Halil BURÇ, Muhsin DURSUN, Haldun ORHUN, Volkan GÜRKAN, AVNİ İLHAN BAYHAN

Tibia diyafiz kırıklarının oymalı kilitli intramedüller çivi ile tedavisi

Amaç: Tibia diyafiz kırıklarının oymalı kilitli intramedüller çivi ile tedavi sonuçları değerlendirildi. Çalışma planı: Çalışmaya, tibia cisim kırığı nedeniyle oymalı kilitli intramedüller çivi ile tedavi edilen 73 erişkin hasta (68 erkek, 5 kadın; ort. yaş 31; dağılım 17-68) alındı. AO/ASIF sınıflamasına göre, 28 kırık tip A, 29 kırık tip B, 16 kırık tip C olarak değerlendirildi. Kırıklar, 12 hastada 1/3 proksimal, 50 hastada 1/3 orta, 11 hastada 1/3 distal diyafiz seviyesinde idi. Yirmi sekiz hastada (%38.4) kapalı kırık vardı. Gustilo-Anderson sınıflamasına göre, 30 hastada (%41.1) derece I, 10 hastada (%13.7) derece II, beş hastada (%6.9) derece IIIA açık kırık vardı. On yedi hastada (%23.3) açık, 56 hastada (%76.7) kapalı redüksiyonu takiben çivileme yapıldı. Kırık oluşumu ile ameliyat arasında geçen süre ortalama 3.4 gün (dağılım 2-11 gün); ortalama takip süresi 48 ay (dağılım 24-60 ay) idi. Hastalar hareket açıklığı, kaynama süresi ve komplikasyonlar açısından değerlendirildi. Fonksiyonel değerlendirmede Johner-Wrush ölçütleri kullanıldı. Sonuçlar: Tüm hastalarda ortalama 18.2 haftada (dağılım 8-52 hafta) kaynama elde edildi. Dört olguya kaynama gecikmesi nedeniyle dinamizasyon uygulandı. Bir hastaya grefonaj uygulandı. Dinamizasyon uygulanan bir hastada geçici duyu kaybı gelişti. Bir olguda radyografik kontrollerde distal kilit vidalarının çivi dışında görülmesi üzerine revizyon uygulandı. Diz ön ağrısı gelişen iki hastada (%2.7) sadece fleksiyon kısıtlılığı görülürken, diğer hastalarda hareket kısıtlılığına rastlanmadı. Johner-Wrush ölçütlerine göre, 45 olguda (%61.6) çok iyi, 28 olguda (%38.4) iyi sonuç elde edildi. Çıkarımlar: Tibia diyafiz kırıklarında oymalı kilitli intramedüller çivi tedavisi, komplikasyon oranı düşük, uygun bir tedavi seçeneğidir. Kontaminasyonu fazla olmayan açık kırıklarda güvenle uygulanabilir.

Anahtar Kelimeler:

Kırık tespiti, intramedüller, Tibia kırıkları, Kırıklar, açık, Kemik çivileri, Kemik vidaları

Treatment of adult tibial diaphysis fractures with reamed and locked intramedullary nailing

Objectives: We evaluated the results of reamed and locked intramedullary nailing for tibial diaphysis fractures. Methods: The study included 73 patients (68 males, 5 females; mean age 31 years; range 17 to 68 years) who were treated with reamed and locked intramedullary nailing for tibial diaphysis fractures. There were 28 AO/ASIF type A, 29 type B, and 16 type C fractures. The fractures involved the proximal 1/3 (n=12), middle 1/3 (n=50), and distal 1/3 (n=11) of the tibial diaphysis. Twenty-eight fractures (38.4%) were closed. According to the Gustilo-Anderson classification, 30 patients (%41.1) had grade I, 10 patients (%13.7) had grade II, and five patients (%6.9) had grade IIIA open fractures. Intramedullary nailing was performed following open reduction in 17 patients (23.3%), and closed reduction in 56 patients (76.7%). The mean time to surgery was 3.4 days (range 2 to 11 days) and the mean follow-up was 48 months (range 24 to 60 months). The patients were evaluated with respect to range of motion, time to union, and complications. Functional results were assessed using the Johner-Wrush criteria. Results: Union was achieved in all the patients within a mean of 18.2 weeks (range 8 to 52 weeks). Four patients required dynamization because of delayed union and grafting was performed in one patient. Transient sensorial deficit occurred in one patient after dynamization. One patient underwent revision surgery because of migration of the distal locking screws. The only limitation of range of motion was seen in flexion of two patients (2.7%) who developed anterior knee pain. According to the Johner-Wrush criteria, functional results were very good in 45 patients (61.6%), and good in 28 patients (38.4%). Conclusion: Treatment of tibial diaphysis fractures with reamed and locked intramedullary nailing is an appropriate choice with a low complication rate. It can be safely used in moderately contaminated open fractures.

Keywords:

Fracture Fixation, Intramedullary, Tibial Fractures, Fractures, Open, Bone Nails, Bone Screws,

___

1. Ege R. Tibia ve fibula cisim kırıkları. In: Ege R, editör. Travmatoloji. 3. cilt. 4. baskı, Ankara: Kadıoğlu Matbaası; 1989. s. 25-61.
2. Court-Brown CM. Fractures of the tibia and fibula. In: Bucholz RW, Heckman JD, editors. Rockwood and Green’s fractures in adults. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 1939-2000.
3. Weller S, Höntsch D. Medullary nailing of femur and tibia. In: Müller ME, Allgöwer M, Schneider R, Willenegger H, editors. Manual of internal fixation: techniques recommended by the AO-ASIF Group. 3rd ed. Berlin: Springer- Verlag; 1991. p. 291-365.
4. Chapman MW. Fractures of the shafts of the tibia and fibula. In: Chapman MW, Szabo RM, Marder R, Vince KG, Mann RA, Lane JM, et al. editors. Chapman’s orthopaedic surgery. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 755-810.
5. Trafton PG. Tibial shaft fractures. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, editors. Skeletal trauma: fractures, dislocations, ligamentous injuries. 2nd ed. Philadelphia: W. B. Saunders; 1998. p. 2187-294.
6. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg [Am] 1976;58:453-8.
7. Canale ST. Tibial shaft fractures. In: Canale ST, Campbell WC, editors. Campbell’s operative orthopaedics. 10th ed. Philadelphia: Mosby; 2003. p. 2754-82.
8. Nicoll EA. Fractures of the tibial shaft. A survey of 705 cases. J Bone Joint Surg [Br] 1964;46:373-87.
9. Sarmiento A. “Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. An outcome analysis of matched pairs of patients” [Comment] (78-A: 1336-1341, Sept. 1997). J Bone Joint Surg [Am] 1998;80:1084-5.
10. Müller ME. The comprehensive classification of fractures of long bones. In: Müller ME, Allgöwer M, Schneider R, Willenegger H, editors. Manual of internal fixation: techniques recommended by the AO-ASIF Group. 3rd ed. Berlin: Springer-Verlag; 1991. p. 118-50.
11. Bone LB, Sucato D, Stegemann PM, Rohrbacher BJ. Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. An outcome analysis of matched pairs of patients. J Bone Joint Surg [Am] 1997;79:1336-41.
12. Littenberg B, Weinstein LP, McCarren M, Mead T, Swiontkowski MF, Rudicel SA, et al. Closed fractures of the tibial shaft. A meta-analysis of three methods of treatment. J Bone Joint Surg [Am] 1998;80:174-83.
13. Hooper GJ, Keddell RG, Penny ID. Conservative management or closed nailing for tibial shaft fractures. A randomised prospective trial. J Bone Joint Surg [Br] 1991; 73:83-5.
14. 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.
15. Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators, Bhandari M, Guyatt G, Tornetta P 3rd, Schemitsch EH, Swiontkowski M, Sanders D, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg [Am] 2008;90:2567-78.
16. Nork SE, Schwartz AK, Agel J, Holt SK, Schrick JL, Winquist RA. Intramedullary nailing of distal metaphyseal tibial fractures. J Bone Joint Surg [Am] 2005;87:1213-21.
17. Alho A, Ekeland A, Strømsøe K, Follerås G, Thoresen BO. Locked intramedullary nailing for displaced tibial shaft fractures. J Bone Joint Surg [Br] 1990;72:805-9.
18. Court-Brown CM. Reamed intramedullary tibial nailing: an overview and analysis of 1106 cases. J Orthop Trauma 2004;18:96-101.
19. Court-Brown CM, Gustilo T, Shaw AD. Knee pain after intramedullary tibial nailing: its incidence, etiology, and outcome. J Orthop Trauma 1997;11:103-5.
20. Cannada LK, Anglen JO, Archdeacon MT, Herscovici D Jr, Ostrum RF. Avoiding complications in the care of fractures of the tibia. J Bone Joint Surg [Am] 2008;90:1760-8.
21. Nassif JM, Gorczyca JT, Cole JK, Pugh KJ, Pienkowski D. Effect of acute reamed versus unreamed intramedullary nailing on compartment pressure when treating closed tibial shaft fractures: a randomized prospective study. J Orthop Trauma 2000;14:554-8.