Journal of military pharmaco-medicine n09 - 2017

Nội dung text: Journal of military pharmaco-medicine n09 - 2017

1. JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 Ho Huu Phuoc* SUMMARY Objectives: To report our experience in minimally invasive treatment for closed and unstable fractures of the distal tibia but no indication of intramedullary nailing. Subjects and methods: Twenty two patients underwent minimally invasive treatment for closed fractures of distal tibia with locking plate reduction under C-arm. Fractures were classified according to the AO system. Results: Mean age was 45.0 years (ranged 16 - 72 years old). Mean time from surgery to full weight-bearing was 11 weeks (ranged 9 - 16 weeks) and until union was 21 weeks (ranged 17 - 23 weeks) without further surgery. Complications were found in two cases (one case of superficial infection, the other of implant exposure and no failures in fixation). Conclusion: Minimally invasive treatment for fractures of distal tibia with locking plate reduction under C-arm is an effective treatment for distal tibia, which avoids the complications associated with other traditional methods of internal fixation and/or external fixation. * Keywords: Distal tibia fracture; Minimally invasive; Locking compression plate. INTRODUCTION for fractures of distal tibia with locking compression plate reduction under C-arm Although diaphyseal fractures of the tibia is a technique aiming to reduce iatrogenic were treated by intramedullary nailing, soft tissue injury and damage to bone unstable fracture of the distal tibia fractures vascularity, as well as preserve the osteogenic extension can present a management fracture haematoma [9]. Promising results dilemma. The management of fractures for closed distal tibial fractures have been of the distal tibia has been controversial. reported using locking compression plate Open reduction and internal fixation requires [7]. There has been an increasing trend extensive soft tissue dissection. High rates toward the use of the locking compression of complications including infection, delayed plate for fracture fixation. The device allows union and non-union have been reported the screws to lock the plate, therefore [1, 2, 6]. Similarly, external fixation of creating a stable, fixed angle device [2]. distal tibia fractures have an established The development of these locks has been place in the treatment, particularly where based on the scientific evidence on bone associated with significant soft tissue biology, especially with reference to preserving injury [5]. Minimally invasive treatment bone blood supply. * 103 Military Hospital Corresponding author: Ho Huu Phuoc (huuphuoc103@gmail.com) Date received: 06/09/2017 Date accepted: 27/11/2017 In this study, we report our results and compression plate reduction under C-arm, experiences in minimally invasive treatment with specific respect to fracture and soft for fractures of distal tibia with locking 195
2. JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 tissue healing, infection rates and other (50,0%); 43-A2: 4 patients (18,2%); complications encountered. 43-A3: 7 patients (31,8%). * Operative technique: SUBJECTS AND METHODS The patient was positioned supine on a We conducted a prospective analysis radiolucent table, with a thigh tourniquet on 22 patients who underwent procedure inflated after exsanguination. The fracture using minimally invasive treatment for was reduced by manual traction and checked fractures of distal tibia with locking plate under C-arm. Then the fibula was fixed reduction under C-arm at 103 Military through a posterolateral approach by a Hospital from September 2015 to June 2017. Our series include closed fractures plate and screws. Next, a 2 cm incision was of distal tibia. made over the medial malleolus. From this incision, a subcutaneous extraperiosteal Fractures were identified according to tunnel was created for the introduction of the AO/OTA classifications. Patients were the plate, using a long blunt instrument. performed directly by consultant orthopaedics The plate used in all cases was the trauma surgeon. Intravenous antibiotics anatomical distal tibia one and then was were given at induction, in accordance passed in this tunnel [9]. with hospital trust policy (levofloxacine and lincodex). * The distribution of the cohort in term of AO/OTA classification: 43-A1: 11 patients A B Figure 1: A: This is a long blunt instrument to create tunnel; B: The kit, locking plate and screws to operate. A B C Figure 2: A: Small incision was made over the medial malleolus; B: After to creating the tunnel, LP was put in the tunnel; C: Use another plate outside the skin to mark and temporary fixed. 197
3. JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 The plate was checked under C-arm. Provisional fixation of the plate was done by 2 Kischners pinning both distal and proximal of the plate. The same plate out skin was used for defining insertion screws, depending on the morphology of bone fracture, but we normally fixed 4 - 6 cortical screws 3.5 mm into the distal and 4 - 6 cortical screws into the proximal. After surgery, anteroposterior and lateral radiographs were used to check the fracture reduction and the congruence of articular surface of the ankle. A A C Figure 3: A: Reduction under C-arm and provisional fixation distal of the plate; B: Two Kirschner pins were used to fix the plate; C: Fixation proximal of the plate under C-arm. Postoperatively, the leg was elevated and anti-oedema drugs were given to guard against postoperative oedema. The slab and stitches were removed 2 weeks after operation and gentle active mobilization was started. RESULTS The average time from injury to surgery 22 patients (9 males, 13 females) with was 7.8 ± 1.81 days. Postoperative mean the average age of 45.0 years (ranged hospital stay was 6.9 ± 1.62 days. Mean from 16 - 72 years) were included. The total period of hospitalization was 13.2 ± causes of injury were: road traffic accident 1.35 days. The patients were followed at (15 patients), fall (4 patients), labour accident 3rd, 6th, 12th week interval and the follow-up (3 patients). was repeated every three months with a 18 patients (81.8%) had high energy minimum of 3 months and a maximum of trauma, among which 15 patients had road 21 months. Average follow-up was 8.2 ± traffic accidents, 3 patients were involved 2.61 months, whose data was utilized for in labor accident. Fractures were classified according to AO/OTA classification (table 1). the analysis of final results. Mean full weight-bearing period in our study was In our study, there were 19/22 patients with fibular fractures and 11 cases were 10.8 ± 1.25 weeks. The mean period of fixed the fibular fractures. 16 out of 22 cases union of fracture was found 20.9 ± 3.24 had combined injuries such as traumatic weeks (20/22 cases). There were two patients brain injury, chest trauma or abdominal trauma. with insufficient time under observation. 197
4. JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 * Postoperative complications: Superficial wound infection: 1 patient (4.5%); surgical wound breakdown with implant exposed: 1 patient (4.5%); no complication: 20 patients (91.0%). A B Figure 4: A: Pre-operative X-ray anteroposterior and lateral; B: Left leg of a 42 year-old female patient with distal tibia fracture. A B C D Figure 5: A: Reduction under C-arm; B: Post-operative X-ray anteroposterior and lateral; C: The incision third day after surgery; D: The incision second month after surgery. Figure 6: 2 month follow-up full weight-bearing of the patient. All the patients were operated in a single stage with initial fibula fixation followed by anterolateral plating. 198
5. JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 DISCUSSION the patients were in age group of 35 to 65 years. The results were correspoding with A variety of treatment options, for the other studies by Jangde et al [8], example, external fixation, intramedullary Harindra et al [2], where mean age was nailing and plate fixation are available, but 48.95, 48.03 years. In Mohamed et al’s there is no consensus on the best treatment study [14], high energy trauma (especially modality with distal tibia fractures [3]. road traffic accident) was the most common Distal diametaphyseal tibia fractures mode of injury and in the study by Harindra are one of the most problematic injuries et al [2] and Devendra et al [6], high-energy to manage and is often associated with distal tibia injuries involve concomitant significant soft tissue injury. The key point fibular fractures in 52 (92.8%), 34 (80.9%) in management of this injury is to recognise cases. Similarly, in our study, we had the importance of the soft tissue component. 19 cases (86.4%) of ipsilateral fibular For quite some time, distal tibia fractures fracture due to high energy trauma. Among have been treated by open reduction and 19 these cases, fibular fixation was internal fixation with plates. The risk of done in 11 patients. 8 patients with minimally soft tissue damage and disrupting blood displaced and well-aligned fibular fracture supply are increased with the classic approach at higher level were not fixed. The results of open reduction and internal fixation. were matching with Amit et al’s findings Post-operative complication afer a long [7]. time leads to increased risk of delayed Despite controversial issue, some authors osseous union and nonunion [2, 6]. However, recommend delayed surgery for patients as for this type of fracture, results of with swelling after distal tibia fractures [4, operative treatment are dependent on the 10]. Mean time from injury to surgery was severity of the initial injury, the quality and 7.8 ± 1.81 days. In the same study by Santosh stability of the reduction. Minimally invasive et al, patients underwent the surgery locking plate techniques reduce iatrogenic within a mean duration of 8.6 days [5], soft tissue trauma and damage to vascularity and in Devendra et al’s study, the time delay of bone fragment resulting in uncomplicated was 6 days. After operation, we found that union. In this study an attempt was made mean hospital stay was 6.9 ± 1.62 days. to evaluate the results of minimally invasive Mean total period of hospitalization was treatment for fractures of distal tibia with 13.2 ± 1.35 days. Izzet et al reported in locking late reduction under C-arm. his study that average hospital stay after The study group included 9 males and operation was 2.6 ± 1.42 days and mean 13 females, indicating males are less total hospitalization was 4.6 ± 1.95 days involved than females [2]. The average [9]. Perhaps the patients in our study had age of patient was 45.0 years, the youngest combined lesions, so the length of stay in 16 years and the oldest 72 years. Most of the hospital of the patients was longer. 199
6. JOURNAL OF MILITARY PHARMACO-MEDICINE N09-2017 In our study, the average full weight- 3. Mirjam V.N, Peter C.S, Kilian R, Joern Z, bearing was 10.8 ± 1.25 weeks. Mohamed Thorsten O.H. Complication after surgical et al made a report that average full management of distal lower leg fractures. weight-bearing period was 8 weeks [14]. Scandinavian Journal of Trauma. Resuscitation In another study by Jangde et al, full and Emergency Medicine. 2016, 24 (146), pp.2-7. weight-bearing reached 13 - 16 weeks [8]. 4. Huasong L, Liaobin C, Kebin L, Post-operative 20/22 cases were followed Songming P, Jien Z, Yang Y. Minimally and the mean period of union of fracture invasive treatment of tibia pilon fractures through arthroscopy and external fixation- was 20.9 ± 3.24 weeks. In comparison assisted reduction. Springer Plus. 2016, Oct, with recent studies, the results revealed 5 (19), pp.19-23. that Santosh’s study average was 22 5. Santosh S.N, Ramanagouda B, Arravind weeks [5]. Amit’s study was 18 weeks [7]. P. Outcome of distal tibia fractures treated There was one case of superficial using MIPPO with a locking compression infection which was treated with oral plate. Journal of Medical and Dental Science antiobiotics. The other case suffered from Research. 2016, Jan, 3 (1), pp.33-38. surgical wound break down with implant 6. Devendra L, Gaurav S, Kavin K, Kiran exposed of fibular. We had to remove the K, Vijay S, Kamran F. Minimally invasive plate for the fourth month after surgery. osteosynthesis of distal tibia fractures using anterolateral locking plate: Evaluation of CONCLUSION results and complications. Chinese Journal of Traumatology. 2016, Jan, 19, pp.39-44 Minimally invasive treatment for fractures 7. Amit C.S, Kirti V.K, Chandrashekhar of distal tibia with locking plate reduction M.B, Kiran N.W, Kisan R.P. Minimally invasive under C-arm is an effective method of percutaneous plate osteosynthesis in distal treatment for closed fractures of distal tibia. tibia fracture: A series of 32 cases. Int J Ortho The use of indirect reduction technique Scien. 2015, Dec, 2 (1), pp.06-09 under C-arm and small incision is a technique 8. Jangde P.K, Dhruw M. Evaluation of which requires a decrease in intra-operative result of minimally invasive plating osteosynthesis soft tissue trauma, avoiding the complications (MIPO) technique in the treatment of fracture associated with other traditional methods of distal tibia: a prospective follow-up study from internal fixation and/or external fixation. Chhattisgarh, India. Govt Medical College, Med Scien. 2015, Sep, 3 (3), pp.258-264. REFERENCES 9. Izzet B, Nadir Y, Vedat B, Tolga T, Kaan Y, 1. Waseem A, Ajay K.M, Masroor A. Kasim K. Minimally invasive percutaneous plate Evaluation of results of minimally invasive osteosynthesis does not increase complication plating osteosynthesis (MIPO) technique in rates in extra-articular distal tibia fractures. treatment of fractures of distal tibia. Int J Res The Open Orthopeadics Journal. 2015, Feb, 9, Orthop. 2017, Jan, 3 (1), pp.7-11 pp.73-77. 2. Harindra H, Mani B.P, Ajay K.V. Minimally 10. Nitin S, Sanjay D, Vasant G, Romil R. invasive percutaneous plate osteosynthesis Minimally invasive percutaneous plate (MIPPO) a technique for treatment of distal osteosynthesis for distal tibia fractures: tibia fracture. Jour of Den and Med Scien. a prospective study. JKIMSU. 2014, Jun, 3 (1), 2016, Dec, 15 (12), pp.31-38. pp.120-124. 200