: My Small Incision Tricks Steven Steinlauf, MD The Orthopaedic Foot and Ankle Institute of South Florida CSFA Tampa, February 2018 Disclosures Smith & Nephew Design surgeon, Royalties
More informationDifficultTibialNailRemovalusingtheExtendedTrochantericOsteotomyTechniquePriortoTotalKneeArthroplasty
: H Orthopedic and Musculoskeletal System Volume 14 Issue 3 Version 1.0 Year 2014 Type: Double Blind Peer Reviewed International Research Journal Publisher: Global Journals Inc. (USA) Online ISSN: 2249-4618
More informationA study of MIPO by locking compression plate fixation in the management of distal tibial metaphyseal fractures
International Journal of Research in Medical Sciences Venkateswarlu K et al. Int J Res Med Sci. 2015 Mar;3(3):675-679 www.msjonline.org pissn 2320-6071 eissn 2320-6012 Research Article DOI: 10.5455/2320-6012.ijrms20150328
More informationFemur Condylar Plate System Procedural Steps.
Femur Condylar Plate System Procedural Steps www.carbo-fix.com 1 Table of Contents Introduction..3 Instrumentation Set... 8 Procedural Steps:...... 12 Ordering Information 19 2 Introduction The CarboFix
More informationA locking plate system that expands a surgeon s options in trauma surgery. Zimmer NCB Plating System
A locking plate system that expands a surgeon s options in trauma surgery Zimmer NCB Plating System The Power of Choice The power of having true intraoperative options is at your fingertips. Using standard
More informationAcUMEDr. LoCKING CLAVICLE PLATE SYSTEM
AcUMEDr LoCKING CLAVICLE PLATE SYSTEM LoCKING CLAVICLE PLATE SYSTEM Since 1988 Acumed has been designing solutions to the demanding situations facing orthopedic surgeons, hospitals and their patients.
More informationA Locking IM Rod that won't back out. Simple and straight to the point! SURGICAL TECHNIQUE
A Locking IM Rod that won't back out. Simple and straight to the point! SURGICAL TECHNIQUE The SLIM (Simple Locking IntraMedullary) System is a new generation of pediatric orthopedic nails specifically
More informationTibial Shaft Fractures
Tibial Shaft Fractures Mr Krishna Vemulapalli Consultant Orthopaedics Surgeon Queens & King George Hospitals Queens Hospital 14/03/2018 Google Maps Map data 2018 Google 10 km Orthopaedics Department Covers
More information