DISTAL THIRD TIBIAL FRACTURE SURGERY WITH FIBULAR FIXATION: IS IT NECESSARY FOR UNION AND ALIGNMENT?

Year 2023, , 308 - 315, 23.09.2023

Necmettin Turgut , Ahmet İnce , Meric Unal

https://doi.org/10.17343/sdutfd.1219295

Abstract

Objective
The management of distal third tibial fractures remain
controversial. The aim of the present study was to
evaluate whether concurrent fibular fixation changes
union rates and aids in alignment in the case of distal
third tibia fractures.
Material and Method
The study included 106 distal third tibia fracture
operation cases in which the distance from the fracture
to the plafond was between 3-12 cm at a single centre
between January 2016 and June 2020. The patients
were divided into three groups according to the status
of the fibula: Group 1 (without fibular fixation with
the presence of a fibula fracture, 47 cases), Group
2 (concurrent fibular fixation with the presence of a
fibular fracture, 38 cases) and Group 3 (intact fibula,
21 cases). All fibular fixation surgeries were performed
with locked plates (LCP) and tibial fixation with either
LCP or intramedullary nailing (IMN). The primary
outcome measures were union and alignment. Age,
gender, AO classification, fibula fracture location,
presence of an open fracture, implant type and time
delay for surgery were also assessed.
Results
None of the variables except the presence of an open
fracture was significant for the union rates or alignment.
The union rate was significantly less if there was an
open fracture in the concurrent fibular fixation group
(p<0.001). Closed fractures were associated with
better union rates according to the logistic regression
analysis (OR=5,00 (%95 CI 2,24-11,48).
Conclusion
The present study suggests that a concurrent fibular
fixation in the case of distal third tibia fractures
improves neither the union rates nor the alignment.
Therefore, we conclude that a fibular fixation is not a
necessity in achieving better results and should not
be performed in case of an open fracture considering
the lesser union rate and the burden involved with an
additional surgery.

Keywords

distal tibia fracture, fibula fracture, nonunion, Gustilo Anderson classification, intramedullary nailing, concurrent fibular fixation

DİSTAL TİBİA KIRIKLARINDA FİBULAR FİKSASYON: KAYNAMA VE DİZİLİM AÇISINDAN GEREKLİ MİDİR?

Abstract

Amaç
Distal 1/3 tibia kırıklarının tedavi yönetimi tartışmalıdır.
Bu çalışmanın amacı aynı zamanda yapılan fibular
fiksasyonun kaynama oranlarını arttırıp arttırmadığını
ve dizilim açısından gerekliliğini değerlendirmektir.
Gereç ve Yöntem
Bu çalışmaya distal 1/3 tibia kırığı nedeniyle tek bir
merkezde Ocak 2016 ile Haziran 2020 arasında opere
edilmiş 106 hasta alındı. Kırıklar plafond seviyesinden
3-12 cm arası mesafede lokalize olarak belirlendi.
Hastalar fibulanın durumuna göre üç gruba ayrıldı:
Grup 1 (bir fibula kırığı var ancak fibular fiksasyon yapılmamış,
47 vaka), Grup 2 (bir fibula kırığı var, eş
zamanlı fibular fiksasyon yapılmış, 38 vaka) and Grup
3 (intakt fibula, 21 vaka). Tüm fibular fiksasyon cerrahileri
kilitli kompresyon plakları ile, tibial fiksasyon ise
kiltli kompresyon plakları veya intramedüller çivileme
ile yapıldı. Primer sonuç ölçütleri kaynama ve dizilim
olarak belirlendi. Yaş, cinsiyet, AO sınıflaması, fibula
kırık seviyesi, açık kırık varlığı, implant tipi ve cerrahiye
kadar geçen süre değerlendirildi.
Bulgular
Açık kırık varlığı haricindeki değişkenlerin hem kaynama
oranlarını hem de dizilimi etkilemediği izlendi.
Kaynama oranı eş zamanlı fibula fiksasyon grubunda
açık kırık varlığında anlamlı oranda daha düşük saptandı
(p<0.001). Kapalı kırıklar lojistik regresyon analizi
yapıldığında daha iyi kaynama oranlarına sahipti
(OR=5,00 (%95 CI 2,24-11,48).
Sonuç
Mevcut çalışma distal 1/3 tibia kırıklarında eş zamanlı
bir fibular fiksasyon ameliyatının ne kaynama oranları
ne de dizilim üzerine olumlu etkisi olmadığını gösterdi.
Bundan dolayı, daha iyi sonuçlar almak için distal
tibia kırıklarında bir fibular fiksasyon cerrahisi zorunluluk
değildir ve açık kırık varlığında hem ek cerrahinin
getirdiği yük hem de daha düşük kaynama oranı nedeni
ile yapılmamasını önermekteyiz.

Keywords

distal tibia kırığı, fibula kırığı, kaynamama, Gustilo Anderson sınıflaması, intramedüller çivileme, eş zamanlı fibular fiksasyon

References

• 1. Barei DP, Nork SE, Bellabarba C, Sangeorzan BJ. Is the Absence of an Ipsilateral Fibular Fracture Predictive of Increased Radiographic Tibial Pilon Fracture Severity? J Orthop Trauma. 2006, 20:6–10. 10.1097/01.bot.0000189589.94524.ff
• 2. Lee YS, Chen SW, Chen SH, Chen WC, Lau MJ, Hsu TL. Stabilisation of the fractured fibula plays an important role in the treatment of pilon fractures: a retrospective comparison of fibular fixation methods. Int Orthop. 2009, 33:695–9. 10.1007/s00264-008-0654-4
• 3. Kwok CS, Crossman PT, Loizou CL. Plate Versus Nail for Distal Tibial Fractures. J Orthop Trauma. 2014, 28:542–8.
• 4. Liu X, Xu W, Xue Q, Liang Q. Intramedullary Nailing Versus Minimally Invasive Plate Osteosynthesis for Distal Tibial Fractures: A Systematic Review and Meta‐Analysis. Orthop Surg. 2019, 11:954–65. Doi: 10.1111/os.12575
• 5. Kumar A, Cain LE, Smith RA, Daniels AU, Crates JM, Charlebois SJ. Effect of Fibular Plate Fixation on Rotational Stability of Simulated Distal Tibial Fractures Treated with Intramedullary Nailing. J Bone Jt Surgery-American Vol. 2004, 86:185–6. Doi: 10.2106/00004623-200401000-00035
• 6. Strauss EJ, Alfonso D, Kummer FJ, Egol KA, Tejwani NC. The Effect of Concurrent Fibular Fracture on the Fixation of Distal Tibia Fractures: A Laboratory Comparison of Intramedullary Nails With Locked Plates. J Orthop Trauma. 2007, 21:172–7.
• 7. Torino D, Mehta S. Fibular Fixation in Distal Tibia Fractures. J Orthop Trauma. 2016, 30:S22–5.
• 8. Bhandari M, Guyatt G, Walter SD, Tornetta P, Schemitsch EH, Swiontkowski M, Sanders D. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Jt Surg - Ser A. 2008, 90:2567–78. Doi: 10.2106/JBJS.G.01694
• 9. Müller ME, Nazarian S, Koch P, Schatzker J. The Comprehensive Classification of Fractures of Long Bones. Springer-Verlag; Berlin 1990.
• 10. 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, 22:307–11.
• 11. Taylor BC, Hartley BR, Formaini N, Bramwell TJ. Necessity for fibular fixation associated with distal tibia fractures. Injury. 2015, 46:2438–42. 10.1016/j.injury.2015.09.035
• 12. Javdan M, Tahririan M, Nouri M. The Role of Fibular Fixation in the Treatment of Combined Distal Tibia and Fibula Fracture: A Randomized, Control Trial. Adv Biomed Res. 2017, 6:48. 10.4103/2277-9175.205190
• 13. Rouhani A, Elmi A, Akbari Aghdam H, Panahi F, Dokht Ghafari Y. The role of fibular fixation in the treatment of tibia diaphysis distal third fractures. Orthop Traumatol Surg Res. 2012, 98:868–72. 10.1016/j.otsr.2012.09.009
• 14. Attal R, Maestri V, Doshi HK, Onder U, Smekal V, Blauth M, Schmoelz W. The influence of distal locking on the need for fibular plating in intramedullary nailing of distal metaphyseal tibiofibular fractures. Bone Joint J. 2014, 96-B:385–9. Doi: 10.1302/0301-620x.96b3.32185
• 15. Morin PM, Reindl R, Harvey EJ, Beckman L, Steffen T. Fibular fixation as an adjuvant to tibial intramedullary nailing in the treatment of combined distal third tibia and fibula fractures: A biomechanical investigation. Can J Surg. 2008, 51:45–50. Doi: 10.1016/S0008-428X(08)50009-9
• 16. Varsalona R, Liu GT. Distal tibial metaphyseal fractures: the role of fibular fixation. Strateg Trauma Limb Reconstr. 2006, 1:42–50. Doi: 10.1007/s11751-006-0005-1
• 17. 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, 20:94–103.
• 18. Kariya A, Jain P, Patond K, Mundra A. Outcome and complications of distal tibia fractures treated with intramedullary nails versus minimally invasive plate osteosynthesis and the role of fibula fixation. Eur J Orthop Surg Traumatol. 2020, 30:1487–98. Doi: 10.1007/s00590-020-02726-y
• 19. Vallier HA, Cureton BA, Patterson BM. Randomized, Prospective Comparison of Plate versus Intramedullary Nail Fixation for Distal Tibia Shaft Fractures. J Orthop Trauma. 2011, 25:736–41.
• 20. Hak DJ. Management of aseptic tibial nonunion. J Am Acad Orthop Surg. 2011, 19:563–73. Doi: 10.5435/00124635- 201109000-00007
• 21. Eralp IL. Treatment of infected nonunion of the juxta-articular region of the distal tibia. ACTA Orthop Traumatol Turc. 2016;50(2):139-46. doi: 10.3944/AOTT.2015.15.0147.
• 22. Thakore R V., Francois EL, Nwosu SK, et al. The Gustilo–Anderson classification system as predictor of nonunion and infection in open tibia fractures. Eur J Trauma Emerg Surg. 2017, 43:651–6. Doi: 10.1007/s00068-016-0725-y