Objectives: To assess the relationship between the distal nail target and postoperative alignment for distal tibia fractures treated with intramedullary nailing. Design: Retrospective cohort study. Setting: A single level 1 trauma center. Patients/Participants: One hundred thirty distal tibia fractures treated with intramedullary nailing over a 10-year period. Main Outcome Measurements: Malalignment >5 degrees. Results: Thirty-eight cases (29.2%) of malalignment >5 degrees included valgus (19 cases, 14.6%), procurvatum (13 cases, 10.0%), recurvatum (1 case, 0.8%), and combined valgus with procurvatum (5 cases, 3.8%). Medially directed nails demonstrated relative valgus (mean lateral distal tibia angle 86.4 vs. 89.4 degrees, P < 0.01) and more frequent coronal malalignment (24 of 78, 30.8% vs. 0 of 52, 0%, P < 0.01). Anteriorly directed nails demonstrated relative procurvatum (mean anterior distal tibia angle 82.8 vs. 80.9 degrees, P < 0.01) and more frequent sagittal malalignment (15 of 78, 19.2% vs. 3 of 52, 5.8%, P = 0.03). Malalignment was less common for nails targeting the central or slightly posterolateral plafond (0 of 30, 0% vs. 38 of 100, 38%), P < 0.01. Multivariate analysis demonstrated the distal nail target (P = 0.03), fracture within 5 cm of the plafond (P = 0.01), as well as night and weekend surgery (P = 0.03) were all independently associated with malalignment. Conclusions: Alignment of distal tibia fractures is sensitive to both injury and treatment factors. Nails should be targeted centrally or slightly posterolaterally to minimize malalignment. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Rupture of the anterior cruciate ligament (ACL) is the one of the most common sports-related injuries. With its poor healing capacity, surgical reconstruction using either autografts or allografts is currently required to restore function. However, serious complications are associated with graft reconstructions and the number of such reconstructions has steadily risen over the years, necessitating the search for an alternative approach to ACL repair. Such an approach may likely be tissue engineering. Recent engineering approaches using ligament-derived fibroblasts have been promising, but the slow growth rate of such fibroblasts in vitro may limit their practical application. More promising results are being achieved using bone marrow mesenchymal stem cells (MSCs). The adipose-derived stem cell (ASC) is often proposed as an alternative choice to the MSC and, as such, may be a suitable stem cell for ligament engineering. However, the use of ASCs in ligament engineering still remains relatively unexplored. Therefore, in this study, the potential use of human ASCs in ligament tissue engineering was initially explored by examining their ability to express several ligament markers under growth factor treatment. ASC populations treated for up to 4 weeks with TGFβ1 or IGF1 did not show any significant and consistent upregulation in the expression of collagen types 1 and 3, tenascin C and scleraxis. While treatment with EGF or bFGF resulted in increased tenascin C expression, increased expression of collagens 1 and 3 were never observed. Therefore, simple in vitro treatment of human ASC populations with growth factors may not stimulate their ligament differentiative potential.

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