Eklem dışı distal tibia kırıklarının tedavisinde minimal invazif plaklı osteosentez ile intramedüller çivilemenin karşılaştırılması

Amaç: Çalışmamızın amacı, eklem dışı distal tibia kırıklarının tedavisinde kullanılan intramedüller çivileme (İMÇ) ve minimal invazif plaklı osteosentezin (MİPO) fonksiyonel ve radyolojik sonuçlarının karşılaştırılmasıdır. Gereç ve Yöntem: Ocak 2008 ve Ocak 2015 tarihleri arasında hastanemizde eklem dışı distal tibia kırığı tanısıyla MİPO ya da İMÇ ile tedavi edilen 59 hasta geriye dönük olarak değerlendirildi. Kırık kaynamasının ve açısal deformitelerin değerlendirilmesi için postoperatif radyografiler kullanıldı. Hastaların fonksiyonel sonuçlarının değerlendirilmesinde ise Olerud-Molender Ankle Scoring (OMAS) yöntemi kullanıldı ve hastaların ayak bileği hareket genişlikleri goniometre ile ölçüldü. Bulgular: Yapılan son değerlendirmede tüm kırıkların kaynadığı görüldü. Kırıkların ortalama kaynama süresi MİPO grubunda 16,1 hafta (12-24 hafta) ve İMÇ grubunda ise 15,5 hafta (10-24 hafta) idi (p= 0.254). Ortalama OMAS skoru İMÇ grubunda 67,5 (40–90) MİPO grubunda ise 63 (30-90) idi (p= 0,12). Ortalama operasyon süresi İMÇ grubunda 95(45-115) dakika ve MİPO grubunda 75 (40-100) dakikaydı (p= 0,04). Ortalama radyasyon maruziyet süresi İMÇ grubunda 30 (8-143) saniye ve MİPO grubunda 17 (5-65) saniyeydi (p= 0,03). Açısal deformiteler İMÇ grubunda 7 (%23) hastada MİPO grubunda 5 (%17) hastada görüldü. Yumuşak doku problemleri ise MİPO grubunda daha fazla hastada görüldü. Sonuç: Sonuç olarak İMÇ ve MİPO distal tibia metafizer bölge kırıklarının tedavisinde güvenle kullanılabilmektedir. İntramedüller çivileme daha fazla hastada açısal deformiteye ve gecikmiş kaynamaya neden olurken MİPO daha sık yumuşak doku sorunlarına ve daha kötü fonksiyonel sonuçlara sebep olabilmektedir.

Comparison of minimally invasive plate osteosynthesis and intramedullary nailing in the treatment of distal extraarticular tibial fractures

Aim: Our study’s aim was to investigate the effectiveness of minimal invasive plate osteosynthesis(MIPO) and intramedullary nailing (IMN) in extraarticular distal tibia fractures and to compare theoutcomes of these two treatment methods.Materials and Methods: Between January 2008 and January 2015, 59 patients had extraarticulardistal tibia fracture and treated with MIPO or IMN were evaluated retrospectively. Postoperative x-rayswere evaluated for fracture consolidation and angular deformities. For the functional evaluations of thepatients Olerud-Molender Ankle Scoring (OMAS) method was used and ankle joint range of motionwas measured by goniometer.Results: At the last visit, all the fractures consolidated. Average union time was 16.1weeks (range, 12-24 weeks) in MIPO group and 15.5 weeks (range 10-24 weeks) in IMN group, respectively (p = 0.254).The mean OMAS scores were 67.5 (range 40–90) and 63 (range 30-90) in the IMN and MIPO groups,respectively (p= 0.12). The mean operation time was 95(range 45-115) minutes in IMN group and75(range 40-100) minutes in MIPO group (p= 0.04). The mean operative radiation exposure timeswere 30(range 8-143) and 17 (range 5-65) seconds in IMN and MIPO groups, respectively (p= 0.03).Angular deformities were found in IMN group at 7 (23%) patients and in MIPO group at 5 (17%)patients, respectively. Soft tissue problems were seen in more patients in MIPO group.Conclusion: In conclusion, IMN and MIPO can be used safely in the treatment of distal tibialmetaphyseal fractures. While IMN caused more angular deformity and more union delay, patientstreated with MIPO had poorer functional results and more soft tissue problems.

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1. Bilat C, Leutenegger A, Ruedi T. Osteosynthesis of 245 tibial shaft fractures: early and late complications. Injury 1994; 35: 349–58.
2. Batten RL, Donaldson LJ, Aldridge MJ. Experience with the AO method in the treatment of 142 cases of fresh fractures of the tibial shaft treated in the UK. Injury 1978; 10:108–14.
3. Lai TC, Fleming JJ. Minimally Invasive Plate Osteosynthesis for Distal Tibia Fractures. Clin Podiatr Med Surg 2018; 35 (2): 223-32.
4. Xue XH, Yan SG, Cai XZ, Shi MM, Lin T. Intramedullary nailing versus plating for extraarticular distal tibial metaphyseal fracture: a systematic review and meta-analysis. Injury 2014; 45 (4): 667-76.
5. Iqbal HJ, Pidikiti P. Treatment of distal tibia metaphyseal fractures; plating versus intramedullary nailing: a systematic review of recent evidence. Foot Ankle Surg 2013; 19 (3):143-7.
6. El Attal R, Hansen M, Rosenberger R, Smekal V, Rommens PM, Blauth M. Intramedullary nailing of the distal tibia illustrated with the Expert(TM) tibia nail. Oper Orthop Traumatol 2011; 23 (5): 397-410.
7. Polat A, Kose O, Canbora K, Yanık S, Guler F. Intramedullary nailing versus minimally invasive plate osteosynthesis for distal extraarticular tibial fractures: a prospective randomized clinical trial. J Orthop Sci 2015; 20 (4): 695-701.
8. Hasenboehler E, Rikli D, Babst R.Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture: a retrospective study of 32 patients. Injury 2007, 38 (3): 365-70.
9. Mauffrey C, McGuinness K, Parsons N, et al. A randomized pilot trial of “Locked Plate” fixations versus intramedullary nail for extraarticular fractures of the distal tibia. J Bone Joint Surg Br 2012; 94: 704–8.
10. Kwok C, Crossman P, Loizou L. Plate versus nail for distal tibia fractures: asystematic review and metaanalysis. J OrthopTrauma 2014; 28:542–8.
11. Hoegel FW, Hoffmann S, Weninger P, Bühren V, Augat P: Biomechanical comparison of locked plate osteosynthesis, reamed and unreamed nailing in conventional interlocking technique, and unreamed angle stable nailing in distal tibia fractures. J Trauma Acute Care Surg 2012; 73 (4): 933–8.
12. Vidović D, Matejčić A, Ivica M, Jurišić D, Elabjer E, Bakota B. Minimally-invasive plate osteosynthesis in distal tibial fractures: Results and complications. Injury 2015; 46 Suppl 6:S96-9.
13. Barcak E, Collinge CA. Metaphyseal Distal Tibia Fractures: A Cohort, Single-Surgeon Study Comparing Outcomes of Patients Treated With Minimally Invasive Plating Versus Intramedullary Nailing. J Orthop Trauma 2016; 30 (5): e169-74.
14. Costa ML, Achten J, Griffin J, Petrou S, Pallister I, Lamb SE, Parsons NR: Fix DT Trial Investigators. Effect of Locking Plate Fixation vs Intramedullary Nail Fixation on 6-Month Disability Among Adults With Displaced Fracture of the Distal Tibia: The UK Fix DT Randomized Clinical Trial. JAMA 2017; 318 (18): 1767-76.
15. Guo JJ, Tang N, Yang HL, Tang TS. A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. J Bone Joint Surg Br 2010; 92 (7): 984-8.
16. Kim JW, Kim HU, Oh CW, Kim JW, Park KC. A Prospective Randomized Study on Operative Treatment for Simple Distal Tibial Fractures-Minimally Invasive Plate Osteosynthesis Versus Minimal Open Reduction and Internal Fixation. J Orthop Trauma 2018; 32 (1): e19-e24.
17. Beytemur O, Baris A, Albay C, Yüksel S, Çaglar S, Alagoz A. Comparison of Intramedullary Nailing and Minimal Invasive Plate Osteosynthesis in the Treatment of Simple Intra-Articular Fractures of the Distal Tibia (AO-OTA Type 43 C1-C2). Acta Orthop Traumatol Turc 2017; 51 (1):12-6.
18. Mioc ML, Prejbeanu R, Deleanu B, Anglitoiu B, Haragus H, Niculescu M. Extraarticular Distal Tibia FracturesControversies Regarding Treatment Options. A Single-Centre Prospective Comparative Study. Int Orthop 2018; 42 (4): 915-9.
19. Vallier HA, Le TT, Bedi A. Radiographic and Clinical Comparisons of Distal Tibia Shaft Fractures (4 to 11 Cm Proximal to the Plafond): Plating Versus Intramedullary Nailing. J Orthop Trauma 2008; 22 (5): 307-11.
20. Wang B, Zhao Y, Wang Q, Hu B, Sun L, Ren C, Li Z, Zhang K, Hao D, Ma T, Lu Y. Minimally invasive percutaneous plate osteosynthesis versus intramedullary nail fixation for distal tibial fractures: a systematic review and meta-analysis. J Orthop Surg Res 2019; 14 (1): 456-60.
21. Liu XK, Xu WN, Xue QY, Liang QW. Intramedullary nailing versus minimally invasive plate osteosynthesis for distal tibial fractures: A Systematic review and meta-Analysis. Orthop Surg 2019; 11 (6): 954-65.