Tibia Cisim Kırıklarının Tedavisinde Oymalı Kanal İçi Çivi Uygulama Sonuçlarının Değerlendirilmesi

Yıl 2014, Cilt: 11 Sayı: 1, 34 - 44, 01.04.2014

Mehmet Akif Altay Cemil Ertürk İslam Baykara Metin Yaptı Baki Volkan Çetin Kemal Yüce İbrahim Avşin Öztürk

Öz

Amaç: Tibia kırıkları tüm uzun kemikler arasında en sık karşılaşılan kırıklardır. Genelde konservatif yaklaşımlar uygulansa da dengesiz ve açık kırıklarda cerrahi tespit gerekmektedir. Kanal içi çivi uygulamaları tibia cisim kırıklarının tedavisinde popüler bir yöntemdir. Ancak açık ve kapalı tibia kırıklarının tedavisinde oymalı ve oymasız uygulamalar üzerindeki tartışmalar halen sürmektedir. Geriye dönük olarak planlana bu çalışmanın amacı açık ve kapalı tibia cisim kırıklarının cerrahi tedavisinde oymalı kanal içi çivi uygulamalarımızın fonksiyonel ve cerrahi sonuçlarını değerlendirmektir.Materyal ve metod: Çalışmamıza tibia cisim kırığı sonrasında kilitli kanal içi çivi uygulanarak tedavi edilen 24 hasta 5 kadın ve 19 erkek dahil edildi. Hastalar kırığın şekline göre iki guruba ayrıldı. Açık kırığı olan 13 hasta ort yaş 31.7±10.7 yıl gurup 1 ve kapalı kırığı olan 11 hasta ort yaş 33.4±10.4 yıl gurup 2 olarak ayrıldı. Sonuçlar fonksiyonel ve radyolojik olarak değerlendirildi. Fonksiyonel değerlendirmede JohnerWrush kriterleri kullanıldı.Bulgular: Ortalama izlem süresi gurup 1 için 25.3±11.5 ay, gurup 2 için ise 23.7±12.6 ay idi. Her iki gurup içinde AO sınıflamasına göre kırık tiplerinin dağılımı benzerdi p > 0.05 . Fonksiyonel ve radyolojik sonuçların karşılaştırılmasında her iki gurup arasında istatistiksel olarak anlamlı bir fark yoktu p > 0.05 . Tüm kırıklarda ortalama 17.3±6.4 haftada solid kaynama sağlandı ve kalıcı sorunlara yol açabilecek herhangi bir sorunla karşılaşılmadı. Kaynamada gecikme olan iki olguda dinamizasyon uygulandı ve ilave bir işleme gereksinim kalmadan yeterli kaynama sağlandı. Johner-Wrush kriterlerine göre fonksiyonel sonuçlar 16 hastada %67 çok iyi ve 8 hastada %33 iyi idi.Sonuç: Tibia diafiz kırıklarının cerrahi tedavisinde oymalı kanal içi çiviler düşük komplikasyon oranına sahip iyi bir tedavi seçeneğidir. Orta derecede kontaminasyon gösteren açık kırıklarda da güvenle uygulanabilirler. Ancak uygulamanın başarısı cerrahi tekniğin uygun şekilde yapılmasının yanı sıra doğru endikasyonun da belirlenmesine bağlıdır

Anahtar Kelimeler

Kırık sabitlemesi, intramedüler, tibia kırıkları, kırıklar, kapalı, kırıklar, açık

Evaluation of tibial shaft fractures treated with reamed intramedullary nailing

Öz

Background: Tibial fractures are the most common of all long bone fractures. Although many tibial fractures may be managed conservatively, a certain subset, including unstable fractures and open fractures, require operative stabilization. Intramedullary nails have become the popular choice of implant in the treatment of tibial shaft fractures. The choice between reamed and unreamed intramedullary nailing fort he treatment of open and closed tibial fractures is an ongoing controversy. The aim of this retrospective study was to evaluate the functional and radiological results of open versus closed tibial shaft fractures treated with reamed intramedullary nailing. Methods: The study included 24 patients 5 woman and 19 man who underwent surgical treatment with intramedullary nailing for tibial shaft fractures. Patients were divided into two groups. Group 1 Open fracture included 13 patients mean age: 31.7±10.7 years . Group 2 Closed fracture consisted of 11 patients mean age: 33.4±11.4 years . Functional and radiologic results were assessed. Johner-Wrush criteria was used for functional assessment. Results: Mean follow-up periods of 25.3±11.5 months and 23.7±12.6 months in group 1 and group 2, respectively. The distrubition of fracture types according to AO classification between the two groups was similar. There was no significant difference between the two groups in terms of functional and radiological results. All fractures healed with solid union within a mean of 17.3±6.4 weeks, and there was no complication that was expected to cause permanent disability. Two patients required dynamization because of delayed union without any other additional procedures. Transient sensorial deficit occured in one patient. According to the Johner-Wrush criteria, functional results were very good in 16 patients 67% , and good in 8 patients 33% . Conclusions: Surgical 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. However, success of the application, in accordance with, depends on the determination of an accurate indication as well as the surgical technique

Anahtar Kelimeler

Fracture Fixation, Intramedullary, tibial fractures, Fractures, Closed, Fractures, Open

Kaynakça

• ) Xue D, Zheng Q, Li H, Qian S, Zhang B, Pan Z. Reamed and unreamed intramedullary nailing for the treatment of open and closed tibial fractures: a subgroup analysis of randomised trials. Int Orthop. ;34(8):1307-13.
• ) Bode G, Strohm PC, Südkamp NP, Hammer TO. Tibial shaft fractures - management and treatment options. A review of the current literature. Acta Chir Orthop Traumatol Cech. 2012;79(6):499-505.
• ) Altay MA, Ertürk C, Altay N, Oztürk IA, Baykara I, Sert C, Isikan UE. Comparison of intracompartmental pressures in a rabbit model of open and closed tibial fractures: an experimental study. Bone Joint J. 2013;95- B(1):111-4.
• ) Müller M.E, Nazartian S, Koch J, Schatzker J. The comprehensive classification of fractures of the long bones. Second ed. Springer-Verlag, New York. :148-82. ) Kádas I, Magyari Z, Vendégh Z, Gloviczki B. Changing the treatment to reduce complication rate in open tibial fractures. Int Orthop. 2009;33(6):1725-31.
• ) Blachut PA, O'Brien PJ, Meek RN, Broekhuyse HM. Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am. 1997;79(5):640-6.
• ) Schmidt AH, Finkemeier CG, Tornetta P. Treatment of closed tibial fractures. Instr Course Lect. ;52:607–22. ) Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF. A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma. 2000;14(3):187-93.
• ) Chalidis BE, Petsatodis GE, Sachinis NC, Dimitriou CG, Christodoulou AG. Reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. Can we expect an optimum result? Strategies Trauma Limb Reconstr. 2009;4(2):89-94.
• ) 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;1939-2000.
• ) Duan X, Al-Qwbani M, Zeng Y, Zhang W, Xiang Z. Intramedullary nailing for tibial shaft fractures in adults. Cochrane Database Syst Rev. 2012;1:CD008241.
• ) 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(4):453–8.
• ) Johner R, Wruhs O. Classification of tibial shaft fractures and correlation with results after rigid internal fixation. Clin Orthop Relat Res 1983;178:7-25.
• ) Court-Brown CM. Reamed intramedullary tibial nailing: an overview and analysis of 1106 cases. J Orthop Trauma 2004;18(2):96–101.
• ) Larsen LB, Madsen JE, Hoiness PR, Ovre S. Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years' follow-up. J Orthop Trauma ;18(3):144–9. ) Klein MP, Rahn BA, Frigg R, Kessler S, Perren SM. Reaming versus non-reaming in medullary nailing: interference with cortical circulation of the canine tibia. Arch Orthop Trauma Surg 1990;109(6):314–6.
• ) Schemitsch EH, Kowalski MJ, Swiontkowski MF, Senft D. Cortical bone blood flow in reamed and unreamed locked intramedullary nailing: a fractured tibia model in sheep. J Orthop Trauma 1994;8(5):373–82.
• ) Reichert IL, McCarthy ID, Hughes SP. The acute vascular response to intramedullary reaming. Microsphere estimation of blood flow in the intact ovine tibia. J Bone Joint Surg Br 1995;77(3):490–3.
• ) Frolke JP, Nulend JK, Semeins CM, Bakker FC, Patka P, Haarman HJ. Viable osteoblastic potential of cortical reamings from intramedullary nailing. J Orthop Res ;22(6):1271–5.
• ) Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch EH. Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg Br 2001;83(1):62–8.
• ) Georgiadis GM, Minster GJ, Moed BR. Effects of dynamization after interlocking tibial nailing: an experimental study in dogs. J Orthop Trauma ;4(3):323–0. ) Egger EL, Gottsauner-Wolf F, Palmer J, Aro HT, Chao EY. Effects of axial dynamization on bone healing. J Trauma 1993;34(2):185–192.
• ) Chalidis BE, Petsatodis GE, Sachinis NC, Dimitriou C G , C h r i s t o d o u l o u A G . R e a m e d i n t e r l o c k i n g intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. Can we expect an optimum result? Strategies Trauma Limb Reconstr. 2009;4(2):89-94.
• ) 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(8):554–8.
• ) Toivanen JA, Vaisto O, Kannus P, Latvala K, Honkonen SE, Jarvinen MJ. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft. A prospective, randomized study comparing two different nail-insertion techniques. J Bone Joint Surg Am 2002;84(4):580–5.
• ) Lefaivre KA, Guy P, Chan H, et al. Long-term follow-up of tibial shaft fractures treated with intramdeullary nailing. J Orthop Trauma 2008;22(8):525-9.
• ) Keating JF, O'Brien PI, Blachut PA, Meek RN, Broekhuyse HM. Reamed interlocking intramedullary nailing of open fractures of the tibia. Clin Orthop Relat Res ;338:182–191. ) Saruhan CS, Algün R, Barış B, Budak K. [Unlocked using of interlocked intramedullary nails in tibial shaft fractures]. Eklem Hastalik Cerrahisi. 2013;24(1):23-9.
• ) Karladani AH, Granhed H, Edshage B, Jerre R, Styf J. Displaced tibial shaft fractures: a prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients. Acta Orthop Scand. 2000;71(2):160-7