Progress about Surgical Approach in Treatment of Tibia Shaft Fracture with Intramedullary Nail / 现代生物医学进展

Tibia shaft fracture is the most common long bone fractures clinically and intramedullary nail fixation is the best choice due to superior biomechanical characteristics for unstable tibia shaft fractures.At present,the common approaches for intramedullary nail insertion are divided into supra-patellar approach and infra-patellar approach.The semi-extended position of supra-patellar approach contributes to better fracture reduction but lead to potential patella-femoral cartilage injury.In contrast,flexion or hyper-flexion position of infra-patellar approach might result in unsatisfactory fracture reduction,then have an impact on clinical outcome.Therefore,the clinical outcome might be different because of approach choice.However,there is no consensus about the optimal surgical approach for intramedullary nailing.Thus,we performed the review to discuss the approaches for tibia intramedullary nailing and compare their strengths and weaknesses.

Ankle Fracture Associated with Tibia Shaft Fractures

PURPOSE: The purpose of this study is to evaluate the incidence of ankle injury in ipsilateral tibial shaft fractures and to assess the risk factors for ankle injury associated with tibial shaft fractures. MATERIALS AND METHODS: Sixty patients with tibial shaft fractures were enrolled in this retrospective study. The incidence and characteristics of ankle injury were evaluated, and fracture classification, fracture site, and fracture pattern of the tibial shaft fractures were analyzed for assessment of the risk factors for ankle injury combined with tibial shaft fractures. RESULTS: Ankle injury occurred in 20 cases (33%). There were four cases of lateral malleolar fracture, four cases of posterior malleolar fracture, two cases of distal tibiofibular ligament avulsion fracture, and 10 cases of complex injury. Fourteen cases (70%) of 20 cases of ankle injury were diagnosed from x-ray films, and the other six cases were recognized in ankle computed tomography (CT). Ankle injury occurred in 45.1% of distal tibial shaft fractures and found in 41.4% of A type, but there was no statistical significance. Ankle injury was observed in 54% of cases of spiral pattern of tibial shaft fracture and the incidence was statistically higher than 19% of cases of non-spiral pattern tibial shaft fracture. CONCLUSION: Ankle injury was observed in 33% of tibial shaft fractures; however, only 70% could be diagnosed by x-ray. Ankle injury occurred frequently in cases of spiral pattern of tibial shaft fracture, and evaluation of ankle injury with CT is recommended in these cases.

A Comparison of the Results between Intramedullary Nailing and Minimally Invasive Plate Osteosynthesis in Distal Tibia Fractures / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to compare the results of treatment of distal tibial fractures between intramedullary (IM) nailing and minimally invasive plate osteosynthesis (MIPO). MATERIALS AND METHODS: Between January 2007 and February 2012, 57 patients (57 cases) were treated for distal tibial fractures. Thirty-two patients (32 cases) were treated with IM nailing (nail group) and the 25 patients (25 feet) were treated with MIPO (plate group). Clinical results were compared using range of motion (ROM) of the ankle joint, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Olerud-Molander score between nail group and plate group. Radiographic results were compared using mean bony union time, coronal and sagittal malunions, and shortening between the groups. RESULTS: Mean ROM of the ankle joint was significantly larger in nail group until 6 months after surgery; however, it was not different between two groups at the last follow-up. AOFAS score and Olerud-Molander score were not different between two groups at the last follow-up. In the nail group, two malunions more than 5 degrees were observed in coronal and sagittal planes, respectively. One case showed non-union in the plate group, however, bone union was obtained after autogeneous bone graft. CONCLUSION: Treatment using IM nailing is more advantageous in terms of postoperative rehabilitation than MIPO in distal tibial fractures.

Percutaneous locking compression plate and interlocking intramedullary nail:a comparison in the treatment of distal tibia shaft fracture / 中国矫形外科杂志

[Objective]To evaluate the radiographic and clinical results of locking compression plate and interlocking intramedullary nail in the treatment of distal tibial shaft fracture(4 to 11cm proximal to tibiotalar joint).[Method]A total of 65 cases of distal tibia shaft fractures were retrospectively reviewed from 2003 to 2007.Thirty-seven cases were treated with locking compression plate as group A,and 28 cases were treated with interlocking intramedullary nail as group B.According to AO classification system,32 cases were type A,12 were type B,21 were type C.[Result]All cases were followed up for 12-24 months(mean,16.5 months).Five cases were found delayed or nonunion,with 1 case in group A and 4 cases in group B.One case in group A and 2 cases in group B were found developed deep infection.Two cases in group A and 8 cases in group B received second operation.The good-to-excellent rates of ankle joint function were 91.9% in group A and 71.4% in group B.The good-to-excellent rates of knee joint function were 97.3% in group A and 78.6% in group B.[Conclusion]Distal tibial shaft fracture could be treated successfully with either percutaneous plates or intramedullary nails.Percutaneous locking plate is better than intramedullary nail in aspect of prevention of delayed union,malunion and second operation.

To assess the management of fracture on middle third of the tibia shaft with Kuntscher nail

46 patients with occult fracture on middle third of tibia shaft due to many causes were surgical treated by intramedullary fixation with Küntscher nail: 37 patients were treated at Viet Duc Hospital from January 1996 to July 1999 and 9 patients were treated at Hospital No 103 from April 1993 to July 1999. Outcomes: very good 27 cases (84.37%), good 5 cases (15.63%). Advantages of this procedure were firm fixation; early rehabilitation that helping bone union; easy to use so that it can be used at all hospitals; dissection of periosteum in this procedure is less than fixation with screw that making less vascular damages and better healing. Disadvantages were higher risk of infections, slower bone union, and this procedure can’t be used for fracture of upper or lower third of tibia shaft

Minimally Invasive Percutaneous Plate Fixation for Distal Tibia Shaft Fractures / 대한정형외과학회잡지

PURPOSE: To review the efficiency of the minimally invasive plate fixation technique for distal tibia shaft fractures. MATERIALS AND METHODS: Between April 1999 and March 2001, 15 patients with distal tibia fractures were treated operatively by minimally invasive percutaneous plate osteosynthesis. There were 10 men and 5 women with an average age of 51 years (range, 20 to 72 years). The patients were followed for an average of 19 months (range, 12 to 30 months). In all patients, the center of fracture was in the distal tibia and either entirely extraarticular or with minimally displaced extension into the ankle joint. The type of fracture was evaluated using the AO/OTA classification. So far as general condition of patients permitted, temporary reduction of fractures with or without passive traction or distractor was performed under intraoperative fluoroscopy. About a 2 cm to 3 cm incision was made in the metaphyseal region proximal or distal to the fracture site, and screws fixation was performed percutaneously. A clinical assessment was evaluated according to Olerud and Molander ankle score. RESULTS: All of the fractures healed with an average time of 15 weeks (range, 10 to 25 weeks). No patient had an angular deformity more than 5 degrees, or shortening of more than 1 cm. All patients had an excellent or satisfactory ankle function. Checkrein deformity was observed in one patient and superficial infections occurred in two, but no patient experienced deep infection or skin necrosis. CONCLUSION: As compared with conventional open reduction and internal plate fixation, minimally invasive percutaneous plate osteosynthesis technique was found to be an effective method of treating distal tibia fractures, because it facilitates the rehabilitation more rapid patient rehabilitation, and induces osteosynthesis with reduced of the rates of infection and nonunion.

Anterior Knee Pain after Tibia Intramedullary Nailing

Treatments of tibia shaft fracture are closed reduction followed by cast immobilization, external fixation, intramedullary nailing and internal fixation with plate and screws. Among these, intramedullary nailing is commonly used method today. The tibia nailing has high rate of union, but malunion, infection, the joint stiffness and anterior knee pain develops frequently. We reviewed the clinical and radiological result of anterior knee pain retrospectively after tibia nailing. The result were as follows: l. Age distribution of tibia shaft fracture was 17 to 76, and mean age was 40 male patients were 35 and female 13. 2. The open fractures were 17 and the closed fractures were 34. 3. The causes of' tibia shaft fracture were traffic accidents(30cases), fall down injuries(6 cases), slip down injuries(1 1 cases) and other injuries(4 cases) Among the these, 19 cases were cornbined with other fractures or neuri.isurgical injuries. 4. The incision methods were recorded as follows: parapatella tendon incision were 9 cases, patella splitting incision were 25 cases and unrecorded were 17cases. 5. According to the radiological analysis, the average nail plateau distance was 10.3mm and the extent of nail protrusion beyond the anterior cortex was -1.73mm. Among these, protrusion of proximal targeting screws were 8 cases. 6. Insertion of nail through the patella tendon was associated with a hipher incidence of knee pain compared to paratendon site of insertion. The extent of nail protrusion were related to anterior knee pain after tibia intramedullary nailing.

Treatment of the Open Tibial Shaft Fractures: a comparison of the Ilizarov external fixator and unreamed interlocking intramedullary nail / 대한정형외과학회잡지

Open fractures of the tibial shaft have a high incidence of complication and often result in poor outcomes. The most common method of stabilization is the external fixation by way of the Ilizarov method but the small diameter interlocking intramedullary nailing has also been introduced. The purpose of this study is to analyze the result of Ilizarov method and to compare its results with those of delayed intramedullary nailing used in the treatment of open tibial shaft fractures. We analyzed 81 patients with open tibial shaft fractures, treated using Ilizarov external fixator, or by delayed locked intramedullary nailing between January 1987 and December 1994. The follow-up period was an average 14.5 months. Out of the 81 patients, 58 patients were treated by nails and 23 patients by Ilizarov external fixators. Both groups were given the same initial management but the operation of the nailing group was delayed until proper soft tissue coverage and healing of the wound were evident. In the Ilizarov method group, 58 fractures obtained union within 26 to 53 weeks (average of 32.8 weeks) and in the nailing group, 23 fractures showed union within 14 to 51 weeks (average of 21.2 weeks). There was a significant difference between the two groups (P<0.05). Complications in the Ilizarov group included 4 nonunions, 12 delayed unions, 3 malalignments, 14 wound infections and 13 stiff ankles. There were no nonunion, 10 delayed unions, 8 malalignments, 6 wound infections and 11 stiff ankles in the nailing group. In this study, the Ilizarov group had more delayed unions and nonunions took a longer period of time to obtain the union, and had a more limited range of motion in the ankle, than the nailing group. The nailing group was easier to manage, especially in the soft tis-sue procedure, and it did not require a high level of compliance while having a relatively low risk of malunion.