The effectiveness of intramedullary nailing on the fixation of tibia diaphyseal fractures: Biomechanical point of view

Yıl 2018, , 221 - 226, 30.09.2018

Tolga Tolunay , Mehmet Orçun Akkurt , Ahmet Şükrü Solak

https://doi.org/10.18663/tjcl.439534

Öz

Aim: The aim of the study was to exhibit the success rate
of nailing on tibia shaft fractures. Biomechanical advantage of the nails was
also evaluated and discussed in this study.

Material
and Methods: Reamed and
static interlocking intramedullary nailing was performed with closed or
mini-open reduction in 35 patients (25 males, 10 females; mean age 37.14±13.13
years). 27 fractures were closed and 8 fractures were open
fractures. The evaluation in the study was performed according to Johner and
Wrush criteria.

Results:
The mean
follow-up period was 12.5
months (range 5 to 20 months).
Union occurred in all patients. Mean union period was 17.02±7.96
weeks. In four cases, a valgus angulation of 2-5 degrees
was detected that whom had distal third tibial fractures. In one case, an
external rotation more than 10⁰ was detected and in another case, grave
claudication was shown. In two cases, extremity shortening of 6-10 mm was seen.
According to ankle and subtalar mobility; 27 (77.1%) of the patients were
recorded as excellent, 7 (20%) good, 1 (2.9%) moderate results. According to
Johner and Wrush criteria; 54.3% of the patients were recorded as excellent,
34.3% good, 8.6% moderate and 2.8% bad results. 

Conclusion: This study suggests that reamed interlocking
intramedullary nailing is an effective method in tibia diaphyseal fractures
because of successful functional results, high union and low complication
rates. On the biomechanical side, anti-rotation of the fixation area and axial
load sharing capacity of nailing has critical demand on fracture healing.

Anahtar Kelimeler

Tibia diaphyseal fractures, biomechanics, intramedullary nailing, interlocking screws

Biyomekanik bakış açısıyla, intramedüller çivilemenin tibia diyafiz kırıklarının fiksasyonu üzerindeki etkinliğinin değerlendirilmesi

Öz

Amaç:
Çalışmanın amacı, tibia diyafiz kırıklarında intramedüller çivilemenin başarı
oranını değerlendirmektir. Bu çalışmada ayrıca çivilerin biyomekanik
avantajları da değerlendirildi ve tartışıldı.

Gereç ve Yöntemler:
Kilitli oymalı intramedüller çivileme, 35 hastada (25 erkek, 10 kadın; yaş
ortalaması 37,14 ± 13,13) kapalı veya mini açık redüksiyon ile yapıldı. Tibia
kırıklarının 27’si kapalı, 8’i açık kırıktı. Tüm hastalara oymalı ve statik
kilitlemeli intramedüller çivileme yapıldı. Çalışmada hastalar Johner ve Wrush
kriterlerine göre değerlendirildi.

Bulgular:
Ortalama takip süresi 12,5 ay (5-20 ay) idi. Hastaların hepsinde kaynama
gerçekleşti. Ortalama kaynama süresi 17,02 ± 7,96 hafta idi. Tibia 1/3 distal
kırığı olan dört olguda 2-5 derecelik valgus açılanması saptandı. Bir olguda,
dış rotasyon 10⁰'dan fazla tespit edildi ve başka bir olguda da yürümede
belirgin aksama tespit edildi. İki olguda, 6-10 mm'lik ekstremite kısalığı
tespit edildi. Ayak bileği ve subtalar eklem hareketlerine göre; hastaların
27'si (%77,1) mükemmel, 7'si (%20) iyi, 1'i (%2,9) orta dereceli olarak
değerlendirildi. Johner ve Wrush kriterlerine göre; hastaların %54,3'ü
mükemmel, %34,3'ü iyi, %8,6'sı orta ve %2,8'i kötü olarak saptandı.

Sonuçlar:
Kilitli oymalı intramedüller çivilemenin, tibia diyafiz kırıklarında başarılı
fonksiyonel sonuçları, yüksek kaynama oranları ve düşük komplikasyon oranları
nedeniyle etkin bir tedavi olduğunu düşünmekteyiz. Biyomekanik açıdan bakacak
olursak, fiksasyon alanının anti-rotasyonunun ve çivilemenin aksiyel yük
paylaşım kapasitesinin, kırık iyileşmesi üzerinde kritik bir öneme sahip olduğu
görülmektedir.

Anahtar Kelimeler

Tibia diyafiz kırıkları, biyomekanik, intramedüller çivileme, kilitleme vidaları

Kaynakça

• 1. Daşar U, Mutlu T, Ülker A, Satılmış AB, Ersan Ö. Erişkin Tibia Diafiz Kırıklarının Cerrahi Tedavisinde Kilitli İntramedüller Çivi Uygulaması. ACTA Med Alanya 2018; 2: 9-13.
• 2. Hu XJ, Wang H. Biomechanical assessment and 3D finite element analysis of the treatment of tibial fractures using minimally invasive percutaneous plates. Exp Ther Med 2017; 14: 1692-1698.
• 3. Schmidt AH, Finkemeier CG, Tornetta P. Treatment of closed tibial fractures. Ferlic DC. Instructional Course Lectures. Colorado, 2003; 607-22.
• 4. Subaşı M, Kesmenli CC, Aslan H, Çakır Ö, Kapukaya A. Tibia kırıklarının intramedüler çivi ile tedavi sonuçları ve bir amputasyon olgusu. Artroplasti Artrosopik cerrahi 2002; 13: 227-32.
• 5. Öztürk İA, Ertürk C, Bilge A, Altay MA, Altay N , Işıkan UE. Tibia Kırıklarında Cerrahi Tedavi Yöntemlerinin Kompartman Basıncına Etkisi. J Harran Univ Med Fac 2017; 14: 160-70.
• 6. Khoury A, Liebergall M, London E, et al. Percutaneous plating of distal tibial fractures. Foot Ankle Int 2002; 23: 818–24.
• 7. Court-Brown CM. Fractures of tibia and fibula. In: Bucholz RW, Heckman JD, Court-Brown C. Rockwood and Green’s Fractures in Adults. Sixth Edition, Philadelphia, Lippincott Williams and Wilkins 2006; 2080-146.
• 8. Martin JS, Marsh JL, Bonar SK, DeCoster TA, Found EM, Brandser EA. Assessment of the AO/ASIF fracture classification for the distal tibia. J Orthop Trauma 1997; 11: 477-83
• 9. Kim PH, Leopold SS. In brief: Gustilo-Anderson classification. Clin Orthop Relat Res 2012; 470: 3270-74.
• 10. 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.
• 11. Burç H, Dursun M, Orhun H, Gürkan V, Bayhan I. Treatment of adult tibial diaphysis fractures with reamed and locked intramedullary nailing. Acta Orthop Traumatol Turc 2009; 43: 7-13.
• 12. Toivanen JA, Honkonen SE, Koivisto AM et al. Treatment of the low energy tibial shaft fractures. Plaster cast compared with intramedullary nailing. Int Orthop 2001; 25: 110-13
• 13. Russell AT. Fractures of the shaft of the tibia. In: Rockwood CA, Green DP(eds). Rockwood and Green’s Fractures in Adults, 4. ed., Philadelphia: Lippincott Company 1996; 2127-99
• 14. Whittle AP, George WW. Fractures of lower extremity, In: S. Terry Canale eds. Campbell’s Operative Orthopaedics Tenth Edition, Philadelphia, Mosby 2003; 2725-72
• 15. Ilizarov GA. The historical background of transosseous osteosynthesis. In: Green SA eds. Transosseous Osteosynthesis, Berlin, Springer-Verlag 1992; 3-62
• 16. Russell TA, Taylor JC, LaVelle DG, Beals NB, Brumfield DL, Durham AG. Mechanical characterization of femoral interlocking intramedullary nailing systems. J Orthop Trauma. 1991; 5: 332-40.
• 17. Karaarslan A, Acar N , Ünal M. Comparison of the Resistance of Proximal Locking Screws in Tibia Nailing System – A Biomechanical Study. Med J SDU 2018; 25: 19-25
• 18. Lin J, Lin SJ, Chen PQ, Yang SH. Stress analysis of the distal locking screws for femoral interlocking nailing. J Orthop Res 2001; 19: 57-63.
• 19. George CJ, Lindsey RW, Noble PC, Alexander JW, Kamaric E. Optimal location of a single distal interlocking screw in intramedullary nailing of distal third femoral shaft fractures. J Orthop Trauma 1998; 12 : 267-72.
• 20. Chen AL, Tejwani NC, Joseph TN, Kummer FJ, Koval KJ. The effect of distal screw orientation on the intrinsic stability of a tibial intramedullary nail. Bull Hosp Jt Dis 2001-2002; 60: 80-83.
• 21. Krettek C, Miclau T, Schandelmaier P, Stephan C, Mohlmann U, Tscherne H. The mechanical effect of blocking screws (“Pollerscrews”) in stabilizing tibia fractures with short proximal or distal fragments after insertion of small diameter intramedullary nails. J Orthop Trauma 1999; 13: 550-53.
• 22. Kenwright J, Gardner T. Mechanical influences on tibial fracture healing. Clin Orthop Relat Res 1998; 355: 179-190.
• 23. Richardson JB, Gardner TN, Hardy JR, Evans M, Kuiper JH, Kenwright J. Dynamisation of tibial fractures. J Bone Joint Surg Br 1995; 77: 412-16.
• 24. Alho A, Ekeland A, Strømsøe K, Follerås G, Thoresen BO. Locked intramedullary nailing for displaced tibial shaft fractures. J Bone Joint Surg Br 1990; 72: 805-9.
• 25. Bechtol JE, Kyle RF, Peren SM. Biomechanics of Intramedullary Nailing Browner BO. The Science and Practice of Intramedullary Nailing. 2nd ed. Lippincott Williams and Wilkins 1996; 85: 105.
• 26. Fairbank AC, Thomas D, Cunningham B, Curtis M, Jinnah RH. Stability of reamed and unreamed intramedullary tibial nails: A biomechanical study. Injury 1995; 26: 483-45.
• 27. Larsen LB, Madsen JE, Høiness PR, Øvre 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 2004; 18: 144-49.
• 28. Chapman MW. The effect of reamed and nonreamed intramedullary nailing on fracture healing. Clin Orthop Relat Res 1998; 355: 230-38.
• 29. 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: 640-46.
• 30. Keating JF, O'Brien PJ, Blachut PA, Meek RN, Broekhuyse HM. Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am 1997; 79: 334-41.
• 31. Bong MR, Kummer FJ, Koval KJ, Egol KA. Intramedullary nailing of the lower extremity: biomechanics and biology. J Am Acad Orthop Surg 2007; 15: 97-106.
• 32. Aitchison GA, Johnstone AJ, Shepherd DE, Watson MA. A comparison of the torsional performance of stainless steel and titanium alloy tibial intramedullary nails: a clinically relevant approach. Biomed Mater Eng 2004; 14: 235-40.