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Table of Contents
REVIEW ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 109-113

The effectiveness of functional brace in the treatment of tibia fracture: A review of literature


1 Department of Orthotics and Prosthetics, Rehabilitation Faculty, Shiraz University of Medical Sciences, Shiraz, Iran
2 Musculoskeletal Research Center, Rehabilitation Faculty, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission14-Aug-2020
Date of Decision20-Oct-2020
Date of Acceptance17-Nov-2020
Date of Web Publication11-Oct-2021

Correspondence Address:
Prof. Mohammad Taghi Karimi
Department of Orthotics and Prosthetics, Rehabilitation Faculty, Shiraz University of Medical Sciences, Shiraz
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/atr.atr_74_20

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  Abstract 


Background and Objectives: Various treatment methods have been used to manage tibia fracture, including conservative and surgical treatment. Various studies investigated the effects of functional brace on fracture of tibia. This review was aimed to summarize the evidence on the effectiveness of functional brace on tibia fracture. Methods: An electronic search was carried out through internationally published scholarly articles in EBSCO, Medline, PubMed, Embase, and ISI Web of Knowledge (from 1950 to 2020) with the following keywords: tibia fracture, healing, conservative treatment, functional orthosis, brace, and patellar tendon-bearing orthosis. The quality of the papers was assessed using the Down and Black tool. Results: On the basis of the keywords, 50 articles were found, of which 11 articles were selected in accordance with the selection criteria. Most of studies support the use of orthosis for tibial fracture. The scores of reporting, external validity, internal validity (bias), and internal validity (confounding) varied between 2–7, 1–2, 1–5, and 2–4, respectively. Conclusions: One of the most important treatment methods for tibia fracture is use of functional brace. Based on the results of the available literature, use of functional brace is a good approach for stable tibia fracture. Some parameters, such as the condition of surrounding muscles, initial shortening, angulations of tibia, and intact of fibula, play significant roles in this regard.

Keywords: Brace, conservative treatment, functional orthosis, healing, patellar tendon-bearing orthosis, tibia fracture


How to cite this article:
Karimi MT, Kamali M. The effectiveness of functional brace in the treatment of tibia fracture: A review of literature. Arch Trauma Res 2021;10:109-13

How to cite this URL:
Karimi MT, Kamali M. The effectiveness of functional brace in the treatment of tibia fracture: A review of literature. Arch Trauma Res [serial online] 2021 [cited 2021 Nov 30];10:109-13. Available from: https://www.archtrauma.com/text.asp?2021/10/3/109/328039




  Introduction Top


The National Center for Health Statistics cites 492,000 tibial fractures per year in the United States.[1] Various treatment methods have been used to manage tibia fracture, including conservative and surgical treatment.[2],[3],[4] Conservative treatment consists of closed reduction and immobilization, close reduction, and easy weight bearing. There is no doubt that the goal of tibia shaft fracture treatment is attainment of body union with a resultant fully functional and painless extremity. This is done by reduction of fracture segments and proper immobilization. Fracture bracing is one of the commonly used conservative treatments used to manage tibia fractures.[3],[4] It was originated by Chinese ancient doctors and was developed by Dehne, Sarmiento, and Latta. The key points behind the use of this orthosis are to maintain alignment, to control motion allowed at the fracture site, and to facilitate healing of fracture.[5],[6],[7] It has been shown that the hard shell of the brace compresses the soft tissue and creates a hybrid pressure like effects which not only exaggerates the osteogenesis but also immobilize the fracture sites.[8]

Various studies investigated the effects of functional brace on healing of tibia fracture.[2],[3],[4],[5],[6],[7],[8] Pandey et al. showed that the subjects with fracture at distal third of tibia have acceptable loss of reduction with the use of functional brace.[9] Sarmiento and Latta in their research on 434 patients with fracture of the middle third of tibia showed that satisfactory results in terms of length shortening and varus angulations can be achieved by use of functional brace.[10] This review article was aimed to summarize the evidence on the effectiveness of functional brace. Moreover, it was aimed to determine the protocol of using functional brace based on the available literature.


  Methods Top


An electronic search was done in a period between 1960 and 2020. The search was done in Google Scholar, ISI Web of Science, PubMed, and Embase. Some keywords such as tibia fracture, healing; conservative treatment, functional orthosis, brace, and patellar tendon-bearing (PTB) orthosis were used. The first selection of the papers was based on the title and abstract. The second selection of the papers was done based on the following criteria:

  1. The paper published in English language
  2. Focused on conservative treatment
  3. Only tibia fracture was considered.


The technical notes and case studies were deleted from the list. [Figure 1] depicts the diagram of article selection procedure in the current review article. Methodological quality of papers was assessed using Down and Black tool. Reliability and validity of Down and Black tools in the evaluation of quality of research papers have been proved.[11] The quality of each paper was evaluated by two expert reviewers (the authors) separately, and the correlations of results were assessed using Pearson's correlation coefficient. The Statistical Package for the Social Sciences (SPSS) software (version 20) IBM company, USA was used for statistical evaluation.
Figure 1: The diagram of article selection procedure used in the current review article

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Some information such as the method of evaluation, number of studies, type of studies, number of subject, follow-up period, and a brief review of outcome are provided in [Table 2] and [Table 3].
Table 2: The main clinical findings of the studies on tibia fractures

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Table 3: The main clinical findings of the studies on tibia fractures

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  Results Top


Fifty papers were selected based on the aforementioned keywords. Finally, 11 papers were selected for final analysis. The quality of the studies is summarized in [Table 1]. As can be seen from this [Table 1], the quality of the studies varied between 16 and 24. One study was on the fractures of the middle part of tibia, 2 on the fracture of distal of tibia, and only one study on the fracture of proximal part of tibia (no information regarding the rests). There was only one article on the comparison between orthosis and surgical treatment. Most of studies support the use of orthosis for tibia fracture.
Table 1: The results of quality assessment (Down and Black tool)

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  Discussion Top


The incidence of tibia fractures is high and is classified into open and close fractures.[16],[17] Various methods have been used to treat tibia fracture including surgery and conservative treatment.[9] Use of functional brace is one of the effective conservative methods used to treat tibia fracture, which seems to be cost-effective. The aim of this review article was to review the evidence to support the effectiveness of brace use in this regard.

As shown in [Table 2] and [Table 3], there were 11 papers on the effectiveness of functional brace on tibia fracture. The quality of the most of papers was high due to the number of subjects and follow-up duration [Table 1]. There was also one study compared the efficiency of use of brace and surgical procedure.[7] As can be seen from the most of these studies, the final output compared with a range obtained from other research. Therefore, the main question posted here is that what is the optimum and acceptable results for treatment of tibia fracture. In other words, what is the acceptable score for shortening and angulations of the tibia?

The acceptable range of tibia shortening and angulations follow tibia fracture is based on the results of various studies.[3],[4],[6],[8],[13] Sarmiento has shown that shortening between 0 and 26 mm is acceptable in the treatment of tibia fracture. However, he emphasized that it should be tried to not exceed shortening more than 12 mm.[2],[3],[14],[18],[19] Regarding the angulations, it would be in an acceptable range if it is <8°.[19] As shown in [Table 2], the outputs of treatment of most of the studies are less than aforementioned threshold. Therefore, it can be concluded that the use of functional brace is acceptable approach in this regard.

The second question posted here is that is there any differences between the outputs of orthotic treatment used for fracture of tibia in various levels? In the research done by Sarmiento et al. on 780 patients with tibia fracture at various levels of tibia, it was shown that there was no association between fracture healing and the location of fracture.[4]

There were also two researches on the healing of fracture of distal part of tibia.[9],[14] In the research done by Pandey et al. on 39 fracture of distal part of tibia, PTB brace was used for the period of 6–8 weeks.[9] The results showed that the average shortening was 6.8 mm with 3.72° and 3.32° angulations in sagittal and frontal planes, respectively. They confirmed that use of PTB brace has acceptance reduction for fracture of distal part of tibia. In contrast in another study done by Jafari and Nozarnejad, 92.3% of patients had shortening of <1 cm for fractured treated with functional brace (for an average of 13.7 weeks).[14] The final deformation was seen in 30.77%. They concluded that the outcome was not satisfactory.

The healing of tibia fracture located in the middle part, treated by the use of functional brace, was studied by Sarmiento and Latta.[10] This study was done on 434 patients and the brace was used for a period of 26.3 days after injury. Based on the results of this research, 97% of fractures healed with 8° or less angulations in mediolateral plane. Moreover, 93.4% of them had angulations with 8 or less. The final shortening was reported as 4.3 mm. Based on the acceptable values of shortening mentioned in previous research, it can be concluded that the output of treatment of tibia fracture in the middle part is acceptable.[3],[4],[6],[12],[13] In other words, it can be used as one of the main treatment approaches for tibia fracture.

What are the main criteria for the use of functional brace for the treatment of tibia fracture?

It should be noted that use of functional brace is based on this hypothesis that immobilization of the joint above and below fracture is not necessary for fracture healing and maintain alignment. Furthermore, the motions at the fracture site should be controlled.[5],[12] The brace harvested the soft tissue of the fracture and finally creates a hydraulic pressure. Therefore, the health status of the muscles surrounding the fracture is an important key to use a functional brace. The other parameter related to condition of fibula. It has been shown that the intact of fibula has a negative influence on the output of orthotic treatment follow tibia fracture. Initial displacement and initial shortening also play a significant role in this regard.[12]


  Conclusions Top


One of the most important treatment methods used for tibia fracture is functional brace. Although there were 11 studies on the effectiveness of this treatment, most of the available studies have an acceptable quality due to high number of the subjects. Based on the results of the available literature, functional brace is a good approach for stable, fracture of tibia. Some parameters such as the condition of surrounding muscles, initial shortening, angulations of tibia, and intact of fibula play a significant role in this regard.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yelin EH, Felts WR. A summary of the impact of musculoskeletal conditions in the United States. Arthritis Rheum 1990;33:750-5.  Back to cited text no. 1
    
2.
Martinez A, Sarmiento A, Latta LL. Closed fractures of the proximal tibia treated with a functional brace. Clin Orthop Relat Res 2003;417:293-302.  Back to cited text no. 2
    
3.
Sarmiento A, Burkhalter WE, Latta LL. Functional bracing in the treatment of delayed union and nonunion of the tibia. Int Orthop 2003;27:26-9.  Back to cited text no. 3
    
4.
Sarmiento A, Gersten LM, Sobol PA, Shankwiler JA, Vangsness CT. Tibial shaft fractures treated with functional braces. Experience with 780 fractures. J Bone Joint Surg Br 1989;71:602-9.  Back to cited text no. 4
    
5.
Sarmiento A, McKellop HA, Llinas A, Park SH, Lu B, Stetson W, et al. Effect of loading and fracture motions on diaphyseal tibial fractures. J Orthop Res 1996;14:80-4.  Back to cited text no. 5
    
6.
Sarmiento A, Latta L. The evolution of functional bracing of fractures. J Bone Joint Surg Br 2006;88:141-8.  Back to cited text no. 6
    
7.
Kuzgun U, Ozturk I, KabukcuogIu Y, Ordveri M. The results of conservative and surgical treatment of tibial plateau fractures. Acta Orthop Traumatol Turc 1991;25:391-3.  Back to cited text no. 7
    
8.
Sarmiento A, Sharpe FE, Ebramzadeh E, Normand P, Shankwiler J. Factors influencing the outcome of closed tibial fractures treated with functional bracing. Clin Orthop Relat Res 1995;315:8-24.  Back to cited text no. 8
    
9.
Pandey BK, Manandhar RR, Sharma S, Pradhan RL, Lakhey S, Rijal KP. Conservative treatment of nonarticular fractures of distal third tibia. JNMA J Nepal Med Assoc 2009;48:292-5.  Back to cited text no. 9
    
10.
Sarmiento A, Latta LL. Fractures of the middle third of the tibia treated with a functional brace. Clin Orthop Relat Res 2008;466:3108-15.  Back to cited text no. 10
    
11.
Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377-84.  Back to cited text no. 11
    
12.
Swenson E, DeHaven K, Sebastianeli W. Pneumatic leg brace after tibial stress fracture for faster return to play. Am J Sports Med 1997;25:322-8.  Back to cited text no. 12
    
13.
Sarmiento A. On the behavior of closed tibial fractures: Clinical/radiological correlations. J Orthop Trauma 2000;14:199-205.  Back to cited text no. 13
    
14.
Jafari D, Nozarnejad P. Outcomes of the isolated closed tibial shaft fractures treated nonsurgically. Med J Islamic Rep Iran 2011;25:21-6.  Back to cited text no. 14
    
15.
Al-Shadedi A, Adnan H, Luay M. Functional bracing in the management of diaphyseal fractures of Tibia. Iraqi Postgrad Med J 2008;7:295-303.  Back to cited text no. 15
    
16.
Madadi F, Vahid Farahmandi M, Eajazi A, Daftari Besheli L, Madadi F, Nasri Lari M. Epidemiology of adult tibial shaft fractures: A 7-year study in a major referral orthopedic center in Iran. Med Sci Monit 2010;16:CR217-21.  Back to cited text no. 16
    
17.
Bengnér U, Ekbom T, Johnell O, Nilsson BE. Incidence of femoral and tibial shaft fractures. Epidemiology 1950-1983 in Malmö, Sweden. Acta Orthop Scand 1990;61:251-4.  Back to cited text no. 17
    
18.
Sarmiento A, Latta LL. Functional fracture bracing. J Am Acad Orthop Surg 1999;7:66-75.  Back to cited text no. 18
    
19.
Sarmiento A, Sobol PA, Sew Hoy AL, Ross SD, Racette WL, Tarr RR. Prefabricated functional braces for the treatment of fractures of the tibial diaphysis. J Bone Joint Surg Am 1984;66:1328-39.  Back to cited text no. 19
    


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    Tables

  [Table 1], [Table 2], [Table 3]



 

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