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Daas S, Jlidi M, Baghdadi N, Bouaicha W, Mallek K, Lamouchi M, Khorbi A. Risk factors for malunion of distal tibia fractures treated by intramedullary nailing. J Orthop Surg Res 2024; 19:5. [PMID: 38169392 PMCID: PMC10762967 DOI: 10.1186/s13018-023-04472-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The treatment of distal tibia fractures (DTF) has historically been a difficult challenge for orthopedic surgeons because of the particular characteristics of this anatomical region. Intra medullary nailing (IMN) remains the best treatment option. However, achieving and maintaining perfect reduction and stable fixation with IMN can be technically challenging due to the large medullary cavity within a short distal fragment. The aim of our study is to determine the risk factors for malunion in DTF treated with IMN. METHODS It is a retrospective study including DTF treated surgically by IMN in the Orthopedics and Trauma Department at a tertiary hospital over a period of 7 years. The quality of reduction was evaluated by radiological assessment of the antero-posterior (AP) and lateral views of the tibia and ankle at the last follow-up. RESULTS Our series included 90 patients with an average age of 44.8 years. Sex-ratio was 2.6. Tobacco use was reported in 35.6% of the patients. Diabetes was present in 11.1% of the patients, and 12.2% of them had open fractures. According to the OTA/AO classification, the majority of injuries were classified as type A1 (76.7%). Fibula fractures were present in 86.7% of cases. The mean follow-up was 48 months. Malunion occurred in 13 cases. Based on the univariate analysis, smoking and dynamic fixation were significantly associated with malunion. In the multiple logistic regression analysis, dynamic fixation was found to be a significant factor that increased the risk of malunion by 7.5 times. CONCLUSION Neither patient demographics nor fracture characteristics were risk factors for malunion. Nevertheless, it should be noted that dynamic nailing must be avoided as it is associated with a higher risk of malunion. Furthermore, one to two medial to lateral distal locking screws provide sufficient stability without the need for additional fibular fixation. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Selim Daas
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Mohamed Jlidi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia.
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Nahla Baghdadi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Walid Bouaicha
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Karim Mallek
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Mouldi Lamouchi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
| | - Adel Khorbi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, AFH City, Mrezgua, 8050, Nabeul, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Palm VF, Hoogendoorn JM, Verhage SM. The role of fibula fixation in combined distal-third tibia and fibula fractures: a systematic literature review. Arch Orthop Trauma Surg 2024; 144:219-228. [PMID: 37831196 DOI: 10.1007/s00402-023-05092-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/26/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE The role of concomitant fibula fracture fixation in distal-third tibia fractures regarding alignment, union, and functional outcome is still a topic of debate. In this review, we summarize the available comparative literature regarding fibula fixation in distal third lower leg fractures. MATERIALS AND METHODS A systematic literature review of articles published between January 2000 and January 2022 in the PubMed, Cochrane, and EMBASE databases about this topic was performed. RESULTS 746 unique studies were identified of which four randomized-controlled trials and six retrospective studies were included. Nine studies compared alignment after tibia fixation with or without fibula fixation, six studies reported on tibial union, and three studies reported on functional outcome between groups. Pooling of data was not possible due to varying outcome measures and inclusion criteria. Fibula fixation was associated with less rotational malalignment, while there does not seem to be consensus regarding the effect on sagittal and coronal alignment. Six studies reported on the effect of fibula fixation on tibial union. None of these studies found a significant difference between treatment modalities. Furthermore, one out of three studies reporting functional outcome described a marginal beneficial functional outcome after fibula fixation. Ultimately, no differences in complication rates between treatment modalities were described. CONCLUSION Fixation of the fibula in distal-third lower leg fractures does not seem to have a significant effect on coronal and sagittal tibial alignment. Furthermore, fibula fixation is associated with significantly less rotational malalignment, although the clinical importance of this finding is questionable as true differences in rotational alignment between treatment modalities are small. Finally, fibula fixation does not affect union, functional outcome, or complication rate as adjuvant to tibia fixation. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Victor Franciscus Palm
- Department of Surgery, Haaglanden Medical Center, Secretariaat Heelkunde F1.31, Lijnbaan 12, 2512VA, The Hague, The Netherlands.
| | - Jochem Maarten Hoogendoorn
- Department of Surgery, Haaglanden Medical Center, Secretariaat Heelkunde F1.31, Lijnbaan 12, 2512VA, The Hague, The Netherlands
| | - Samuel Marinus Verhage
- Department of Surgery, Haaglanden Medical Center, Secretariaat Heelkunde F1.31, Lijnbaan 12, 2512VA, The Hague, The Netherlands
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Goudjo EUEM, Metchihoungbe CS, Mihluedo-Agbolan AK, Houegban ASCR, Teko DV, Miaffo OEDD, Gnassingbe K. Treatment of long bone fractures in children by elastic stable intramedullary nailing: Outcome and challenges in a unit with restricted technical platform. Afr J Paediatr Surg 2023; 20:184-190. [PMID: 37470553 PMCID: PMC10450106 DOI: 10.4103/ajps.ajps_33_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/14/2022] [Accepted: 06/01/2022] [Indexed: 01/22/2023] Open
Abstract
Introduction Elastic stable intramedullary nailing (ESIN), developed by the Nancy school in France, is the gold standard for surgical treatment of long bone fractures in children. In Africa, few works have been devoted specifically to this technique. Objective This study aimed to describe the outcome and to present the challenges with this technique in the treatment of long bone fractures in children. Patients and Methods This was a prospective and descriptive study over 4 years including patients aged 0-15 years old operated using ESIN. Results Sixty-two patients underwent ESIN, of whom 44 patients (70.96%) were for femur fractures, nine patients (14.52%) for tibia and fibula fractures and nine patients (14.52%) for humerus fractures. The majority of the patients treated with ESIN were children older than 6 years. Nine patients (14.51%) and 13 patients (20.98%) underwent ESIN following polytrauma and multiple fractures, respectively. Seven patients (11.29%) were operated on through-closed ESIN method. The unavailability of image intensifier (38.71%) and the presence of bone callus (40.32%) were the major reasons for using the open ESIN method. Thirty-three patients (53.23%) had minor or major complications. The majority of patients had satisfactory therapeutic outcomes. Conclusion ESIN gives good results, even when the fracture site is approached.
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Affiliation(s)
| | | | | | | | | | | | - Komla Gnassingbe
- Department of Paediatric Surgery, University of Lome, Lomé, Togo
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Greenfield J, Appelmann P, Lafon Y, Bruyère-Garnier K, Rommens PM, Kuhn S. A comparative biomechanical study of the Distal Tibia Nail against compression plating for the osteosynthesis of supramalleolar corrective osteotomies. Sci Rep 2021; 11:18834. [PMID: 34552116 PMCID: PMC8458440 DOI: 10.1038/s41598-021-97968-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 07/21/2021] [Indexed: 11/09/2022] Open
Abstract
The Distal Tibia Nail (DTN; Mizuho, Japan) has demonstrated higher biomechanical stiffness to locking plates in previous research for A3 distal tibia fractures. It is here investigated as a fixation option for supramalleolar corrective osteotomies (SMOT). Sixteen Sawbones tibiae were implanted with either a DTN (n = 8) or Medial Distal Tibia Plate (MDTP; n = 8) and a SMOT simulated. Two surgical outcome scenarios were envisaged: "best-case" representing an intact lateral cortex, and "worst-case" representing a fractured lateral cortex. All samples were subjected to compressive (350 N, 700 N) and torsional (± 4 Nm, ± 8 Nm) testing. Samples were evaluated using calculated construct stiffness from force-displacement data, interfragmentary movement and Von Mises' strain distribution. The DTN demonstrated a greater compressive stiffness for the best-case surgical scenario, whereas the MDTP showed higher stiffness (p < 0.05) for the worst-case surgical scenario. In torsional testing, the DTN proved more resistant to torsion in the worst-case surgical setup (p < 0.05) for both ± 4 Nm and ± 8 Nm. The equivalent stiffness of the DTN against the MDTP supports the use of this implant for SMOT fixation and should be considered as a treatment option particularly in patients presenting vascularisation problems where the MDTP is an inappropriate choice.
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Affiliation(s)
- Julia Greenfield
- Univ Gustave Eiffel, IFSTTAR, LBMC, UMR_T9406, Univ Lyon, 25 Avenue François Mitterrand, 69500, Bron, France.,Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Philipp Appelmann
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Yoann Lafon
- Univ Gustave Eiffel, IFSTTAR, LBMC, UMR_T9406, Univ Lyon, 25 Avenue François Mitterrand, 69500, Bron, France
| | - Karine Bruyère-Garnier
- Univ Gustave Eiffel, IFSTTAR, LBMC, UMR_T9406, Univ Lyon, 25 Avenue François Mitterrand, 69500, Bron, France
| | - Pol Maria Rommens
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Sebastian Kuhn
- Department of Orthopaedics and Traumatology, University Medical Centre of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany. .,Department of Digital Medicine, Medical Faculty OWL, Bielefeld University, Universitätsstr. 25, 33615, Bielefeld, Germany.
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Peng J, Long X, Fan J, Chen S, Li Y, Wang W. Concomitant Distal Tibia-Fibula Fractures Treated with Intramedullary Nailing, With or Without Fibular Fixation: A Meta-Analysis. J Foot Ankle Surg 2021; 60:109-113. [PMID: 33218862 DOI: 10.1053/j.jfas.2020.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 04/15/2020] [Accepted: 05/04/2020] [Indexed: 02/03/2023]
Abstract
There is no consensus on whether a fibular fracture should be fixed when a concurrent extra-articular distal tibia fracture is managed with intramedullary nails. We evaluated the use of fibular fixation in a meta-analysis of randomized trials and observational studies. Two researchers independently assessed the quality of eligible studies and extracted the data. We analyzed 4 trials with a pooled sample of 283 patients (mean age, 24 to 43 years; 141 men), 94 who had undergone fibular fixation and 189 who had not. Two randomized trials assessed on the Cochrane risk-assessment criteria were determined to have a moderate risk of bias, and 2 retrospective cohort studies evaluated with the Newcastle-Ottawa Scale were considered to be high quality. Tibia malalignment at follow-up times ranging from 12 to 72 weeks was reported in 20% (19/94) of patients in the fibular-fixation group and 67% (126/189) of patients in the nonfixation group, indicating that fibular fixation was significantly associated with a lower risk of malalignment (risk ratio, 0.34; 95% confidence interval [CI] 0.13 to 0.92; p = .03). The groups did not differ in the proportion of patients with malalignment immediately after surgery, delayed union, nonunion, or infection. When distal extra-articular tibia-fibular fractures are treated with intramedullary nails, fibular fixation may decrease the risk of late malalignment. Further randomized controlled trials with higher quality are required to verify the result.
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Affiliation(s)
- Jing Peng
- Surgeon, Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China
| | - Xiaotao Long
- Surgeon, Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China
| | - Jun Fan
- Surgeon, Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China.
| | - Shiyang Chen
- Surgeon, Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China
| | - Yang Li
- Surgeon, Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China
| | - Wei Wang
- Surgeon, Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China
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