Eklem Dışı Tibia Kırıkları Tedavisinde Minimal İnvaziv Plak Osteosentez Uygulama Sonuçlarını Etkileyen Faktörler

Amaç: Bu çalışmada eklem dışı tibia kırıkları minimal invaziv plak osteosentezi (MİPO) ile tedavi edilen hastalar değerlendirilerek hasta ve tedavi yöntemine ait çeşitli faktörlerin; fonksiyonel, klinik ve radyografik sonuçlara olan etkisinin araştırılması amaçlanmıştır.Gereç ve Yöntemler: Ekim 2010 – Nisan 2014 tarihleri arasında eklem dışı tibia kırıkları MİPO tekniği ile tedavi edilen 33 hasta değerlendirildi. Ameliyat öncesi hasta faktörleri, fonksiyonel skor ve ameliyat esnasındaki cerrahi teknikle ilgili faktörler ile fonksiyonel skor, klinik ve radyolojik sonuçlar ile kıyaslandı.Bulgular: Ortalama yaş 46,1 (20-70) idi. Kırıkların %12,1’i proksimalde, %33,3’ü diafizde, 18 (%54,5)’i distalde oluşmuştu. Kırıkların 4 (%12,1)’i tip 1 açık, 4 (%12,1)’i tip 2 açık, diğer 25 (%75,8) kırık ise kapalı kırıktı. Tüm hastaların kırıkları ortalama 21,2 haftada kaynadı. Direkt travma sonucu daha sık görülen parçalı kırıkların daha geç kaynadığı tespit edildi. Komplikasyon gelişen altı hastanın kırığı daha geç kaynadı. Dizilim bozukluğu 5 dereceden fazla olan hasta sayısı ameliyat sonrası 3 (%9,1) iken, 12. ayda 4 (%12,1) olarak tespit edildi. Fonksiyonel durumları LEFS skoru ile değerlendirilen hastaların LEFS skorundaki ortalama 4,72 puanlık düşüşü klinik olarak anlamlı değildi. Plak kırık uzunluk oranının; kaynama süresi, dizilim ve LEFS skorundaki değişimle ilişkisi olmadığı görüldü. Sonuç: MİPO yöntemi özellikle parçalı kırıklarda ve metafizer bölge kırıklarında göreceli stabilite ve biyolojik kaynamanın avantajları ile hızlı kaynama sağlayarak fonksiyonel iyileşmeyi sağlamaktadır. Diafizer bölgenin basit kırıklarında açısal ve torsiyonel stabil fiksasyon sağlaması sebebi ile MİPO alternatif bir tedavi yöntemidir.

Anahtar Kelimeler:

Tibia kırıkları, minimal invaziv plak osteosentezi, mipo

Factors Effecting Results Of Minimally Invasive Plate Osteosynthesis For Extra-Articular Tibia Fractures

Aim: In this study we aimed to analyze the relationships between patient and treatment related factors and healing time, alignment, LEFS score by evaluating the results of patients whom were treated with MIPO for extra-articular tibial fractures. Material and Method: Thirty-three patients with extra-articular tibial fractures that were treated with MIPO between October 2010- April 2014 in our clinic were included in the study. Patient related factors and surgical technique details were compared with functional, clinical and radiological results. Results: Mean age of 33 patients was 46.1 (20-70). 12.1% of fractures was proximal, 33.3% was diaphyseal, 54.5% was distal; 4 (12.1%) of them were type 1 open, 4 (12.1%) were type 2 open, remaining 25 (75.8%) were closed fractures. All fractures were healed an average of 21.2 weeks. Comminuted fractures which are result of direct trauma frequently healed later. Also fractures of six patients with complications healed within longer union times. There were 3 (9.1%) patients with more than 5 degrees malalignment at the beginning and 4 (12.1%) at 12th month. Patients’ functional status which were evaluated with LEFS score showed 4.72 decrease at an average but this much is clinically not significant. Plate span ratio was not correlated with union time, malalignment and change in LEFS score. Conclusion: MIPO method allows rapid functional healing especially in comminuted fractures and metaphyseal region fractures with relative stability and advantages of biologically healing. With torsional and angular stability MIPO is a good treatment option in simple fractures of diaphyseal region. this study we aimed to analyze the relationships between patient factors, treatment factors and healing time, alignment, LEFS score by evaluating the results of patients whom were treated with MIPO for extra-articular tibial fractures.Material and Method: In our study pre-operative patient factors and functional scores of 33 patients whose extra-articular tibial fractures were treated with MIPO between October 2010- April 2014 and intra-operative surgical technique factors were checked against functional, clinical and radiological results. Results were statistically compared.Results: Mean age of 33 patients was 46.1 (20-70). 12.1% of fracture was proximal, 33.3% was diaphyseal, 54.5% was distal tibial fracture; 4 (12.1%) of them were type 1 open, 4 (12.1%) were type 2 open, other 25 (75.8%) were closed fractures. All fractures healed within a mean of 21.2 weeks union time. Comminuted fractures which occur with direct trauma more frequently healed within longer union times. Fractures of six patients with complication healed within longer union times. There were 3 (9.1%) patients with more than 5 degrees malalignment at the beginning and 4 (12.1%) at 12th month. Patients’ functional status were evaluated with LEFS score and 4.72 point drop in mean is clinically not important. Plate span ratio is not related with union time, alignment and change in LEFS score. Conclusion: MIPO method allows rapid functional healing especially in comminuted fractures and metaphyseal region fractures with relative stability and biologically union. MIPO is a good treatment option with torsional and angular stability in simple fractures of diaphyseal region.

Keywords:

Tibia fractures, minimally invasive plate ostheosynthesis,

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Perren SM. The concept of biological plating using the limited contact-dynamic compression plate (LC-DCP). Scientific background, design and application. Injury. 1991;22 Suppl 1:1-41.
Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002;84(8):1093-110.
Alnahdi AH, Alrashid GI, Alkhaldi HA, Aldali AZ. Cross-cultural adaptation, validity and reliability of the Arabic version of the Lower Extremity Functional Scale. Disabil Rehabil. 2015:1-8.
Krettek C, Miclau T, Grun O, Schandelmaier P, Tscherne H. Intraoperative control of axes, rotation and length in femoral and tibial fractures. Technical note. Injury. 1998;29 Suppl 3:C29-39.
Gautier E, Sommer C. Guidelines for the clinical application of the LCP. Injury. 2003;34 Suppl 2:B63-76.
Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther. 1999;79(4):371-83.
Court-Brown CM. Fractures of the Tibia and Fibula. In: Bucholz WR, Heckman DJ, Court-Brown CM, editors. Rockwood and Green’s Fractures in Adults. 2. 6 ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 2080-146.
Bhat R, Wani MM, Rashid S, Akhter N. Minimally invasive percutaneous plate osteosynthesis for closed distal tibial fractures: a consecutive study based on 25 patients. Eur J Orthop Surg Traumatol. 2015;25(3):563-8.
Rijal L, Sagar G, Mani K, Joshi KN, Joshi A. Minimizing radiation and incision in minimally invasive percutaneous plate osteosynthesis (MIPPO) of distal tibial fractures. Eur J Orthop Surg Traumatol. 2013;23(3):361-5.
Ronga M, Longo UG, Maffulli N. Minimally invasive locked plating of distal tibia fractures is safe and effective. Clin Orthop Relat Res. 2010;468(4):975-82.
Li B, Yang Y, Jiang LS. Plate fixation versus intramedullary nailing for displaced extra-articular distal tibia fractures: a system review. Eur J Orthop Surg Traumatol. 2015;25(1):53-63.
Naik MA, Arora G, Tripathy SK, Sujir P, Rao SK. Clinical and radiological outcome of percutaneous plating in extra-articular proximal tibia fractures: a prospective study. Injury. 2013;44(8):1081-6.
Aksekili MA, Celik I, Arslan AK, Kalkan T, Ugurlu M. The results of minimally invasive percutaneous plate osteosynthesis (MIPPO) in distal and diaphyseal tibial fractures. Acta Orthop Traumatol Turc. 2012;46(3):161-7.
Pichler W, Grechenig W, Tesch NP, Weinberg AM, Heidari N, Clement H. The risk of iatrogenic injury to the deep peroneal nerve in minimally invasive osteosynthesis of the tibia with the less invasive stabilisation system: a cadaver study. J Bone Joint Surg Br. 2009;91(3):385-7.
Lidder S, Masterson S, Grechenig C, Clement H, Gansslen A, Grechenig S. The risk of neurovascular injury in minimally invasive plate osteosynthesis (MIPO) when using a distal tibia anterolateral plate: a cadaver study. Acta Chir Orthop Traumatol Cech. 2014;81(5):313-6.
Deangelis JP, Deangelis NA, Anderson R. Anatomy of the superficial peroneal nerve in relation to fixation of tibia fractures with the less invasive stabilization system. J Orthop Trauma. 2004;18(8):536-9.
Ozsoy MH, Tuccar E, Demiryurek D, Bayramoglu A, Hayran M, Cavusoglu AT, et al. Minimally invasive plating of the distal tibia: do we really sacrifice saphenous vein and nerve? A cadaver study. J Orthop Trauma. 2009;23(2):132-8.
Mirza A, Moriarty AM, Probe RA, Ellis TJ. Percutaneous plating of the distal tibia and fibula: risk of injury to the saphenous and superficial peroneal nerves. J Orthop Trauma. 2010;24(8):495-8.
Kayali C, Agus H, Eren A, Ozluk S. How should open tibia fractures be treated? A retrospective comparative study between intramedullary nailing and biologic plating. Ulus Travma Acil Cerrahi Derg. 2009;15(3):243-8.
Borg T, Larsson S, Lindsjo U. Percutaneous plating of distal tibial fractures. Preliminary results in 21 patients. Injury. 2004;35(6):608-14.
Krackhardt T, Dilger J, Flesch I, Hontzsch D, Eingartner C, Weise K. Fractures of the distal tibia treated with closed reduction and minimally invasive plating. Arch Orthop Trauma Surg. 2005;125(2):87-94.
Khalsa AS, Toossi N, Tabb LP, Amin NH, Donohue KW, Cerynik DL. Distal tibia fractures: locked or non-locked plating? A systematic review of outcomes. Acta Orthop. 2014;85(3):299-304.
Boldin C, Fankhauser F, Hofer HP, Szyszkowitz R. Three-year results of proximal tibia fractures treated with the LISS. Clin Orthop Relat Res. 2006;445:222-9.
Egol KA, Weisz R, Hiebert R, Tejwani NC, Koval KJ, Sanders RW. Does fibular plating improve alignment after intramedullary nailing of distal metaphyseal tibia fractures? J Orthop Trauma. 2006;20(2):94-103.
Guven M, Ceviz E, Demirel M, Ozler T, Kocadal O, Onal A. Minimally invasive osteosynthesis of adult tibia fractures by means of rigid fixation with anatomic locked plates. Strategies Trauma Limb Reconstr. 2013;8(2):103-9.