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Young Ninja Group (ages 3-5)

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Myron Markov
Myron Markov

Classic Botter 7.4 Tibia: How to Avoid Detection and Ban by GMs


The re-establishment of joint congruity and stability determines the success of the treatment.11 Successful treatment of tibial plateau fractures comprises a reconstruction of the articular surface, usually with open reduction of the tibial plateau. However, ORIF has been associated with complications attributed to soft tissue compromise12 despite the evolution of minimally invasive techniques.13 Alternatively, management by external fixation (ExFix; using indirect reduction through closed manipulation or minor open reduction by limited access incisions) has been a satisfactory alternative when the soft tissue integrity is affected severely.14,15 The better management choice is still not clear.




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Metcalfe et al. in 2015 compared ExFix and ORIF for the management of bicondylar tibial plateau fractures and found no significant difference in the postoperative complications, radiological evaluations, and functional outcomes.16 However, the study samples and measured complications were not comprehensive. This study aims a more inclusive and up-to-date meta-analysis for high-energy complex tibial plateau fractures.


Our study samples for this meta-analysis included Schatzker type IV fractures. There are two reasons for this inclusion. First, the three column-classification elaborated by Kfuri et al.17 stresses the importance of the posterior column, present in the coronal section of the articular surface of a tibial plateau posteromedial fracture (a subtype of Schatzker type IV), which may require ExFix as definitive treatment. This is recommended because of the inaccessibility and difficulty of stabilising the posteromedial part of the medial fragment. Second, the medial part of the tibial plateau is denser than the lateral; therefore, a higher force is needed to produce the fracture which supports classifying type IV fractures as high-energy types.17


In this meta-analysis, ORIF was found to be superior to ExFix in radiological and functional outcomes without reaching statistical significance. This may arise from allowing for better visualisation of fracture configuration and achieving an anatomical reduction, but there are compromises made over soft tissue integrity and to the disruption of biological osteosynthesis. External fixators with different specific frame types ranging from circular hexapod, hybrid, to classic Ilizarov have gained popularity and allow for adequate closed reduction, permit early weight-bearing while respecting the soft tissue envelope. Various types of complications arise from the method of treatment itself, ranging from pin-site infections, prolonged time of healing, and the inconvenience of the device location outside the body leading to poorer patient tolerance or compliance. Furthermore, ExFix might jeopardise the absolute quality of reduction as most is done percutaneously or by closed methods; however, it remains unclear as to whether this affects functional outcomes ultimately because of the lack of long-term follow-up in the literature.25,39,46,47


Secondary OA remains an issue after intra-articular fractures of the knee. A pooled analysis of seven studies showed a significantly higher rate of secondary OA in the ExFix group than in the ORIF group with statistical significance. In addition to the cartilage injury, malalignment after treatment is considered an important factor of poor outcome after tibial plateau fracture with a higher risk of OA.9,46 Although less invasive, ExFix does not allow for an anatomic realignment of the joint surface, which may influence the integrity of the reduction. The loss of anatomical reduction at the articular surface may lead to increased joint reactive forces linked to development of OA.


Heterotopic ossification is rare in tibial plateau fractures. A pooled analysis of two studies done in 2009 and 2018 showed a significantly higher rate of HTO in ORIF. This is attributed possibly to either the post-reduction use of bone graft or bone graft substitutes27,32,44 or to the mechanical stimuli from plate placement within a leg compartment that has been subject to soft tissue compromise which alters the pH, oxygen tension, and availability of micronutrients.48


Boa tarde, eu segui seu vídeo certinho mas no address da direção do player vieram 3 valores, os 3 adress sempre davam o mesmo valor, eu peguei o primeiro valor dos 3, encontrei os valores de life/mana/pos/speed/name etc... mas quando clico em READ eles não aparecem no bot. obs: o cliente é OTC8. E esse OT que mencionei está em alta agora por isso comentei, é um tibia NFT.


Pois é eu segui seu vídeo certinho mas no address da direção do player vieram 3 valores, os 3 adress sempre davam o mesmo valor, eu peguei o primeiro valor dos 3, encontrei os valores de life/mana/pos/speed/name etc... mas quando clico em READ eles não aparecem no bot. obs: o cliente é OTC8. E esse OT que mencionei está em alta agora por isso comentei, é um tibia NFT.


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